64FR39607 Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2000, Part 1/9

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[Federal Register: July 22, 1999 (Volume 64, Number 140)]
[Proposed Rules]
[Page 39607-39656]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr22jy99-30]

[[Page 39607]]

_______________________________________________________________________

Part III

Department of Health and Human Services

_______________________________________________________________________

Health Care Financing Administration

_______________________________________________________________________

42 CFR Parts 410, 411, 414, and 415

Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule for Calendar Year 2000; Proposed Rule

[[Page 39608]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 410, 411, 414, and 415

[HCFA-1065-P]

RIN 0938-AJ61

Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule for Calendar Year 2000

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would make several changes affecting
Medicare Part B payment. The changes include: implementation of
resource-based malpractice insurance relative value units (RVUs);
refinement of resource-based practice expense RVUs; payment for
physician pathology and independent laboratory services, RVUs related
to ventricular assist devices, percutaneous thrombectomy of an
arteriovenous fistula, pulse oximetry, temperature gradient studies,
venous pressure determinations, and pulmonary stress testing;
discontinuous anesthesia time; optometrist services; prostate
screening; diagnostic tests; the use of an operating microscope; use of
CPT modifier -25; qualifications for nurse practitioners; an increase
in the work RVUs for pediatric services; removal of the x-ray as a
prerequisite for chiropractic manipulation; the exclusion of payment
for assisted suicide; adjustments to the practice expense RVUs for
physician interpretation of Pap smears; and revisions to the work RVUs
for new and revised CPT codes for calendar year 1999. In addition,
since we established the physician fee schedule on January 1, 1992, our
experience indicates that some of our Part B payment policies need to
be reconsidered. This proposed rule would correct inequities in
physician payment and solicits public comments on specific proposed
policy changes.

DATES: Comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on
September 20, 1999.

ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-1065-P, P.O. Box, 9013
Baltimore, MD 21244-9013.
If you prefer, you may deliver your written comments (1 original
and 3 copies) to one of the following addresses:

Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-16-03, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code HCFA-1065-P. Comments received timely will be available
for public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 443-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7061).

FOR FURTHER INFORMATION CONTACT:
Bob Ulikowski, (410) 786-5721 (for issues related to the resource-based
malpractice relative value units).
Carolyn Mullen, (410) 786-4589 (for issues related to resource-based
practice expense relative value units).
Jim Menas, (410) 786-4507 (for issues related to physician pathology
services and independent labs and discontinuous anesthesia time).
Ken Marsalek, (410) 786-4502 (for issues related to optometrist
services).
Bill Larson, (410) 786-4639 (for issues related to the coverage of
prostate screening).
Regina Walker-Wren, (410) 786-9160 (for issues related to nurse
practitioner qualifications).
Dorothy Honemann, (410) 786-5702 (for issues related to x-ray
requirement for chiropractic services).
Bill Morse, (410) 786-4520 (for issues related to diagnostic tests).
Diane Milstead, (410) 786-3355 (for all other issues).

SUPPLEMENTARY INFORMATION: To assist readers in referencing sections
contained in this preamble, we are providing the following table of
contents. Some of the issues discussed in this preamble affect the
payment policies but do not require changes to the regulations in the
Code of Federal Regulations.

Table of Contents

I. Background
A. Legislative History
B. Published Changes to the Fee Schedule
II. Specific Proposals for Calendar Year 1999
A. Resource-Based Malpractice Relative Value Units
1. Current Relative Value Unit System
2. Proposed Methodology for Developing Resource-Based Relative
Value Units
B. Resource-Based Practice Expense Relative Value Units
C. Practice Expense Relative Value Units for a Physician's
Interpretation of Abnormal Papanicolaou Smears
D. Physician Pathology Services and Independent Laboratories
E. Discontinuous Anesthesia Time
F. Optometrist Services
G. Assisted Suicide
H. CPT Modifier -25
I. Nurse Practitioner Qualifications
J. Relative Value Units for Pediatric Services
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
L. Pulse Oximetry, Temperature Gradient Studies, and Venous
Pressure Determinations
M. Removal of Requirement for x-ray Before Chiropractic
Manipulation
N. Coverage of Prostate Cancer Screening Tests
O. Diagnostic Tests
1. Supervision of Diagnostic Test
2. Independent Diagnostic Testing Facilities
P. New and Revised Relative Value Units for Calendar Year 1999
1. Ventricular Assist Device Implantations (CPT Codes 33975 and
33976)
2. Use of Operating Microscope (CPT Code 69990)
3. Pulmonary Stress Testing (CPT Codes 94620 and 94621)
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
A. Resource-Based Malpractice Relative Value Units
B. Resource-Based Practice Expense
C. Practice Expense for Physician Interpretation of Abnormal
Papanicolaou Smears
D. Technical Component of Physician Pathology Services and
Independent Laboratories
E. Discontinuous Anesthesia Time
F. Optometrist Services
G. Assisted Suicide
H. CPT Modifier -25
I. Nurse Practitioner Qualifications
J. Relative Value Units for Pediatric Services
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
L. Pulse Oximetry, Temperature Gradient Studies, and Venous
Pressure Determinations
M. Removal of Requirement for X-ray Before Chiropractic
Manipulation
N. Coverage of Prostate Cancer Screening Tests
O. Diagnostic Tests
1. Supervision of Diagnostic Test
2. Independent Diagnostic Testing Facilities
P. New and Revised Relative Value Units for Calendar Year 1999
1. Ventricular Assist Device Implantations
2. Use of Operating Microscope
3. Pulmonary Stress Testing
Q. Budget Neutrality

[[Page 39609]]

R. Impact on Beneficiaries
Addendum A--Explanation and Use of Addenda B
Addendum B--2000 Relative Value Units and Related Information Used
in Determining Medicare Payments for 2000

In addition, because of the many organizations and terms to which
we refer by acronym in this proposed rule, we are listing these
acronyms and their corresponding terms in alphabetical order below:

AANA American Association of Nurse Anesthetists
AMA American Medical Association
ASA American Society of Anesthesiologists
BBA Balanced Budget Act of 1997
CF Conversion factor
CFR Code of Federal Regulations
CPT [Physicians'] Current Procedural Terminology [4th Edition,
1997, copyrighted by the American Medical Association]
CRNA Certified Registered Nurse Anesthetist
E/M Evaluation and management
GAF Geographic adjustment factor
GPCI Geographic practice cost index
HCFA Health Care Financing Administration
HCPCS HCFA Common Procedure Coding System
HHS [Department of] Health and Human Services
HMO Health maintenance organization
IDTFs Independent Diagnostic Testing Facilities
JUAs Joint Underwriting Associations
MEDPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MGMA Medical Group Management Association
NPI National provider identifier
OBRA Omnibus Budget Reconciliation Act
PC Professional component
PCF Patient Compensation Fund
RUC [AMA's Specialty Society] Relative [Value] Update Committee
RVU Relative value unit
TC Technical component

I. Background

A. Legislative History

Since January 1, 1992, Medicare has paid for physician services
under section 1848 of the Social Security Act (the Act), ``Payment for
Physicians'' Services.'' This section contains three major elements:
(1) A fee schedule for the payment of physician services; (2) a
sustainable growth rate for the rates of increase in Medicare
expenditures for physician services; and (3) limits on the amounts that
nonparticipating physicians can charge beneficiaries. The Act requires
that payments under the fee schedule be based on national uniform
relative value units (RVUs) based on the resources used in furnishing a
service. Section 1848(c) of the Act requires that national RVUs be
established for physician work, practice expense, and malpractice
expense.
Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments
in RVUs because of changes resulting from a review of those RVUs may
not cause total physician fee schedule payments to differ by more than
$20 million from what they would have been had the adjustments not been
made. If this tolerance is exceeded, we must make adjustments to the
conversion factors (CFs) to preserve budget neutrality.

B. Published Changes to the Fee Schedule

We published a final rule on November 25, 1991 (56 FR 59502) to
implement section 1848 of the Act by establishing a fee schedule for
physician services furnished on or after January 1, 1992. In the
November 1991 final rule (56 FR 59511), we stated our intention to
update RVUs for new and revised codes in the American Medical
Association's (AMA's) Physicians' Current Procedural Terminology (CPT)
through an ``interim RVU'' process every year. The updates to the RVUs
and fee schedule policies are as follows:
<bullet> November 25, 1992, a final notice with comment period on
new and revised RVUs only (57 FR 55914).
<bullet> December 2, 1993, a final rule with comment period (58 FR
63626) to revise the refinement process used to establish physician
work RVUs and to revise payment policies for specific physician
services and supplies. (We solicited comments on new and revised RVUs
only.)
<bullet> December 8, 1994, a final rule with comment period (59 FR
63410) to revise the geographic adjustment factor (GAF) values, fee
schedule payment areas, and payment policies for specific physician
services. The final rule also discussed the process for periodic review
and adjustment of RVUs not less frequently than every 5 years as
required by section 1848(c)(2)(B)(i) of the Act.
<bullet> December 8, 1995, a final rule with comment period (60 FR
63124) to revise various policies affecting payment for physician
services including Medicare payment for physician services in teaching
settings, the RVUs for certain existing procedure codes, and to
establish interim RVUs for new and revised procedure codes. The rule
also included the final revised 1996 geographic practice cost indices
(GPCIs).
<bullet> November 22, 1996, a final rule with comment period (61 FR
59490) to revise the policy for payment for diagnostic services,
transportation in connection with furnishing diagnostic tests, changes
in geographic payment areas (localities), and changes in the procedure
status codes for a variety of services.
<bullet> October 31, 1997, a final rule with comment period (62 FR
59048) to revise the geographic practice cost index (GPCI), physician
supervision of diagnostic tests, establishment of independent
diagnostic testing facilities, the methodology used to develop
reasonable compensation equivalent limits, payment to participating and
nonparticipating suppliers, global surgical services, caloric
vestibular testing, and clinical consultations. The final rule also
implemented certain provisions of the Balanced Budget Act of 1997 (the
BBA) (Public Law 105-33), enacted on August 5, 1997, and implemented
the RVUs for certain existing procedure codes and established interim
RVUs for new and revised procedure codes.
<bullet> November 2, 1998, a final rule with comment period (63 FR
58814) to revise the policy for resource-based practice expense RVUs,
medical direction rules for anesthesia services, and payment for
abnormal Pap smears. Also, we rebased the Medicare Economic Index from
a 1989 base year to a 1996 base year. Under the law, we are required to
develop a resource-based system for determining practice expense RVUs.
The BBA delayed, for 1 year, implementation of the resource-based
practice expense RVUs until January 1, 1999. Also, the BBA revised our
payment policy for nonphysician practitioners, for outpatient
rehabilitation services, and for drugs and biologicals not paid on a
cost or prospective payment basis. In addition, the BBA permits certain
physicians and practitioners to opt out of Medicare and furnish covered
services to Medicare beneficiaries through private contracts and
permits payment for professional consultations via interactive
telecommunication systems. Furthermore, we finalized the 1998 interim
RVUs and issued interim RVUs for new and revised codes for 1999. This
final rule also announced the calendar year 1999 Medicare physician fee
schedule conversion factor under the Medicare Supplementary Medical
Insurance (Part B) program as required by section 1848(d) of the Act.
The 1999 Medicare physician fee schedule conversion factor was
$34.7315.
This proposed rule would affect the regulations set forth at--
<bullet> Part 410, Supplementary medical insurance benefits;
<bullet> Part 411, Exclusions from Medicare and limitations on
Medicare payment;
<bullet> Part 414, Payment for Part B medical and other services;
and

[[Page 39610]]

<bullet> Part 415, Part B carrier payments for physicians' services
to beneficiaries in providers.

II. Specific Proposals for Calendar Year 1999

A. Resource-Based Malpractice Relative Value Units

1. Current Relative Value Unit System
Section 1848(c)(2)(C) of the Act requires each service paid under
the physician fee schedule be comprised of three components: work,
practice expense, and malpractice. The practice expense and malpractice
expense RVUs equal the product of the base allowed charges and the
practice expense and malpractice percentages for the service. Base
allowed charges are defined as the national average allowed charges for
the service furnished during 1991, as estimated using the most recent
data available. For most services, we used 1989 charge data ``aged'' to
reflect the 1991 payment rules, since those were the most recent data
available for the 1992 fee schedule. The work RVUs have been resource-
based since the inception of the fee schedule in 1992. They are
primarily based on a study of physician work conducted by researchers
at the Harvard School of Public Health. The work values for new and
revised codes added since 1992 are primarily based on the
recommendations of the American Medical Association's Relative Value
Update Committee (RUC). For detailed descriptions of the establishment
of resource-based work RVUs, see the June 5, 1991 proposed rule (56 FR
25792) and the November 25, 1991 final rule (56 FR 59502) on the
original fee schedule and the May 3, 1996 proposed rule (61 FR 19992)
on the five-year refinement of resource-based work RVUs.
The practice expense RVUs were not resource-based but were rather
charge-based from 1992 to 1998. In most cases, the practice expense
RVUs were calculated on a statutory formula. They were derived from the
product of ``base allowed charges'' and service-specific practice
expense percentages. The base allowed charge is the national average
allowed charge for the service furnished in 1991. The service-specific
practice expense percentage is a weighted average of the practice
expense percentages of the specialties performing the service. For new
codes after 1991, the practice expense RVUs were extrapolated from the
values for existing similar codes or from the work RVUs.
Section 121 of the Social Security Act Amendments of 1994 (Public
Law 103-432), enacted on October 31, 1994 and amended by the BBA,
required us to develop a methodology and implement resource-based
practice expense RVUs effective for services furnished in 1998. Section
4505 of the BBA postponed implementation of resource-based practice
expense RVUs until 1999 and provided for a gradual four-year
transition, with resource-based practice expense RVUs becoming fully
effective in 2002. For a detailed explanation of resource-based
practice expense RVUs see the June 5, 1998 proposed rule (63 FR 30818)
and the November 2, 1998 final rule (63 FR 58814) on the fee schedule.
Malpractice RVUs are currently charge-based, using the same
statutory formula discussed above for practice expense RVUs but using
weighted specialty-specific malpractice expense percentages and 1991
average allowed charges. As with practice expense RVUs, malpractice
RVUs for new codes after 1991 were extrapolated from similar existing
codes or from work RVUs. Section 4505(f) of the BBA requires us to
implement resource-based malpractice RVUs for services furnished
beginning in 2000. With the implementation of resource-based
malpractice RVUs and full implementation of resource-based practice
expense RVUs in 2002, all physician fee schedule RVUs will be resource-
based, thus eliminating the last vestiges of payment inequities that
resulted from charges that did not accurately reflect the relative
resources involved in providing a service.
2. Proposed Methodology for Developing Resource-Based Malpractice RVUs
The resource-based malpractice RVUs are based on actual malpractice
premium data and current Medicare payment data on allowed services and
charges, RVUs, and specialty payment percentages. Subjective judgment
is primarily limited to the mapping of Medicare specialties to the
various insurer premium risk groups.
We decided to use malpractice premium data because they represent
the actual malpractice expense to the physician. In addition,
malpractice premium data are widely available. We also considered using
procedure-specific actual malpractice claims paid data as recommended
by the Medicare Payment Advisory Committee (MEDPAC). However, we do not
believe that such an approach is viable because inquiries to
malpractice insurance experts revealed that the data are not available
in sufficient quantity and breadth to be useful. Consultation with
insurers informed us that they do not track malpractice payments on an
individual CPT procedure code basis. If any such data did exist, we
believe that they would likely be limited to a few very high-risk
procedures and not be widely and consistently available on a national
basis. Constructing national RVUs requires consistent national data for
all procedures.
Moreover, even if such data existed on a consistent national basis,
it is virtually impossible to determine which specific procedure
performed in treating an illness produced the adverse outcome leading
to the settlement or award or to accurately apportion the settlement or
award among the procedures. For example, in the case of cancer, a
symptom missed during a visit or a faulty x-ray or MRI could all
contribute to a late diagnosis. Similarly, the cause of the claim could
be the chemotherapy, the radiation therapy, the surgery, or any
combination thereof.
Discussions with the industry lead us to conclude that the primary
determinants of malpractice liability costs are physician specialty,
level of surgical involvement, and the individual physician's
malpractice history.
Actual malpractice premium data were collected for the top 20
Medicare physician specialties measured by dollars of reimbursement.
Premiums were for a $1 million/$3 million mature claims-made-policy (a
policy covering claims made rather than services provided during the
policy term). Data were collected from all 50 States, Washington, D.C.,
and Puerto Rico. Data were collected from commercial and physician-
owned insurers and from joint underwriting associations or JUAs,
typically, State government administered risk pooling insurance
arrangements in areas where commercial insurers have left the market.
Adjustments were made to reflect mandatory patient compensation fund or
PCF (a fund to pay for any claim beyond the statutory amount thereby
limiting an individual physician's liability in cases of a large suit)
surcharges in States where PCF participation is mandatory. The premium
data collected represent at least 50 percent of physician malpractice
premiums paid in each State, with the average being 77 percent.
Malpractice insurers generally use five-digit codes developed by
the Insurance Services Office (ISO), an advisory body serving property
and casualty insurers, to classify physician specialties into different
risk classes for premium rating purposes. ISO codes classify physicians
not only by specialty, but in many cases also by whether or not the
specialty performs

[[Page 39611]]

surgical procedures. A given specialty could thus have two ISO codes,
one for use in rating a member of that specialty who performs surgical
procedures and another for rating a member of that specialty who does
not perform surgery. Medicare uses its own system of specialty
classification for payment and data purposes. It was therefore
necessary to map Medicare specialties to ISO codes and insurer risk
classes. Different insurers, while using ISO codes, have their own risk
class categories. To assure consistency, we used the risk classes of
St. Paul Companies, one of the oldest and largest malpractice insurers.
Table 1 crosswalks Medicare specialties to ISO codes and St. Paul risk
classes used.

Table 1.--Crosswalk of Medicare Specialty Code To Malpractice ISO Code and St. Paul's Risk Class
--------------------------------------------------------------------------------------------------------------------------------------------------------
ISO code Risk class
Medicare code Medicare -------------------------------------------------------- St. Paul's description
description Surgery Other Surgery Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
01............ General practice. 80117 80420 4 1 Family/Gen. Practitioners--No Obstetrical.
02............ General surgery.. 80143 80143 5 5 Surgery-General.
03............ Allergy/ 80254 80254 1A 1A Allergy.
Immunology.
04............ Otolaryngology... 80159 80265 3 1 Otarhinolaryngology.
05............ Anesthesiology... 80151 80151 5A 5A Anesthesiology.
06............ Cardiology....... 80150 80255 6 1 Cardiovascular Disease.
07............ Dermatology...... 80282 80256 2 1A Dermatology.
08............ Family practice.. 80117 80420 4 1 Family/Gen. Practitioners--No Obstetrical.
10............ Thoracic surgery. 80104 80241 3 1 Gastroenterology.
11............ Internal medicine 80284 80257 2 1 Internal medicine.
13............ Neurology........ 80152 80261 8 2 Neurology.
14............ Neurosurgery..... 80152 80261 8 2 Neurology.
16............ Obstetrics/ 80167 80244 2 1 Gynecology.
Gynecology.
18............ Ophthalmology.... 80114 80263 2 1 Ophthalmology.
20............ Orthopedic 80501 80501 5 5 Surgery Orthopedic--excluding Spinal Surgery.
surgery.
22............ Pathology........ 80292 80266 2 1A Pathology.
24............ Plastic and 80156 80156 5 5 Surgery Plastic.
reconstructive
surgery.
25............ Physical medicine 80235 80235 1 1 Physical medicine and rehab.
and rehab.
26............ Psychiatry....... 80249 80249 1A 1A Psychiatry.
29............ Pulmonary disease 80269 80269 1 1 Pulmonary Disease.
30............ Diagnostic 80280 80253 2 2 Radiology.
radiology.
33............ Thoracic surgery. 80144 80144 6 6 Surgery Thoracic.
34............ Urology.......... 80145 80145 3 3 Urological Surgery.
36............ Nuclear medicine. 80262 80262 1 1 Nuclear medicine.
37............ Pediatric 80293 80267 2 1 Pediatrics.
medicine.
38............ Geriatric 80105 80243 1 1 Geriatrics.
medicine.
39............ Nephrology....... 80108 80260 3 3 Nephrology.
40............ Hand surgery..... 80169 80169 5 5 Hand Surgery.
44............ Infectious 80279 80246 1 1 Infectious disease.
disease.
46............ Endocrinology.... 80103 80238 3 1 Endocrinology.
65............ Physical 80235 80235 1 1 Physical medicine and rehab.
therapist
(independently
practice.
66............ Rheumatology..... 80252 80252 1 1 Rheumatology.
67............ Occupational 80233 80233 1A 1A Occupational Med.
therapist
(independently
practice.
77............ Vascular surgery. 80146 80146 6 6 Vascular Surgery.
78............ Cardiac surgery.. 80141 80141 6 6 Cardiac Surgery.
82............ Hematology....... 80278 80245 2 1 Hematology.
83............ Hematology/ 80278 80245 2 1 Hematology.
oncology.
84............ Preventive 80231 80231 1 1 General Preventive Medicine.
medicine.
93............ Emergency 80157 80102 5 4 ER Physician.
medicine.
98............ Gynecologist/ 80167 80244 4 1 Gynecology.
oncologist.
--------------------------------------------------------------------------------------------------------------------------------------------------------

Some physician specialties, nonphysician practitioners, and other
entities (for example, independent diagnostic testing facilities) paid
under the physician fee schedule could not be assigned an ISO code. We
crosswalked these specialties to physician specialties assigned an ISO
code and a risk class. The unassigned specialties and the specialty to
which they were assigned are shown in Table 2.

Table 2.--Crosswalk for Unassigned Specialties
------------------------------------------------------------------------
Unassigned speciality Cross walk speciality
------------------------------------------------------------------------
Addiction Medicine.................. Psychiatry.
Chiropractor, Licensed.............. Internal Medicine.
Clinical Nurse Practitioner......... Internal Medicine.
Clinic or Other Group............... All Physicians.
Clinical Psychologist............... Psychiatry.
Clinical Social Worker.............. Psychiatry.
Colorectal Surgery.................. General Surgery.
Critical Care (intensivists)........ All Physicians.
CRNA/AA............................. Family Practice.
Independent Lab..................... All Physicians.
Independent Physiological Lab....... All Physicians
Interventional Radiology............ Radiology.
Manipulative Therapy................ All Physicians.

[[Page 39612]]

Maxillofacial Surgery............... Plastic Surgery.
Medical Oncolgy..................... Gynecology.
Neuropsychiatry..................... Psychiatry.
Nurse Practitioners................. Internal Medicine.
Optometrist......................... All Physicians.
Oral Surgery........................ All Physicians.
Peripheral Vascular Disease......... All Physicians.
Physician Assistants................ Family Practice.
Podiatry............................ All Physicians.
Psychologist (Billing Indep.)....... Psychiatry.
Radiation Oncology.................. Radiology.
Surgical Oncology................... All Physicians.
------------------------------------------------------------------------

We originally considered two malpractice premium-based alternatives
for resource-based malpractice RVUs. One was based solely on specialty
premium differences and did not reflect differences in risk-of-service
among procedures provided by the specialty. Risk-of-service reflects
how services differ in their contributions to professional malpractice
liability. For example, if a physician often performs a complex,
difficult surgical procedure, this would have a larger effect on the
physician's premium risk classification than a simple office visit. We
realized that if we did not account for risk-of-service differences all
procedures that might be performed exclusively by a given specialty
would have the same resource-based malpractice RVUs, even though they
might vary considerably in effort, difficulty, total payment, and their
contribution to that specialty's malpractice liability.
The alternative which we are proposing, uses the same basic
methodology with one added computation. In order to reflect differences
in risk-of-service, in step (3) below we propose to multiply the
specialty premium-based malpractice RVUs by the procedure's work RVUs.
We believe that time, intensity, and difficulty of services are
correlated with malpractice risk. Since the work RVUs reflect
differences in time, intensity, and difficulty among procedures and are
generally accepted as accurate, we believe that they are the best
available proxy for determining risk-of-service.
Our proposed methodology is as follows:
(1) Compute a national average premium for each specialty.
Insurance rating area malpractice premiums for each specialty were
mapped to the county level. The specialty premium for each county was
then multiplied by the county total RVUs, which had been divided by the
county malpractice geographic practice cost index (GPCI) to normalize
the data for geographical differences. (Since malpractice RVUs are
multiplied by locality malpractice GPCIs in calculating fee schedule
payments, if the locality RVUs are not ``deflated'' by the malpractice
GPCIs, the locality cost differences as reflected by the GPCIs would be
counted twice.) The product of premiums and RVUs was then summed for
all counties by specialty. This number was divided by the total RVUs
for all counties for each specialty. This yields a national average
premium for each specialty.
Table 3 shows the national average premiums for the years 1990-95
for the 20 specialties on which we collected premium data. We used an
average of the 3 most recent years, 1993-95, in our calculation. We
plan to collect more recent data (1996-1998) to use in future
refinement of malpractice RVUs, but do not expect that these more
recent data will result in any significant changes since Table 3 shows
that on a national average basis malpractice premiums have been
remarkably stable in recent years.

Table 3.--National Average Premiums (1990-1995) Calculated Using 1997 RVU Weights
--------------------------------------------------------------------------------------------------------------------------------------------------------
Annual
ISO Specialy 1990 avg 1991 avg 1992 avg 1993 avg 1994 avg 1995 avg trend
--------------------------------------------------------------------------------------------------------------------------------------------------------
80114....................... Ophthalmology.................. 11,538 11,098 10,637 10,747 10,773 11,359 -0.3
80143....................... General surgery................ 28,231 26,683 25,405 25,896 26,876 28,286 0.0
80144....................... Thoracic surgery............... 37,740 37,123 35,439 37,045 38,320 41,001 1.7
80145....................... Urology........................ 16,798 16,285 15,432 15,161 15,669 16,620 -0.2
80151....................... Anesthesiology................. 23,437 20,986 19,536 17,406 17,409 16,877 -6.4
80152....................... Neurosurgery................... 50,743 45,248 48,788 52,124 54,027 57,679 2.6
80154....................... Orthopedic surgery............. 40,312 39,145 36,734 37,455 38,607 40,569 0.1
80156....................... Plastic and reconstructive 32,951 31,062 30,087 29,193 30,056 32,594 -0.2
surgery.
80159....................... Ootolaryngology................ 23,697 21,369 20,146 18,926 19,661 20,657 -2.7
80244 *..................... OB/GYN......................... 46,724 44,726 43,300 12,676 13,264 N/A N/A
80249....................... Psychiatry..................... 5,662 5,597 5,574 6,748 7,204 7,766 6.5
80269....................... Pulmonary disease.............. 7,807 7,675 7,202 8,068 8,517 9,198 3.3
80274....................... Gastroenterology............... 9,985 9,754 9,709 10,468 10,944 11,612 3.1
80280....................... Diagnostic radiology........... 9,748 9,496 9,404 10,280 10,675 11,394 3.2
80281....................... Cardiology..................... 10,437 10,225 10,187 11,895 12,360 13,138 4.7
80282....................... Dermatology.................... 9,004 8,768 8,750 10,392 10,905 11,541 5.1
80284....................... Internal medicine.............. 10,349 10,093 9,905 10,931 11,421 12,122 3.2
80288....................... Neurology...................... 10,613 10,479 10,789 11,721 12,289 13,179 4.4
80292....................... Pathology...................... 8,332 7,868 7,482 8,554 8,818 9,369 2.4
80423....................... General practice............... 10,081 9,777 9,662 10,006 10,399 10,989 1.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
* 1990-92 data reflects Obsterical malpractice premium. 93-94 is for Geneologist. 95 premium not available.

(2) Calculate a risk factor for each specialty. Differences among
specialties in malpractice premiums reflect differences in their
malpractice exposure or risk. Relative differences among specialties in
national average malpractice premiums can be expressed as specialty
risk factors. These risk factors are an index calculated by dividing
the national average premium for each specialty by the national average
premium for the specialty with the lowest average premium, psychiatry.
Table 4 shows the risk factors, surgical and non-surgical, by
specialty.

[[Page 39613]]

Table 4.--Medicare Specialties and Risk Factor Assignment
----------------------------------------------------------------------------------------------------------------
Non-Surgical Risk Factors Surgical Risk Factors
----------------------------------------------------------------------------------------------------------------
Code Medicare description Risk factor Code Medicare description Risk factor
----------------------------------------------------------------------------------------------------------------
0.................... All Physicians.......... 1.50 0 All Physicians.......... 2.53
01................... General practice........ 1.21 01 General practice........ 3.10
02................... General surgery......... 3.99 02 General surgery......... 3.99
03................... Allergy/Immunology...... 1.00 03 Allergy/Immunology...... 1.00
04................... Otolaryngology.......... 1.21 04 Otolaryngology.......... 2.83
05................... Anesthesiology.......... 2.34 05 Anesthesiology.......... 2.34
06................... Cardiology.............. 1.21 06 Cardiology.............. 5.84
07................... Dermatology............. 1.00 07 Dermatology............. 1.51
08................... Family practice......... 1.21 08 Family practice......... 3.10
10................... Gastroenterology........ 1.21 10 Gastroenterology........ 2.64
11................... Internal medicine....... 1.21 11 Internal medicine....... 1.58
12................... Osteopathic manipulative 1.50 12 Osteopathic manipulative 2.53
therapy. therapy.
13................... Neurology............... 1.61 13 Neurology............... 8.16
14................... Neurosurgery............ 1.61 14 Neurosurgery............ 8.16
16................... Obstetrics/Gynecology... 1.21 16 Obstetrics/Gynecology... 3.10
18................... Ophthalmology........... 1.21 18 Ophthalmology........... 1.54
19................... Oral surgery (dentists 1.50 19 Oral surgery (dentists 2.53
only). only).
20................... Orthopedic surgery...... 4.28 20 Orthopedic surgery...... 4.28
22................... Pathology............... 1.00 22 Pathology............... 1.28
24................... Plastic and 4.35 24 Plastic and 4.35
reconstructive surgery. reconstructive surgery.
25................... Physical medicine and 1.21 25 Physical medicine and 1.21
rehab. rehab.
26................... Psychiatry.............. 1.00 26 Psychiatry.............. 1.00
28................... Colorectal surgery 4.28 28 Colorectal surgery 4.28
(formerly proctology). (formerly proctology).
29................... Pulmonary disease....... 1.21 29 Pulmonary disease....... 1.21
30................... Diagnostic radiology.... 1.54 30 Diagnostic radiology.... 1.54
31................... Roentgenology, radiology 1.54 31 Roentgenology, radiology 1.54
(osteopaths only). (osteopaths only).
33................... Thoracic surgery........ 5.54 33 Thoracic surgery........ 5.54
34................... Urology................. 2.26 34 Urology................. 2.26
35................... Chiropractic............ 1.21 35 Chiropractic............ 1.61
36................... Nuclear medicine........ 1.21 36 Nuclear medicine........ 1.21
37................... Pediatric medicine...... 1.21 37 Pediatric medicine...... 1.61
38................... Geriataric medicine..... 1.21 38 Geriataric medicine..... 1.21
39................... Nephrology.............. 2.64 39 Nephrology.............. 2.64
40................... Hand surgery............ 4.28 40 Hand surgery............ 4.28
44................... Infectious disease...... 1.21 44 Infectious disease...... 1.21
46................... Endocrinology........... 1.21 46 Endocrinology........... 2.64
48................... Podiatry................ 1.50 48 Podiatry................ 2.53
62................... Psychologist (billing 1.00 62 Psychologist (billing 1.00
independently). independently).
65................... Physical therapist 1.21 65 Physical therapist 1.21
(independently (independently
practicing). practicing).
66................... Rheumatology............ 1.21 66 Rheumatology............ 1.21
67................... Occupational therapist 1.00 67 Occupational therapist 1.00
(independently (independently
practicing). practicing).
68................... Clinical psychologist... 1.00 68 Clinical psychologist... 1.00
70................... Multispecialty clinic or 1.50 70 Multispecialty clinic or 2.53
group practice. group practice.
71................... Diagnostic x-ray........ 1.54 71 Diagnostic x-ray........ 1.54
76................... Peripheral vascular 1.50 76 Peripheral vascular 2.53
disease. disease.
77................... Vascular surgery........ 5.84 77 Vascular surgery........ 5.84
78................... Cardiac surgery......... 5.84 78 Cardiac surgery......... 5.84
79................... Addiction medicine...... 1.00 79 Addiction medicine...... 1.00
81................... Critical care........... 1.50 81 Critical care........... 2.53
82................... Hematology.............. 1.21 82 Hematology.............. 1.61
83................... Hematology/oncology..... 1.21 83 Hematology/oncology..... 1.61
84................... Preventive medicine..... 1.21 84 Preventive medicine..... 1.21
85................... Maxillofacial surgery... 4.28 85 Maxillofacial surgery... 4.28
86................... Neuropsychiatry......... 1.00 86 Neuropsychiatry......... 1.00
90................... Medical oncology........ 1.21 90 Medical oncology........ 3.10
91................... Surgical oncology....... 1.50 91 Surgical oncology....... 2.53
92................... Radiation oncology...... 1.54 92 Radiation oncology...... 1.54
93................... Emergency medicine...... 3.10 93 Emergency medicine...... 4.28
94................... Interventional Radiology 1.54 94 Interventional Radiology 1.54
98................... Gynecologist/oncologist. 1.21 98 Gynecologist/oncologist. 3.10
----------------------------------------------------------------------------------------------------------------

(3) Calculate malpractice RVUs for each code. Resource-based
malpractice RVUs were calculated for each procedure. First, the
percentage of a specific service provided by each specialty was
determined from payment records. This percentage was then multiplied by
the specialty's risk factor. The products for all specialties for the

[[Page 39614]]

procedure are then summed, yielding a specialty-weighted malpractice
RVU reflecting the weighted malpractice costs across all specialties
for that procedure. This number was then multiplied by the procedure's
work RVUs to account for differences in risk-of-service. We realize
that adjusting for risk-of-service using work RVUs may not exactly
reflect risk-of-service differences because certain procedures with
relatively high work RVUs may have low malpractice claim frequencies
while certain procedures with relatively low work RVUs may have high
malpractice claim frequencies. We were unable to find an acceptable
alternative to work RVUs for determining risk-of-service and would
welcome any suggestions.
As mentioned above, certain specialties may have more than one IOS
rating class and risk factor. The surgical risk factor for a specialty
was used for surgical services and the non-surgical risk factor for
evaluation and management services. Also, for obstetrics/gynecology,
the lower gynecology risk factor was used for all codes except those
obviously surgical services, in which case the higher surgical risk
factor was used.
Certain codes have no physician work RVUs. The overwhelming
majority of these codes are the technical components (TCs) of
diagnostic tests, such as x-rays and cardiac catheterization, that have
a distinctly separate technical component (the taking of an x-ray by a
technician) and professional component (the interpretation of the x-ray
by a physician). Examples of other codes with no work RVUs are
audiology tests and injections and infusions. These codes are usually
done by nonphysicians, for example, audiologists and nurses,
respectively. In many cases, the non-physician or entity furnishing the
TC is distinct and separate from the physician ordering and
interpreting the test. We believe it appropriate for the malpractice
RVUs assigned to TCs to be based on the malpractice costs of the non-
physician or entity, not the professional liability of the physician.
Our proposed methodology, however, would result in zero malpractice
RVUs for codes with no physician work since we propose the use of
physician work RVUs to adjust for risk-of-service, as explained
earlier. We believe that zero malpractice RVUs may be inappropriate
because nonphysician health practitioners and entities such as IDTFs
also have malpractice liability and carry malpractice insurance.
Therefore, we are proposing to retain the current malpractice RVUs for
all services with zero work RVUs. We are open to comments and
suggestions for constructing malpractice RVUs for codes with no
physician work.
(4) Rescale for budget neutrality. The law requires that changes to
fee schedule RVUs be budget neutral. The current malpractice RVUs and
the proposed resource-based malpractice RVUs were constructed using
entirely different methodologies and data and are not directly related
to each other. Thus, the last step is to adjust for budget neutrality
by rescaling the proposed malpractice RVUs so that the total proposed
resource-based malpractice RVUs equals the total current malpractice
RVUs. The new resource-based malpractice RVUs for each procedure were
multiplied by the frequency count for that procedure to determine the
total resource-based malpractice RVUs for each procedure. This was
summed for all procedures to determine the total fee schedule resource-
based malpractice based RVUs. This was compared to the total current
charge-based malpractice RVUs, and the appropriate adjustment was made
to attain budget neutrality. The raw unadjusted resource-based
malpractice RVUs were multiplied by 0.0291 so that the conversion to
resource-based malpractice RVUs maintains the same level of
expenditures for the malpractice component.
The proposed resource-based malpractice RVUs are shown in Addendum
B. These values have been adjusted for budget neutrality on the basis
of the most recent available data. They do not reflect the final budget
neutrality adjustment, which we will make for the final rule on the
basis of more recent data. We do not believe, however, that the values
will change significantly as a result of the final budget-neutrality
adjustment.
Because of the differences in the sizes of the three fee schedule
components, implementation of the resource-based malpractice RVUs will
have much smaller payment effects than the previous implementations of
resource-based work RVUs and resource-based practice expense RVUs. On
average, work represents about 54.5 percent of payment for a procedure
under the fee schedule, practice expense about 42.3 percent, and
malpractice about 3.2 percent. Thus, a 20 percent change in practice
expense or work RVUs would yield a change in payment of about 8 to 11
percent. In contrast, a corresponding 20 percent change in malpractice
values would yield a change in payment of only about 0.6 percent. The
mean frequency-weighted current malpractice RVU is about 0.08 which
equates to about $2.78 in 1999. Estimates of the effects on payment by
specialty and selected high-volume procedures can be found in the
impact section of this rule.
We are requesting comments on our proposed methodology and
resource-based malpractice RVUs.
We are proposing to add a new Sec. 414.22(c)(3) (Relative value
units (RVUs)) to specify that, for services furnished in the year 2000
and subsequent years, the malpractice RVUs are based on the relative
malpractice insurance resources for each service.

B. Resource-Based Practice Expense Relative Value Units

1. Resource-Based Practice Expense Legislation
Section 121 of the Social Security Act Amendments of 1994 (Public
Law 103-432), enacted on October 31, 1994, requires us to develop a
methodology for a resource-based system for determining practice
expense RVUs for each physician's service beginning in 1998. In
developing the methodology, we must consider the staff, equipment, and
supplies used in providing medical and surgical services in various
settings.
The legislation specifically requires that, in implementing the new
system of practice expense RVUs, we must apply the same budget-
neutrality provisions that we apply to other adjustments under the
physician fee schedule.
The BBA was enacted on August 5, 1997, before publication of the
October 1997 (62 FR 59103) final rule. Section 4505(a) of the BBA
delayed the effective date of the resource-based practice expense RVUs
until January 1, 1999. In addition, the BBA provided for the following
revisions in the requirements to change from charge-based practice
expense RVUs to resource-based RVUs.
Instead of paying for all services entirely under a resource-based
RVU system in 1999, section 4505(b) of the BBA provided for a 4-year
transition period. The practice expense RVUs for the year 1999 will be
the sum of 75 percent of charge-based RVUs and 25 percent of the
resource-based RVUs. For the year 2000, the percentages will be 50
percent charge-based RVUs and 50 percent resource-based RVUs. For the
year 2001, the percentages will be 25 percent charge-based RVUs and 75
percent resource-based RVUs. For subsequent years, the RVUs will be
totally resource-based.
Section 4505(e) of the BBA provided that, in 1998, the practice
expense RVUs would be adjusted for certain services in anticipation of
the implementation of resource-based practice expenses

[[Page 39615]]

beginning in 1999. Thus, practice expense RVUs for office visits were
increased. For other services whose practice expense RVUs exceeded 110
percent of the work RVUs and which were furnished less than 75 percent
of the time in an office setting, the 1998 practice expense RVUs were
reduced to a number equal to 110 percent of the work RVUs. This
limitation did not apply to services that had proposed resource-based
practice expense RVUs in the June 18, 1997 proposed rule (62 FR 33196)
that increased from their 1997 practice expense RVUs. The procedure
codes affected and the final RVUs for 1998 were published in the
October 31, 1997 final rule (62 FR 59103).
Section 4505(d)(3) also required that a proposed rule be published
by May 1, 1998, with a 90-day comment period. A final rule was
published on November 2, 1998 and the transition began on January 1,
1999.
The BBA also required that we develop new resource-based practice
expense RVUs. In developing these new practice expense RVUs, section
4505(d)(1) required us to--(1) use, to the maximum extent practicable,
generally accepted accounting principles that recognize all staff,
equipment, supplies, and expenses, not just those that can be tied to
specific procedures, and use actual data on equipment use and other key
assumptions; (2) consult with organizations representing physicians
regarding the methodology and data to be used; and (3) develop a
refinement process to be used during each of the four years of the
transition period.
2. Current Methodology for Computing Practice Expense Relative Value
Units
Effective with services furnished after January 1, 1999, we
established a new methodology for computing resource-based practice
expense RVUs that uses the two significant sources of actual practice
expense data we have available--the Clinical Practice Expert Panel
(CPEP) data and the American Medical Association's (AMA's)
Socioeconomic Monitoring System (SMS) data. This methodology is based
on an assumption that current aggregate specialty practice costs are a
reasonable basis for establishing initial estimates of relative
resource costs of physicians' services across specialties. It then
allocates these aggregate specialty practice costs to specific
procedures and, thus, can be seen as a ``top-down'' approach. The
following summarizes the general methodology used. (For more specific
information refer to the June 5, 1998 proposed rule (63 FR 30826) and
the November 2, 1998 final rule with comment (63 FR 58816).)

Practice Expense Cost Pools

We used actual practice expense data by specialty, derived from the
1995 through 1997 SMS survey data, to create six cost pools:
administrative labor, clinical labor, medical supplies, medical
equipment, office supplies, and all other expenses. There were three
steps in the creation of the cost pools. They are as follows:
Step (1) We used the AMA's SMS survey of actual cost data to
determine practice expenses per hour by cost category. The practice
expense per hour for each physician respondent's practice was
calculated as the practice expenses for the practice divided by the
total number of hours spent in patient care activities by the
physicians in the practice. The practice expenses per hour for the
specialty are an average of the practice expenses per hour for the
respondent physicians in that specialty.
Step (2) We determined the total number of physician hours, by
specialty, spent treating Medicare patients. This was calculated from
physician time data for each procedure code and the Medicare claims
data. The primary sources for the physician time data were surveys
submitted to the AMA's RUC and surveys performed and developed by a
research team at the Harvard School of Public Health in a cooperative
agreement with us for the initial establishment of the work RVUs.
Step (3) We then calculated the practice expense pools by specialty
and by cost category by multiplying the practice expenses per hour for
each category by the total physician hours.
For services with work RVUs equal to zero (including the TC of
services with PC and TC), we created a separate practice expense pool
using the average clinical staff time from the CPEP data (since these
codes by definition do not have physician time), and the ``all
physicians'' practice expense per hour.

Cost Allocation Methodology

For each specialty, we separated the six practice expense pools
into two groups, direct costs and indirect costs, and used a different
allocation basis for each group.
<bullet> For direct costs, which include clinical labor, medical
supplies, and medical equipment, we used the CPEP data as the
allocation basis. The CPEP data for clinical labor, medical supplies,
and medical equipment were used to allocate the clinical labor, medical
supplies, and medical equipment cost pools, respectively.
For the separate practice expense pool for services with work RVUs
equal to zero, we are using, as an interim measure, 1998 practice
expense RVUs to allocate the direct cost pools (clinical labor, medical
supplies and medical equipment).
Also, for all radiology services that are assigned work RVUS, we
used the 1998 practice expense RVUs as an interim measure to allocate
the direct practice expense cost pool for the specialty of radiology.
For all other specialties that perform radiology services that are
assigned work RVUs, we used the CPEP data for radiology services in the
allocation of that specialty's direct practice expense cost pools.
<bullet> For indirect costs, which include administrative labor,
office expenses, and all other expenses, we used the total direct costs
or the 1998 practice expense RVUs, as described above, in combination
with the physician fee schedule work RVUs, to allocate the cost pools.
We converted the work RVUs to dollars using the Medicare CF (expressed
in 1995 dollars for consistency with the SMS survey years).
<bullet> For procedures performed by more than one specialty, the
final procedure code allocation was a weighted average of allocations
for the specialties that perform the procedure, with the weights being
the frequency with which each specialty performs the procedure on
Medicare patients.

Other Methodological Issues

<bullet> Global Practice Expense Relative Value Units.
For services with the PC and TC paid under the physician fee
schedule, the global practice expense RVUs are set equal to the sum of
the PC and TC.
<bullet> Practice Expenses per Hour Adjustments and Specialty
Crosswalks
Since many specialties identified in our claims data did not
correspond exactly to the specialties included in the practice expenses
tables from the SMS survey data, it was necessary to crosswalk these
specialties to the most appropriate SMS specialty category. We also
made the following adjustments to the practice expense per hour data
(For the rationale for these adjustments, see the November 2, 1998
proposed rule):
+ We set the medical materials and supplies practice expenses per
hour for the specialty of ``oncology'' equal to the ``all physician''
medical materials and supplies practice expenses per hour.
+ We based the administrative payroll, office, and other practice
expenses per hour for the specialties of ``physical therapy'' and
``occupational therapy'' on data used to develop the salary equivalency
guidelines for these

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[[Page 39616]]

specialties. We set the practice expense per hour for the direct cost
categories equal to the ``all physicians'' practice expense per hour
from the SMS survey data.
+ Due to uncertainty concerning the appropriate crosswalk and time
data for the nonphysician specialty ``audiologist,'' we derived the
resource-based practice expense RVUs for codes performed by
audiologists from the practice expenses per hour of the other
specialties that perform these codes.
+ For the specialty ``emergency medicine'' we used the ``all
physician'' practice expense per hour to create practice expense cost
pools for the categories ``clerical payroll'' and ``other expenses.''
+ For the specialty ``podiatry'' we used the ``all physician''
practice expenses per hour to create the practice expense pool.
+ For the specialty ``pathology'' we removed the supervision and
autopsy hours reimbursed through Part A of the Medicare program from
the practice expense per hour calculation.
+ For the specialty ``maxillofacial prosthetics'' we used the ``all
physician'' practice expenses per hour to create practice expense cost
pools and, as an interim measure, allocated these pools using the 1998
practice expense RVUs.
+ We split the specialty ``radiology'' practice expense per hour
into ``radiation oncology'' practice expense per hour and ``radiology
other than radiation oncology'' practice expense per hour and used this
split practice expense per hour to create practice expense cost pools
for these specialties.
+ Time Associated with the Work Relative Value Units.
The time data resulting from the refinement of the work RVUs have
been, on the average, 25 percent greater than the time data obtained by
the Harvard research team for the same services. We increased the
Harvard research team's time data to ensure consistency between these
data sources.
For services with no assigned physician times, such as dialysis,
physical therapy, psychology and many radiology and other diagnostic
services, we calculated estimated total physician times based on work
RVUs, maximum clinical staff time for each service as shown in the CPEP
data, or the judgment of our clinical staff.
We calculated the time for the anesthesia CPT codes 00100 through
01996 using the base and time units from the anesthesia fee schedule
and the Medicare allowed claims data.
3. Refinement

Background

Section 4505(d)(1)(C) of the BBA requires us to develop a

refinement process to be used during each of the four years of the

transition period. In the June 1998 proposed rule, (63 FR 30823), we
did not propose a specific long-term refinement process. Rather, we set
out the parameters for an acceptable refinement process for practice
expense RVUs and solicited comments on our proposed process. Most of
the approximately 14,000 comments we received on the proposed rule
approved of our general ``top down'' approach to the calculation of
practice expense RVUs. However, many concerns were raised regarding the
specific steps in our methodology, the practice expense per hour data,
and detailed code level data. In response to these comments, we made
adjustments for those situations in which we were convinced an
adjustment was appropriate without the need for further data or input
(see the November 2, 1998 (63 FR 58818) final rule). We also indicated
that we would consider other comments for possible future refinement
and that RVUs for all codes would be considered interim for 1999 and
for future years during the transition period.
As part of the initial refinement process, in the November 2, 1998
final rule, page 58818, we outlined the steps we are undertaking to
resolve the outstanding general methodological issues. These steps
include--the establishment of a mechanism to receive additional
technical advice for dealing with these broad practice expense RVU
methodological issues; evaluation of any additional recommendations
from the GAO, MEDPAC, and the Practicing Physicians Advisory Council;
and consultation with physicians' and other groups about these issues.
In addition, we solicited comments and suggestions about methodology
from organizations that have a broad range of interest and expertise in
practice expense and survey issues. We especially encouraged
organizations that represent a broad range of physician, practitioner,
and provider groups (for example, groups that represent both
specialties receiving increases and those receiving decreases in
Medicare payments) with expertise in practice cost issues to make
specific recommendations regarding such issues as criteria for using
alternative survey data, methods for validating data collected in the
future, and possible alternatives for the allocation of indirect
expenses.
We also discussed a proposal submitted by the RUC, which was
supported by almost every medical specialty society, for the
establishment of a Practice Expense Advisory Committee (PEAC), to
review comments and make recommendations on the code-specific CPEP data
(that is, the clinical staff types and times, medical supplies, and
medical equipment needed for each procedure) during this refinement
period. This committee would report to the RUC, which would make final
recommendations to us.
Current Status of Refinement Activities
As stated above, one of our main strategies for resolving the
outstanding practice expense methodological issues was to seek a
mechanism for obtaining expert advice and technical support. To this
end we have awarded a contract beginning in May 1999 to obtain this
assistance in evaluating various aspects of our practice expense
methodology. As also discussed above, the RUC, through the PEAC, will
give us recommendations on the refinement of procedure-specific inputs.
The PEAC held its organizing meeting in February 1999 and met again in
April to begin the task of refining the code-specific CPEP data.
We believe that the awarding of the methodological support contract
and the establishment of the PEAC represent important steps in our
refinement process. However, at this time, our contractor has just
begun the task of assisting us with the major methodological issues
that we face in refining the resource-based practice expense RVUs. In
addition, the PEAC's recommendations on changes to the code-level
inputs have not yet been forwarded by the RUC. Therefore, we are able
to propose only a few changes in our practice expense methodology or in
the code-specific inputs in this proposed rule. However, we will
consider additional changes for the final rule, based on any
recommendations we receive from the RUC or PEAC or other commenters.
These changes, if accepted, would be established as interim values and
would be effective January 1, 2000. The following discusses more
specifically the status of refinement activities and the specific
changes we are proposing for the various aspects of our practice
expense methodology.

Top-Down Methodology

As we have already discussed, we now have a contractor to assist us
in refining our practice expense methodology. This support will help us
to pinpoint weaknesses in our top-down methodology and will also aid us
in generating alternative solutions to the identified problems. Among
the

[[Page 39617]]

activities we have requested the contractor to undertake are:
<bullet> The evaluation of the validity and reliability of SMS data
for the specialty and subspecialty groups.
<bullet> The identification and evaluation of alternative and
supplementary data sources from specialty and multi-specialty
societies.
<bullet> The development of options for validating the Harvard and
RUC physician procedure time data.
<bullet> The evaluation of the indirect cost allocation
methodology.
<bullet> The development of options for the five-year review of
practice expense RVUs.
We intend to keep the medical community informed about all of these
activities and to seek their input.

SMS Data

Background

We received comments from a large number of medical specialty
societies, both on our June 1998 proposed rule and our November 2, 1998
final rule, which expressed concern that their specialty or
subspecialty was not adequately represented in the SMS survey data used
to compute their practice expense per hour. In addition, several
specialties, primarily nonphysician groups, were not included in the
SMS data, making it necessary for us to crosswalk their practice
expense per hour to an included specialty. A large number of these
specialties either have submitted supplementary data or have expressed
a desire to collect new data that they believe would more accurately
reflect the practice expense per hour for their specialty.
While we appreciate the effort that these organizations have
expended or are willing to expend, we are not yet in a position to use
this supplementary or new data in our practice expense calculations. It
is important to understand that, given the budget neutrality
restrictions under which we are working, any increase in one
specialty's practice expense pool will lead to a decrease for other
specialties. Therefore, until we have developed reliable and
standardized criteria for accepting and validating additional
specialty-specific data, it would be inequitable to make any
significant changes based on these data.
We recognize that this delay in indicating what additional data
would be acceptable might be frustrating to those groups that believe
that the SMS data does not accurately account for all of their costs.
For that reason, we are ensuring that a priority of the technical
contractor discussed above is to determine (1) the circumstances, if
any, under which we should consider use of survey data other than the
SMS data; (2) the appropriate form of these surveys; and (3) how these
surveys or future SMS surveys can be appropriately validated for our
use. We hope to be in a position to discuss this in more detail in the
final rule to be published this fall.
Adjustment to Direct Patient Care Hours for Pathology
In the November 1998 final rule, we made adjustments to the direct
patient care hours for pathologists to account for the fact that the
time spent performing autopsies and supervising technicians are Part A
services. The pathologists, supported by the AMA, also requested that
we eliminate some of the time for ``personally performing nonsurgical
laboratory procedures including reports'' because this time also
includes some Part A services. We did not make this latter adjustment
in the final rule because we did not have the data on what precise
adjustment to make. We now have information to propose this adjustment
as well. The SMS survey shows that pathologists reported 6.77 hours per
week in personally performing nonsurgical laboratory procedures
including time writing reports. The College of American Pathologists
recommended that 45 percent of the 6.77 hours, which represents three
hours, be removed from total patient care hours. The pathologists argue
that they are providing specific services to attending physicians, but
we will not allow separate payment because the attending physician does
not request a consultation. This problem is unique to this specialty
and, as this change will have no discernible negative impact on any
other specialty, we are proposing to remove these three hours from the
total patient care hours for pathologists.

CPEP Data

RUC Recommendations
As we stated above, the PEAC is beginning to review the procedure-
specific CPEP inputs. Because most major physician specialties are
represented on the PEAC and they will determine which codes are
discussed at each meeting, we plan to wait until we receive
recommendations from the RUC before making significant changes to most
code-specific inputs. However, there are a number of egregious errors
or anomalies that were pointed out in the public comments we received
on the June 1998 proposed rule and the November 1998 final rule that we
intend to address in the final rule this fall.

Physicians' Clinical Staff in the Facility Setting

In some of the original CPEP panels and in subsequent meetings,
various specialties have argued that the physician's own clinical staff
performs certain services for a hospital patient. In our initial
``bottom-up'' practice expense proposal in the June 1997 proposed rule,
we edited out all of the clinical staff time in the facility setting.
It was our contention then, and still is now, that Medicare already
pays for services performed for a facility patient through some other
mechanism, that these services are not typically performed by a
physician's own staff and that recognizing these inputs is arguably
inconsistent with the law and with our regulations. However, in our
1998 ``top-down'' proposal we used the raw CPEP inputs without applying
edits to any of the data, and the clinical staff time in the facility
setting was therefore included.
We are proposing to exclude from the raw CPEP data all staff time
allotted to the use of clinical staff in the facility setting. This
CPEP data is used in our methodology solely to allocate the specialty-
specific practice expense pools to the individual codes. We would not
make an adjustment to the SMS data because we cannot separately
identify the costs related to physicians' clinical staff time in
hospitals and we do not believe that these costs are typically
incurred. We propose to make this adjustment now before extensive
refinement efforts are undertaken. We are also soliciting comments,
information and data regarding situations where the recognition of
costs associated with the use of a physician's clinical staff in a
facility would be appropriate. We will consider these responses for the
final rule.
There are several arguments to be made for excluding the costs of
clinical staff in the facility setting from the raw CPEP data used in
calculating the practice expense payment for any service:
1. Medicare should not pay twice for the same service.
Many specialties argue that their clinical staff performs various
duties for the hospital patient, examples of which are presented below;
all these and other facility clinical staff services are already paid
for by Medicare through a mechanism other than physician practice
expense.

--Assistant at Surgery--Medicare will make a separate payment for a
physician assistant, nurse practitioner or clinical nurse specialist
acting as assistant at surgery. Therefore, their

[[Page 39618]]

time cannot also be counted as a practice expense input in the CPEP
data.
--Scrub Nurse--Medicare already pays the hospital for all nursing
services provided to a hospital patient, including scrub nurse
services, either through the DRG payment or on a cost basis.
--Monitoring Patients Undergoing Conscious Sedation--In order to meet
accreditation standards, all hospitals must already have staff
available to monitor these patients. Medicare pays the hospital for
this service or makes separate payment for a certified registered nurse
anesthetist. To include staff time in the CPEP data for this service
would result in a duplicate payment.
--Reviewing Charts, Making Patient Rounds, Pulling Chest Tubes--These
activities are physicians' services that are paid for through the
physician work RVUs. Physicians may choose to delegate some of their
work to their clinical staff. However, unless the work RVUs are
commensurately reduced, it would be inappropriate to also include this
staff time in the practice expense calculations.
--Making Phone Calls from the Physician's Office--Phone calls
concerning the patient made to the family or the facility are
considered an administrative cost. The staff time for these services is
paid for under our indirect practice expense allocation.

Unless we were to reduce the DRG payment made to hospitals or the
work RVUs used to determine physician payment, the inclusion of the
costs of any of this clinical staff time in the calculation of
procedure-specific practice expenses would essentially lead to a
duplication of Medicare payment. We welcome comments from hospitals,
physicians, and others on this issue.
2. It is not a typical practice for most specialties to use their
own staff in the facility setting.
While physician practice patterns may vary by specialty, by
practice size and configuration and by individual practitioner, we pay
only one rate, with the exception of a geographic adjuster, for a given
site for any specific service. Therefore, the CPEP inputs for each
service cannot reflect all variations in practice patterns, but are
rather meant to represent the clinical staff times, supplies, and
equipment that are used for the typical patient receiving that service.
We have not seen sufficient data to convince us that the use of the
physician's clinical staff in the facility setting is a typical
practice. The American Hospital Association performed a survey of a
sample of their members which indicated that this practice occurred
only occasionally. Because we do not believe that physicians typically
incur costs for bringing their staff into the facility setting, the
aggregate SMS data should contain few costs for such services.
Therefore, we are not proposing to eliminate any clinical staff
expenses from the surgical specialties' aggregate SMS practice expense
data.
3. Inclusion of these costs is arguably inconsistent with both the
law and Medicare regulations.

--Section 1862(a)(14) of the Act, which discusses exclusions from
coverage, states that,

``Notwithstanding any other provision of this title, no payment may
be made under part A or part B * * * for any expenses incurred for
items or services which are other than physicians' services (as defined
in regulations promulgated specifically for purposes of this paragraph)
* * * and which are furnished to an individual who is a patient of a
hospital * * * by an entity other than the hospital * * * unless the
services are furnished under arrangements. * * *''

(This section also exempts services of physician assistants, nurse
practitioners, clinical nurse specialists, certified nurse-midwife
services, qualified psychologist services, and services of certified
registered nurse anesthetists from the above exclusion.)

--In Sec. 411.15, (Particular Services Excluded from Coverage)
subparagraph (m)(1), we paraphrase the above provision for hospital
inpatients and add that ``services subject to exclusion under this
paragraph include * * * services incident to physicians' services.''
Section 411.15(m)(2) implements the exceptions to this exclusion, among
them ``physician services that meet the criteria of Sec. 415.102(a) of
this chapter for payment on a reasonable charge or fee schedule
basis.''
--Section 415.102(a) contains the definition of physicians' services
required by section 1862(a)(14) of the Act and the criteria referred to
in Sec. 411.15(m) above: ``If the physician furnishes services to
beneficiaries in providers, the carrier pays on a fee schedule basis
provided the following requirements are met: (1) The services are
personally furnished for an individual beneficiary by a physician. (2)
The services contribute directly to the diagnosis or treatment of an
individual beneficiary. (3) The services ordinarily require performance
by a physician.''
--On September 8, 1998, we published a proposed rule on a prospective
payment system for hospital outpatient services (63 FR 47552). This
rule proposes to add Sec. 410.39 which embodies in regulation for the
hospital outpatient setting the exclusion in Sec. 411.15 described
above. Section 410.39(c) would exempt from the exclusion physicians'
services that meet the requirements of Sec. 415.102(a) as described
above, physician assistant, nurse practitioner, clinical nurse
specialist, certified nurse midwife, and qualified psychologist
services, as well as services of an anesthetist.

A reading of all of the above suggests that no payment should be
made under the physician fee schedule for the costs of physicians'
clinical staff used in the hospital setting. Services performed by non-
physician clinical staff do not fulfill the definition of services
personally furnished by a physician, and, therefore, the exception to
the exclusion created by section 1862(a)(14) of the Act does not apply.
In addition, nursing services, such as those performed by a scrub nurse
working for a physician, do not ordinarily require performance by a
physician and, thus, are not physicians' services for the purpose of
section 1862(a)(14) of the Act. Finally, services ``incident to a
physician's service'' are explicitly excluded from coverage in the
hospital setting by Sec. 411.15(m)(1).
Table 5, ``Impact on Total Allowed Charges by Specialty of
Excluding the Cost of Clinical Staff in the Facility Setting,'' shows
the impact of the proposed changes on each major specialty's total
allowed charges. As can be seen from this table, anesthesia and cardiac
surgery face a decrease of 8 percent over the transition period, while
thoracic surgery has a decrease of 6 percent over the same period. No
other specialty has a decrease of more than 2 percent. The increases
are spread throughout the specialties, with rheumatology standing to
gain the most with a 5 percent increase, followed by orthopedic
surgery, obstetrics and gynecology and podiatry each with a 3 percent
increase.
It is not surprising that the practice expenses for cardiac and
thoracic surgery and anesthesiology would decrease if clinical staff in
the facility is excluded given the clinical staff time in the CPEP
data. The raw CPEP data for the cardiac and thoracic codes contain up
to 57 hours of clinical staff time in the hospital for a given
procedure. For example, the total facility clinical staff

[[Page 39619]]

time of 24 hours for CPT code 33771 (repair of great vessels defect)
includes nearly seven hours for a physician assistant to act as
assistant at surgery, which can be billed separately, and over six
hours for a scrub nurse that we pay the hospital to provide.
The anesthesia CPEP panel also added inputs of up to 195 minutes
clinical staff time per procedure in the facility setting, which is
particularly inexplicable for such a hospital-based specialty. This
time is divided between a registered nurse, physician assistant, and an
anesthesia technician. It is in no way clear for what purposes an
anesthesiologist would employ a nurse or a physician assistant, but in
any case we pay the hospital for all nursing care and we make separate
payment for a physician assistant.
We welcome comments on this entire issue and particularly solicit
information about any possible appropriate use of physicians' clinical
staff in the facility setting that we should consider for our final
rule.

Table 5.--Impact on Total Allowed Charges by Specialty of Excluding the
Cost of Clinical Staff in the Facility Setting
------------------------------------------------------------------------
Impact on
total
Specialty payments
(percent)
------------------------------------------------------------------------
ANESTHESIOLOGY............................................. -8
CARDIAC SURGERY............................................ -8
CARDIOLOGY................................................. -2
CLINICS.................................................... -1
DERMATOLOGY................................................ 2
EMERGENCY MEDICINE......................................... -1
FAMILY PRACTICE............................................ 2
GASTROENEROLOGY............................................ -2
GENERAL PRACTICE........................................... 2
GENERAL SURGERY............................................ 0
HEMATOLOGY ONCOLOGY........................................ 1
INTERNAL MEDICINE.......................................... 0
NEPHROLOGY................................................. 0
NEUROLOGY.................................................. 1
NEUROSURGERY............................................... 1
OBSTETRICS/GYNECOLOGY...................................... 3
OPHTHALMOLOGY.............................................. 1
ORTHOPEDIC SURGERY......................................... 3
OTHER PHYSICIAN............................................ 0
OTOLARYNGOLOGY............................................. 2
PATHOLOGY.................................................. 0
PLASTIC SURGERY............................................ 1
PSYCHIATRY................................................. -1
PULMONARY.................................................. -2
RADIATION ONCOLOGY......................................... 0
RADIOLOGY.................................................. 0
RHEUMATOLOGY............................................... 5
THORACIC SURGERY........................................... -6
UROLOGY.................................................... 2
VASCULAR SURGERY........................................... 0
OTHERS
CHIROPRACTOR............................................... 0
NONPHYSICIAN PRACTITIONER.................................. 0
OPTOMETRIST................................................ 2
PODIATRY................................................... 3
SUPPLIERS.................................................. 0
------------------------------------------------------------------------

Physician Time

Background

Under the ``top down'' methodology we are using to calculate the
resource-based practice expense for physicians' services, the physician
time attributed to each service has now become a significant factor in
determining the RVUs assigned to that service. Therefore, it is vital
that there is confidence in the accuracy of these times. As we
discussed above, we have a contract to assist us in resolving many of
the outstanding methodological issues we face in refining our ``top
down'' approach. One of the tasks this contractor will undertake is to
develop options for validating the 1992 Harvard research team study and
the AMA/RUC physician time data.
Pediatric Surgery Physician Time Data
In its comments on the June 1998 proposed rule, the American
College of Surgeons stated that the physician time assigned to
pediatric surgery codes was based on erroneously low physician time
data from the original Harvard study, rather than on later data from
the study of pediatric services performed by the same Harvard study
team for the American Pediatric Surgical Association in 1992. The
comment further stated that the latter data were used as the basis for
the work RVUs assigned to these 48 pediatric surgical services. We
responded in the final rule that such inaccuracies in the physician
time data would be considered during the refinement process. We are
currently analyzing the data needed to make the appropriate corrections
and will update the physician times for these 48 pediatric surgical
services in the final rule.
Physical Therapy and Occupational Therapy Times
In the November 1998 final rule we did not use the RUC physician
time data for the physical therapy codes (CPT 97001 through 97770) as
we believed these times to be inaccurate. Instead, we set the time for
these procedures using the judgment of our clinical staff. In its
comments on the final rule, the American Physical Therapy Association
(APTA) stated that the times that we used were too low because it
appeared that we used only intra-service time. The American
Occupational Therapy Association, in its comments on the proposed rule,
also objected to our reduction in times for outpatient rehabilitation
codes. While APTA conceded that the RUC survey data on the times for
these services could cause confusion, APTA also argued that we should
recognize some preservice and postservice times for physical therapy
services. APTA made specific recommendations that included such
preservice and postservice times, while acknowledging that, because
multiple procedures are often performed at the same session, there
could be overlap in these times. We agree that it is appropriate to
include some preservice and postservice times for these procedures and
have adjusted the total code-specific times used to create the practice
expense pools as shown in Table 6, ``Revised Times for CPT codes 97001
through 97770.''

Table 6.--Revised Times for CPT Codes 97001 Through 97770
------------------------------------------------------------------------
Total time
used for
HCFA 11/2/ Revised
HCPCS 98 final time
rule (minutes)
(minutes)
------------------------------------------------------------------------
97001......................................... 30 42
97002......................................... 20 25
97003......................................... 45 57
97004......................................... 30 35
97010......................................... 5 5
97012......................................... 15 15
97014......................................... 13 13
97016......................................... 18 18
97018......................................... 13 13
97020......................................... 14 14
97022......................................... 15 15
97024......................................... 15 15
97026......................................... 10 10
97028......................................... 9 9
97032......................................... 18 18
97033......................................... 14 14
97034......................................... 16 16
97035......................................... 12 12
97036......................................... 15 15
97110......................................... 15 18
97112......................................... 15 18
97113......................................... 15 18
97122......................................... 15 18
97124......................................... 15 18
97250......................................... 15 18
97261......................................... 15 18
97265......................................... 15 18
97504......................................... 15 18
97520......................................... 15 18
97530......................................... 15 18
97535......................................... 15 18
97537......................................... 15 18
97542......................................... 15 18

[[Page 39620]]

97750......................................... 15 18
97703......................................... 15 18
97770......................................... 15 18
------------------------------------------------------------------------

RUC Time Database
The primary sources for the physician time data used in creating
the specialty-specific practice expense pools are the surveys done for
the initial establishment of the work RVUs and the surveys submitted to
the AMA's RUC. We have been informed by the AMA that some of the RUC
times we used for the November 1998 final rule differed from the times
found in the official RUC database. The AMA also conveyed to us that
the RUC is currently verifying their database with the relevant
specialties and plans to send it to us in time for its use in the final
rule.

Crosswalk Issues

Physical and Occupational Therapy Indirect Costs
We currently crosswalk physical and occupational therapy services
to the ``all physician'' practice expense per hour for direct costs.
However, for indirect costs we believed that the crosswalk to ``all
physicians'' would overstate the actual practice expense for therapy
services. Instead we used the data used to develop the therapy salary
equivalency guidelines to create the practice expense per hour for
these costs. These guidelines, which were developed for therapists
working under contract for a facility, assume a required space of 250
square feet per therapist. Organizations representing both physical and
occupational therapists objected that this estimate of 250 square feet
was insufficient to reflect expenses for therapists in private
practice. After further consideration of these comments and after
consultation with industry representatives, we agree that these space
requirements may not be representative of the actual space needed by
independent therapists. Based on our analysis of the available data, we
have increased the space requirements to 500 square feet.
Vascular Surgery
The SMS survey sample of 10 vascular surgeons is too small for us
to calculate accurately a practice expense per hour for this specialty.
In the 1998 proposed and final rules, we combined their data with that
of the cardiac and thoracic surgeons to create a combined practice
expense pool for all three specialties. The Society for Vascular
Surgery commented that this crosswalk understated the actual practice
expense for their specialty because vascular surgery services generally
involved patients with more co-morbidities, included more evaluation
and management services and thus were more office-based. We agree that
the current crosswalk might not appropriately approximate the
specialty's costs, and we are proposing to change vascular surgery's
crosswalk to the ``all physician'' practice expense per hour.
Calculation of Practice Expense Pools--Other Issues
In the November 2, 1998 final rule, in response to the many
commenters that objected to the reductions published in the June 5,
1998 proposed rule for services with no work RVUS, we created, as an
interim solution, a separate practice expense pool for all services
with zero work RVUs. We used the ``all physicians'' category for the
practice expense per hour for this pool and, instead of allocating this
pool by the CPEP data, we used the 1998 RVUs as the allocator.
This was of benefit to most of the services included in this
expense pool, but some specialties, such as sleep medicine, neurology,
ophthalmology, and pathology that had not commented on problems with
their services with no work RVUs were negatively affected by this
methodological change relative to the June 5, 1998 proposal. We have
subsequently received comments from societies for these specialties
requesting that these services be taken out of this special pool and be
treated like the vast majority of codes. As many of these services are
provided by other specialties as well and such a change could have an
impact across specialties, we are seeking comments both on such an
adjustment in general and on specific services that should either be
included or excluded from the adjustment. However, if we do remove
codes from the zero work RVU pool in our final rule, we plan to do it
in a uniform manner across families or categories of codes, instead of
allowing individual services to be placed in or out of the ``zero work
RVU'' practice expense pool depending on which method yields the
highest RVUs.
Table 7, ``Approximate Additional Changes in the Practice Expense
RVUs for Codes That Might Be Removed from the Zero Work Pool,'' shows
the list of codes that we are considering removing from the ``zero work
RVU'' pool, and Table 8, ``Additional Impact on Total Allowed Charges
by Specialty of Removing Selected Codes from the Zero Work Pool,''
shows the impact of this change by specialty.

Table 7.--Approximate Additional Changes in Practice Expense RVUs for Codes That Might Be Removed From the ``Zero-Work'' Pool
--------------------------------------------------------------------------------------------------------------------------------------------------------
Approx. change in non- Approx. change in
HCPCS MOD Description facility practice facility practice
expense RVUs expense RVUs
--------------------------------------------------------------------------------------------------------------------------------------------------------
88104......................................... TC Cytopathology, fluids........... 0.52 0.52
88106......................................... TC Cytopathology, fluids........... 0.28 0.28
88107......................................... TC Cytopathology, fluids........... 0.09 0.09
88108......................................... TC Cytopath, concentrate tech...... 0.42 0.42
88125......................................... TC Forensic cytopathology.......... 0.08 0.08
88160......................................... TC Cytopath smear, other source.... 0.92 0.92
88161......................................... TC Cytopath smear, other source.... 0.25 0.25
88162......................................... TC Cytopath smear, other source.... 0.21 0.21
88170......................................... TC Fine needle aspiration.......... -0.11 -0.11
88171......................................... TC Fine needle aspiration.......... -0.44 -0.44
88172......................................... TC Evaluation of smear............. 0.44 0.44
88173......................................... TC Interpretation of smear......... 0.57 0.57
88180......................................... TC Cell market study............... 0.41 0.41
88182......................................... TC Cell market study............... 0.86 0.86

[[Page 39621]]

88300......................................... TC Surg path, gross................ 0.3 0.3
88302......................................... TC Tissue exam by pathologist...... 0.71 0.71
88304......................................... TC Tissue exam by pathologist...... 0.5 0.5
88305......................................... TC Tissue exam by pathologist...... 0.69 0.69
88307......................................... TC Tissue exam by pathologist...... 1.2 1.2
88309......................................... TC Tissue exam by pathologist...... 1.85 1.85
88311......................................... TC Decalcify tissue................ -0.01 -0.01
88312......................................... TC Special stains.................. 1.3 1.3
88313......................................... TC Special stains.................. 1 1
88314......................................... TC Histochemical stain............. 0.5 0.5
88318......................................... TC Chemical histochemistry......... 0.43 0.43
88319......................................... TC Enzyme histochemistry........... 0.93 0.93
88323......................................... TC Microslide consultation......... 0.58 0.58
88331......................................... TC Pathology consult in surgery.... -0.18 -0.18
88332......................................... TC Pathology consult in surgery.... -0.15 -0.15
88342......................................... TC Immunocytochemistry............. 0.98 0.98
88346......................................... TC Immunofluorescent study......... 1.09 1.09
88347......................................... TC Immunofluorescent study......... 1.06 1.06
88348......................................... TC Electron microscopy............. 3.87 3.87
88349......................................... TC Scanning electron microscopy.... 4.43 4.43
88355......................................... TC Analysis, skeletal muscle....... 1.46 1.46
88356......................................... TC Analysis, nerve................. 0.46 0.46
88358......................................... TC Analysis, tumor................. 0.67 0.67
88362......................................... TC Nerve teasing preparations...... 0.3 0.3
88365......................................... TC Tissue hybridization............ 1.21 1.21
92060......................................... TC Special eye evaluation.......... 1.13 1.13
92065......................................... TC Orthoptic/pleoptic training..... 0.67 0.67
92081......................................... TC Visual field examination(s)..... 0.6 0.6
92082......................................... TC Visual field examination(s)..... 0.74 0.74
92083......................................... TC Visual field examination(s)..... 0.96 0.96
92135......................................... TC Opthalmic dx imagining.......... 0.96 0.96
92235......................................... TC Eye exam with photos............ 1.44 1.44
92240......................................... TC Icg angiography................. 1.44 1.44
92250......................................... TC Eye exam with photos............ 1.17 1.17
92265......................................... TC Eye muscle evaluation........... 0.29 0.29
92270......................................... TC Electro-oculography............. 0.61 0.61
92275......................................... TC Electroretinography............. -0.23 -0.23
92283......................................... TC Color vision examination........ 0.05 0.05
92284......................................... TC Dark adaptation eye exam........ 0.57 0.57
92285......................................... TC Eye photography................. 1.41 1.41
92286......................................... TC Internal eye photography........ 1.02 1.02
92325......................................... ........................ Modification of contact lens.... -0.08 -0.28
92326......................................... ........................ Replacement of contact lens..... -1.4 -1.58
92354......................................... ........................ Special spectacles fitting...... -8.78 -9.09
92355......................................... ........................ Special spectacles fitting...... -4.05 -4.36
92358......................................... ........................ Eye prosthesis serive........... -0.72 -0.91
92371......................................... ........................ Repair & adjust spectacles...... -0.36 -0.54
92392......................................... ........................ Supply of low vision aids....... -3.94 -4.13
92393......................................... ........................ Supply of artificial eye........ -12.84 -13.02
92395......................................... ........................ Supply of spectacles............ -1.16 -1.34
92396......................................... ........................ Supply of contact lenses........ -2.12 -2.3
93307......................................... TC Echo exam of heart.............. -2.9 -2.9
93350......................................... TC Echo transthoracic.............. 4.55 4.55
95805......................................... TC Multiple sleep latency test..... -0.56 -0.56
95806......................................... TC Sleep study, unattended......... -3.07 -3.07
95807......................................... TC Sleep study, attended........... -0.04 -0.04
95808......................................... TC Polysomnograph, 1-3............. 5.62 5.62
95810......................................... TC Polysomnography, 4 or more...... 5.9 5.9
95811......................................... TC Polysomnography w/cpap.......... 5.54 5.54
95812......................................... TC Electroencephalogram (EEG)...... 0.84 0.84
95813......................................... TC Electroencephalogram (EEG)...... 0.55 0.55
95816......................................... TC Electroencephalogram (EEG)...... 0.85 0.85
95819......................................... TC Electroencephalogram (EEG)...... 1.04 1.04
95822......................................... TC Sleep electroencephalogram...... -0.62 -0.62
95824......................................... TC Electroencephalography.......... -0.38 -0.38
95829......................................... TC Surgery electrocorticogram...... 3.41 3.41
95875......................................... TC Limb exercise test.............. -0.02 -0.02
95923......................................... TC Autonomic nervous func test..... 0.93 0.93
95930......................................... TC Visual evoked potential test.... 0.21 0.21

[[Page 39622]]

95950......................................... TC Ambulatory eeg monitoring....... -3.35 -3.35
95951......................................... TC EEG monitoring/videorecord...... 22.62 22.62
95954......................................... TC EEG monitoring/giving drugs..... 1.7 1.7
95956......................................... TC EEG monitoring/cable/radio...... 13.85 13.85
--------------------------------------------------------------------------------------------------------------------------------------------------------

Table 8.--Additional Impact on Total Allowed Charges by Specialty of
Removing Selected Codes From the ``Zero Work'' Pool
------------------------------------------------------------------------
Impact on
Specialty total payments
(percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................................... 0
CARDIAC SURGERY......................................... 0
CARDIOLOGY.............................................. -2
CLINICS................................................. 0
DERMATOLOGY............................................. 2
EMERGENCY MEDICINE...................................... 0
FAMILY PRACTICE......................................... 0
GASTROENTEROLOGY........................................ 0
GENERAL PRACTICE........................................ -1
GENERAL SURGERY......................................... 0
HEMATOLOGY ONCOLOGY..................................... -1
INTERNAL MEDICINE....................................... -1
NEPHROLOGY.............................................. 0
NEUROLOGY............................................... 0
NEUROSURGERY............................................ 0
OBSTETRICS/GYNECOLOGY................................... 0
OPHTHALMOLOGY........................................... 3
ORTHOPEDIC SURGERY...................................... 0
OTHER PHYSICIAN......................................... 0
OTOLARYNGOLOGY.......................................... -1
PATHOLOGY............................................... 8
PLASTIC SURGERY......................................... 0
PSYCHIATRY.............................................. 0
PULMONARY............................................... 0
RADIATION ONCOLOGY...................................... -2
RADIOLOGY............................................... -1
RHEUMATOLOGY............................................ -1
THORACIC SURGERY........................................ 0
UROLOGY................................................. 0
VASCULAR SURGERY........................................ -1
OTHERS:
CHIROPRACTOR........................................ 0
NONPHYSICIAN PRACTITIONER........................... 0
OPTOMETRIST......................................... 3
PODIATRY............................................ 0
SUPPLIERS........................................... 16
------------------------------------------------------------------------

Site-of-Service Differential

Clarification of Site-of-Service Policy
We wish to clarify the circumstances under which either the non-
facility or facility RVUs are used to calculate payment for a service.
In the November 2, 1998 final rule, we defined hospitals, skilled
nursing facilities (SNFs), and ambulatory surgical centers (ASCs) as
facilities for practice expense purposes. For the purposes of the
physician practice expense calculation, all other sites-of-service are
considered non-facility. The distinction between the non-facility and
facility setting takes into account the higher expenses of the
practitioner in the non-facility setting, where the practitioner
typically bears the cost of the resources--clinical staff, supplies,
and equipment--associated with the service.
The major purpose of the site-of-service distinction is to ensure
that Medicare does not make a duplicate payment for any of the practice
expenses incurred in performing a service for a Medicare patient. When
the beneficiary is a hospital, SNF, or ASC patient, the facility itself
is paid for the clinical staff, supplies, and equipment needed to take
care of that patient, and the lower facility rate should be paid to the
practitioner. Therefore, if the patient is a facility patient or a
facility will bill for the service, the practitioner must bill using
the facility site-of-service designation. We are modifying the language
in Sec. 414.22(b)(5)(i) in order to clarify this policy. There are also
three further clarifications that need to be made with respect to this
policy.
(1) When a procedure is performed in an ASC that is not on the
Medicare approved list of ASC procedures, we do

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not make a facility payment to the ASC. In this situation, the ASC is
considered a physician's office and the non-facility RVUs would be
used.
(2) Because of the hospital bundling requirement, only the hospital
can bill for therapy services provided to hospital patients. In
addition, through PM-AB-98-63, ``Prospective Payment System for
Outpatient Rehabilitation Services and Application of Financial
Limitations,'' dated October 1998 and our final rule of November 2,
1998, we advised our fiscal intermediaries to require SNFs to bill
Medicare directly for all outpatient therapy services provided to their
SNF residents in a noncovered Part A stay and to their nonresidents
covered under Part B. Because only the facility can bill for therapy
services provided to hospital and SNF patients, the payment for the
full practice expense must be reflected in the facility payment.
Therefore, the higher non-facility RVUs are used to pay for therapy
services even in the facility setting.
(3) While a SNF is considered a facility, a nursing home is not.
Many are mixed facilities with a combination of nursing home and SNF
patients. Practitioners, such as podiatrists, have commented that it is
not always easy to determine into which category the patient falls. We
are clarifying our policy to state that practitioners, such as
podiatrists, should designate their service as a facility service,
unless they verify that no Part A claim will be made for the service,
in which case the ``non-facility'' designation can be used. However, we
note that there might be lower per patient costs in a mixed facility or
a nursing home setting, where multiple patients can be seen in a single
visit to the site, than in the office setting. We welcome comments on
ways to examine the relative costs of treating patients in these
different settings, so that we can determine whether an adjustment to
certain non-facility practice expense payments is appropriate.
Limitation on Facility RVUs
The non-facility RVUs would be expected to be higher than the
facility RVUs for a given service, because the practitioner bears the
costs of the necessary clinical staff, supplies, and equipment. Because
of anomalies in our calculations, generally due to the different mix of
specialties delivering the service in the two settings, for some codes
the facility RVUs are higher than the non-facility RVUs. We are
proposing to limit the facility rate so that it cannot be higher than
the non-facility rate for any given code. Because of budget neutrality,
any decrease in the facility RVUs will be offset by a corresponding
increase in RVUs spread throughout the physician fee schedule. This
change has negligible impact on any specialty.

C. Practice Expense Relative Value Units for a Physician's
Interpretation of Abnormal Papanicolaou Smears

In the November 1998 final rule (63 FR 58814), we revised the codes
for a physician's interpretation of an abnormal Papanicolaou (Pap)
smear to include three HCPCS level II codes (P3001, G0124, and G0141)
in addition to the CPT code 88141. We included the HCPCS level II codes
to accommodate differences in Pap smear technology. We evaluated the
practice expense RVUs for each of these three codes in a slightly
different manner for the 1999 physician fee schedule. We now believe
that it would be more appropriate to evaluate the work, practice
expense, and malpractice RVUs for these codes identically and
comparable to the values for CPT code 88141. We are proposing to make
the practice expense RVUs identical for these codes since there are no
significant differences between them.

D. Physician Pathology Services and Independent Laboratories

Physician pathology services consist of a technical component and a
professional component. The technical component refers to the slide
preparation, staining, and other duties performed by the laboratory
technologist. The professional component refers to the physician's
interpretation.
A hospital laboratory may furnish the technical component of the
physician pathology service directly to its patients or it may have an
independent laboratory furnish the service. Before the implementation
of the hospital inpatient prospective payment system (PPS), the
independent laboratory had two payment options:
<bullet> It could make an arrangement with the hospital and have
the hospital bill the intermediary, and the hospital could be paid on a
reasonable cost basis for the service.
<bullet> It could bill the carrier directly for the service and be
paid on a reasonable charge basis.
In most cases, the independent laboratory furnished a service that
combined the technical and professional components and billed the
carrier for the complete physician pathology service.
When developing PPS, we considered requiring the hospital to
include in its costs the technical component of the physician pathology
service to a patient by an independent laboratory. This would have been
consistent with our general policy of including the cost of hospital
services to hospital inpatients by outside suppliers in the diagnosis-
related group (DRG) payment. Instead, we decided to allow the
independent laboratory to continue to bill the carrier for the complete
service. The rationale, based on discussions with the College of
American Pathologists, was that the technical component was an
incidental service to the physician pathology service. At that time it
was not treated as a service in and of itself, and the independent
laboratory usually billed for the complete service. It was believed
that requiring the separation and identification of the technical
component service would have been disruptive to traditional billing
practices for independent laboratories.
When PPS began, hospitals that furnished the technical component of
the physician pathology service directly included that cost in their
base period cost report. This cost was used to calculate the
standardized amounts that are the basis for payment under PPS.
Therefore, hospitals are paid for providing the technical component of
the service through the standardized amounts. It was our understanding
that most hospital laboratories furnished the technical component
service directly to its patients. Even though the hospital that
contracted out its physician pathology services did not include any of
the cost of technical component services in its base period cost, when
PPS was fully implemented, this hospital would have been paid the same
PPS rate as that paid to other hospitals that had included technical
component costs.
Currently, under the physician fee schedule, an independent
laboratory can bill and receive payment for the technical component of
physician pathology services for a hospital inpatient. We believe this
is in conflict with the hospital rebundling provision in section
1862(a)(14) of the Act and has created a perverse incentive for the
type of activity that the bundling provision was intended to prevent.
Based on the way PPS rates are constructed, we believe that we are
paying for the technical component twice; once to the hospital through
the PPS payment and again to the independent laboratory through the
physician fee schedule.
Generally, historically larger hospitals used independent
laboratories on an ``as needed'' basis and smaller hospitals contracted
with independent laboratories for their physician pathology service.
Recently, though, we have become aware that more hospitals are
considering contracting their in-

[[Page 39624]]

house technical component physician pathology services to an outside
laboratory if our policy remained unchanged. The hospital could
continue to be paid for the technical component service under the PPS,
and the independent laboratory could bill its carrier for the same TC

under the physician fee schedule.

Because we believe that a hospital patient's technical component is
already included in payment under PPS, we are proposing to revise our
regulations to end payments to independent laboratories under the
physician fee schedule for technical component services furnished to
hospital inpatients. Specifically, we propose to revise Sec. 415.130(c)
to state that, after December 31, 1999, we would only pay hospitals for
their inpatients' technical component services.
Section 4104(c) of OBRA 1990 (Public Law 101-508) instructed HCFA,
in establishing ancillary policies under the physician fee schedule, to
``consider an appropriate adjustment to reflect the technical component
of furnishing physician pathology services through a laboratory that is
independent of a hospital and separate from an attending or consulting
physician's office.'' We considered this issue when we implemented the
physician fee schedule and established a separate payment for the
technical component of physician pathology services furnished both to
hospital patients and non-hospital patients.
However, we have now reconsidered this policy with respect to
hospital inpatients because it seems inconsistent with the hospital
rebundling provision and we believe it creates an incentive to shift
the location where the services are provided, thereby conflicting with
the purpose of the hospital rebundling provision. We have anecdotal
information that hospitals are having a pathologist establish an
``independent'' laboratory near the hospital, intending that the new
laboratory perform the technical components of physician pathology
services and bill for those technical components and that there would
be no reduction in PPS payment to the hospital. We believe our proposal
is necessary in order for Medicare to avoid making double payment in
such circumstances. We believe that the language of section 4104(c) of
OBRA 1990 provides sufficient authority for us to determine that, in
the case of hospital patients, it is not appropriate for us to provide
for independent laboratories to bill the TC of pathology services
directly.
Under our proposal, independent laboratories would still be able to
bill and receive payment from their Medicare carrier for the technical
component of a physician pathology service furnished to beneficiaries
who are not hospital inpatients. For the technical component of
physician pathology services provided by an independent laboratory to a
hospital inpatient, the independent laboratory would have to make
arrangements with a hospital to receive payment.
The physician fee schedule regulations would continue to allow the
independent laboratory to bill and receive payment under the physician
fee schedule for the technical component of physician pathology
services to hospital outpatients. Of course, the hospital could, if it
chose instead, make an arrangement with the independent laboratory and
be paid on a reasonable cost basis for this service. However, payment
is made under only one method and only to one of these entities.
Since we will be publishing final regulations to implement the
outpatient prospective payment system and have received comments and
concerns about the outpatient technical component of physician
pathology services, we will address that issue in context of those
regulations.

E. Discontinuous Anesthesia Time

Payment for anesthesia services is based on the sum of base units
plus time units multiplied by a locality-specific anesthesia conversion
factor. Under the current regulations at Sec. 414.46(a)(1) (Additional
rules for payment of anesthesia services), the base unit is the value
for each anesthesia code reflecting all activities other than
anesthesia time. These activities include preoperative and
postoperative visits, the administration of fluids or blood incident to
anesthesia care, and monitoring services.
Anesthesia time, as defined under Sec. 414.46(a)(2), starts when
the anesthesiologist or certified register nurse anesthetist (CRNA)
begins to prepare the patient for anesthesia care and ends when the
anesthesiologist or CRNA is no longer in personal attendance; that is,
when the patient may be placed safely under postoperative care. Time
units are computed by the carrier based on the reported anesthesia
time. (For purposes of this section and as described in section
1861(bb) of the Act, the term CRNA includes an anesthesiologist
assistant (AA)).
In the normal course of the administration of an anesthetic, the
following events occur:
<bullet> Establishment of venous access.
<bullet> Acquisition of initial monitoring information (blood
pressure, oximetry, electrocardiogram).
<bullet> Induction of anesthesia (general, regional, block,
monitored anesthesia care).
<bullet> Maintenance of anesthesia during the surgical procedure.
<bullet> Conclusion of anesthesia attendance.
In many situations, once the anesthesiologist or CRNA is in
attendance he or she remains continuously with the patient for all five
events. This represents continuous anesthesia time.
There may be instances, however, when there is a break in the
continuous presence of the anesthesiologist or CRNA in the events
listed above. Discontinuous anesthesia time could occur when a regional
or block technique is used, resulting in a break between the induction
of the anesthesia and the maintenance of the anesthesia. For example, a
patient may receive an upper extremity block for hand or arm surgery in
a location other than the operating room, and there may be a time
period following the start of the anesthetic and prior to moving the
patient to the operating room during which the patient can be safely
observed by non-anesthesia personnel.
A break in anesthesia time could also occur between the periods
when the anesthesiologist or CRNA obtains initial monitoring
information and induces anesthesia. This usually occurs when a patient
is being prepared in the operating room for induction of anesthesia
and, for some reason, the surgeon is delayed or unavailable. In this
instance, the anesthesiologist or CRNA may leave the patient under the
observation of the operating room nurse until it is appropriate to
proceed with the induction of the anesthesia.
Discontinuous anesthesia time could also occur in facilities that
use anesthesia ``induction'' rooms where anesthesiologists or CRNAs may
start IVs, thereby increasing efficiency in the use of operating room
time. In these cases, there could be breaks at any point in the time
periods between the establishment of the venous access, acquisition of
the initial monitoring information, and induction of the anesthesia.
We are proposing to revise our regulations to allow
anesthesiologists and CRNAs to sum up blocks of time around a break in
continuous anesthesia care as long as there is continuous monitoring of
the patient within the blocks of time. We propose to revise our
regulations in Sec. 414.46 to include this exception to the general
requirement.

[[Page 39625]]

The current regulations on anesthesia time units refer to
anesthesiologists and medically-directed CRNAs. However, the
calculation of anesthesia time units also applies to claims for
services submitted by CRNAs who are not medically-directed. Thus, we
are proposing to revise the regulation text at Sec. 414.60 (Payment for
the services of CRNAs) to clarify this issue. These revisions are
necessary to link the payment methodology for CRNA services to the
payment methodology for physician anesthesia services.
These revisions would not alter the fundamental principle that
anesthesia time represents a continuous block of time when a patient is
under the care of an anesthesiologist or CRNA. Nor would this proposal
alter our policy that an anesthesiologist or CRNA may not bill time
units for the pre-anesthesia examination and evaluation; these services
will continue to be included as part of the base unit component.

F. Optometrist Services

Before 1987, the services of optometrists were covered only if
related to the condition of aphakia. Effective April 1, 1987, section
9336 of the Omnibus Budget Reconciliation Act of 1986 (OBRA 1986)
(Public Law 99-509), enacted on October 21, 1986, amended section
1861(r)(4) of the Act to expand coverage of optometrists services.
Thus, coverage has been expanded to include services otherwise covered
by Medicare that an optometrist is legally authorized to perform as a
doctor of optometry by the State in which the optometrist performs
them.
We are conforming Sec. 410.23 (Limitations on services of an
optometrist) of the regulations to be consistent with the statutory
provision that has been implemented through manual provisions. The
regulations would specify that Medicare Part B pays for the services of
a doctor of optometry, acting within the scope of his or her license,
if the services would be covered as physicians' services when performed
by a doctor of medicine or osteopathy.

G. Assisted Suicide

Section 9 of Public Law 105-12 (The Assisted Suicide Funding
Restriction Act of 1997) added section 1862(a)(16) of the Act. Public
Law 105-12 prohibits the use of Federal funds to furnish or pay for any
health care service or health benefit coverage for the purpose of
causing, or assisting to cause, the death of any individual. The
prohibition does not apply to withholding or withdrawing medical
treatment, nutrition, or hydration. In addition, the prohibition does
not apply to furnishing a service to alleviate pain, even if doing so
may increase the risk of death, as long as the purpose is not to cause
or assist in causing death. The list of programs to which the
prohibition applies includes the Medicare program.
We are conforming the regulations to the Medicare law amendment
contained in ``The Assisted Suicide Funding Restriction Act of 1997''
by adding a new paragraph (q) to Sec. 411.15 (Particular services
excluded from coverage) to exclude from coverage any health care
service for the specific purpose of causing, or assisting to cause, the
death of an individual.

H. CPT Modifier -25

Payment under the Medicare physician fee schedule is based on the
relative resources or work involved in providing a service. Under
current policy, if a patient visits a physician for a minor procedure
(for example, a minor surgery or an office based endoscopy) and
receives no other services, the physician may only bill for the
procedure and may not also bill for an office visit since no other
services were provided.
If, however, in addition to the procedure the physician also
provides significant, separately identifiable evaluation and management
(E/M) services beyond the usual preoperative and postoperative services
associated with the procedure, these services should be billed with
modifier -25 and are separately payable. The E/M service does not have
to be unrelated to the procedure and the same diagnosis is not
sufficient reason to deny payment for the E/M service. This policy is
described in section 15501.1 of the Medicare Carriers Manual and is
consistent with CPT coding definitions.
To avoid any confusion on this point, we are proposing that for
procedures where the global surgery rules do not apply (for example,
the global code is ``XXX'' in the database), a provider may only bill
for a separately identifiable
E/M service by using the CPT modifier -25. Since every procedure has an
inherent E/M component, in order for an E/M service to be billed, there
must be a significant, separately identifiable service documented in
the medical record. While there has been concern raised that physicians
and others may be billing separately for E/M services that are part of
the underlying procedure, we understand that there are times that such
E/M services are provided and billed because they truly are separate
and significant.

Example 1: A woman visits her rheumatologist for a follow-up
visit. The visit is to monitor the status of her rheumatoid
arthritis and the medication regime she has been following
(methotrexate and non-steroidal anti-inflammatory drugs). During the
few days prior to her visit she has experienced increased pain in
her left knee. At the visit the rheumatologist notes the knee is
markedly swollen and aspirates it. The rheumatologist should
appropriately bill an E/M visit code with a modifier -25 in addition
to the procedure code for the knee aspiration. (The knee aspiration
is a significant, separately identifiable procedure which occurs
during a routine visit.)
Example 2: A cardiac patient visits the physician specifically
for a previously scheduled echography test. An E/M service should
not be billed. (The assumption is the E/M service is built into the
procedure and, therefore, should not be billed.)

Requiring the use of modifier -25 will assist carriers in claims
adjudication and eliminate unnecessary denials when providers
appropriately attach modifier -25 to E/M services that are significant
and separately identifiable from the procedure. A separate diagnosis is
not necessary. Additionally, using this modifier will alert physicians
to the need for documentation in the medical record to support proper
payment.

I. Nurse Practitioner Qualifications

In the November 2, 1998, final rule (63 FR 58814), we specified the
qualifications for a nurse practitioner (NP). On May 12, 1999 we
published a correction notice to the final rule (64 FR 25456). The
final NP qualifications in Sec. 410.75 (Nurse practitioner's services)
require that, after December 31, 1999, for Medicare Part B coverage of
his or her services, an NP must--
<bullet> Possess a master's degree in nursing;
<bullet> Be a registered professional nurse who is authorized by
the State in which the services are furnished to practice as a nurse
practitioner in accordance with State law; and,
<bullet> Be certified as a nurse practitioner by the American
Nurses Credentialing Center or other recognized national certifying
bodies that have established standards for nurse practitioners as
defined in paragraphs (b)(1) and (b)(2) of Sec. 410.75.
Subsequent to the publication of the NP qualifications, we gave
additional consideration to the qualifications because we realized that
the qualifications would exclude many experienced NPs from continuing
to qualify as NPs under the Medicare program.
We gave particular consideration to the qualification criteria that
require an NP to have a master's degree and national certification for
the following reasons--

[[Page 39626]]

<bullet> Many NPs who had been practicing for 10 to 20 years or
more did not graduate from master's level programs;
<bullet> Several States still do not require a master's degree for
NPs to practice;
<bullet> Numerous NPs without master's degrees who have been
practicing for 10 to 20 years or more in rural underserved areas and
serving indigent populations were grandfathered by States for licensure
and insurance payment purposes;
<bullet> Experienced women's health NPs will not be required to
have a master's degree as a condition for national certification until
2007;
<bullet> We did not allow the NP population a transition time to
enable NPs to achieve national certification or earn a master's degree;
and
<bullet> The requirements for NPs were never implemented by
regulations but are contained in section 2158 of the Medicare Carriers
Manual. Nevertheless, it was under these qualifications, which did not
require NPs to have a master's degree, that many individuals have been
issued NP billing numbers, and no problems in practice have been
reported.
Prior to the publication of the NP qualifications, an advanced
nurse could qualify under section 2158 of the Medicare Carriers Manual
(HCFA Pub 14-3) as a NP if he or she--
<bullet> Was a registered professional nurse currently licensed to
practice in the State in which the services are furnished;
<bullet> Satisfied the applicable requirements for qualification of
NPs of the State in which the services are furnished; and,
<bullet> Met at least one of the following requirements:
<bullet> Was currently certified as a primary care nurse
practitioner by the American Nurses' Association or by the National
Board of Pediatric Nurse Practitioners and Associates; or,
<bullet> Had satisfactorily completed a formal educational program
of at least one academic year that prepares registered nurses to
perform an expanded role in the delivery of primary care and that
includes at least four months (in the aggregate) of classroom
instruction, and that awards a degree, diploma, or certification for
successful completion of the program; or,
<bullet> Had successfully completed a formal education program
(that does not qualify under the immediately preceding requirement)
that prepares registered nurses to perform an expanded role in the
delivery of primary care and have been performing that expanded role
for at least 12 months during the 18 month period immediately preceding
February 8, 1978, the effective date for provision of the services of
nurse practitioners as reflected in the conditions of certification for
health clinics.
Thus, NPs could have obtained Medicare billing numbers as NPs
without a master's degree or national certification if the State did
not require such certification. NPs who currently have billing numbers
can continue to bill the Medicare program for their services until the
end of this year without a master's degree or national certification.
NPs can apply to the Medicare program for a billing number until the
end of this year if they meet the NP qualifications at section 2158 of
the Medicare Carriers Manual (as set out above).
It was not our intention to establish qualifications in the 1998
final rule that would cause experienced NPs who have been furnishing
services to Medicare patients to be barred from billing under the
Medicare program because they do not posses a master's degree or
national certification. Also, it was not our intention to inadvertently
preclude NPs, solely on the basis of their not having a master's
degree, from billing under the Medicare program and providing services
to Medicare patients located in rural underserved areas and indigent
populations where access to care is extremely limited.
We are proposing to revise Sec. 410.75 to specify NP qualifications
that are less restrictive, but that still ensure that quality services
are furnished to Medicare patients. We propose to require progressively
enhanced qualifications, providing lead time for NPs to obtain a
Medicare billing number under section 2158 criteria or national
certification. The requirement that a NP applying for a Medicare
billing number for the first time must have a master's degree in
nursing as of January 1, 2003 will provide these NPs with enough time
to earn such a degree. We believe it is reasonable to require,
ultimately, a master's degree as the minimum educational level for new
practitioners independently treating beneficiaries and directly billing
the Medicare program.
The proposed NP qualifications require that for Medicare Part B
coverage of his or her services, a nurse practitioner must meet the
qualifications of either (1) or (2) below--
(1)(i) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(2) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000.
Nurse practitioners having and maintaining valid Medicare billing
numbers will not lose these numbers or the ability to bill the Medicare
program for covered services solely on the basis of education and
credentialing.
(3) On or after January 1, 2001, nurse practitioners applying for a
Medicare billing number for the first time must meet the standards for
nurse practitioners as defined in paragraphs (1)(i) and (1)(ii).
(4) On or after January 1, 2003, nurse practitioners applying for a
Medicare billing number for the first time must possess a master's
degree in nursing and meet the standards for nurse practitioners as
defined in paragraphs (1)(i) and (1)(ii) above.

J. Relative Value Units for Pediatric Services

It has come to our attention that the work RVUs for approximately
48 pediatric surgical services are inappropriate. The present values
reflect the evaluation and management (E/M) services of the
postoperative period as determined in the original Harvard study and
not the subsequent Harvard study of 1992. Thus, when we readjusted the
work RVUs for global surgical services to account for increases in the
work RVUs for E/M services during the 5-year review, we did not adjust
the work RVUs for these pediatric services appropriately. We are
proposing to change the RVUs for the
E/M services during the global surgical period for pediatric surgical
services to reflect the findings of the 1992 Harvard study and are in
the process of analyzing the data to determine the specific changes to
be made. Changing the RVUs for E/M services during the global surgical
period would result in increases in the work RVUs for these codes. The
actual increases would be reflected in the final rule.

K. Percutaneous Thrombectomy of an Arteriovenous Fistula

One editorial revision made by the AMA for the (Physicians')
Current Procedural Terminology (CPT) (4th Edition, 1999) was the
addition of the word ``external'' to CPT codes 36860 and 36861, which
describe declotting a cannula. Previously some professional
organizations had recommended using

[[Page 39627]]

these codes to describe the percutaneous declotting of a dialysis graft
or arteriovenous fistula. The editorial revision, however, makes it
clear that using CPT codes 36860 and 36861 for percutaneous declotting
is inappropriate. There are currently no CPT codes for the percutaneous
thrombectomy or revision of an arteriovenous fistula.
We have received a recommendation from the Society of
Cardiovascular and Interventional Radiology to create a temporary HCFA
Common Procedure Coding System (HCPCS) code, bundling several
activities regarding percutaneous thrombectomy of a dialysis graft or
fistula. The HCPCS code would be used until the AMA creates a permanent
CPT code. We are proposing to implement a HCPCS code, defined as
``percutaneous thrombectomy and/or revision, arteriovenous fistula,
autogenous or nonautogenous dialysis graft.'' We are defining it
analogously to open surgical procedures, CPT codes 36831 to 36833. We
are proposing a 90-day global period for this service to be consistent
with the open surgical procedure codes and to facilitate comparisons
with them. More than one CPT code may be required to describe them.
Moreover, we do not have an independent evaluation of the work RVUs
involved, such as a RUC recommendation. Therefore, we are proposing
individual local carrier pricing for the new HCPCS code.

L. Pulse Oximetry, Temperature Gradient Studies, and Venous Pressure
Determinations

There are certain simple diagnostic procedures, that is, CPT codes
94760, 94761, 94762, 93740, and 93770 (pulse oximetry and venous
pressure determinations), that have separate CPT codes. However, the
technical work involved in these procedures is small, while the
physician work involved in interpreting them is included in an E/M
service or a more complex procedure. Moreover, in the inpatient
hospital setting, the technical expense of performing these procedures
is included in the DRG payment. In the physician office setting, the
practice expenses associated with the procedures are included in the
staff and equipment costs reported in the AMA's Socioeconomic
Monitoring Survey that we have used to establish the resource-based
practice expenses in 1999. We believe that continuing to pay separately
for these codes duplicates amounts included in both facility payments
and PERVUs. In order to avoid duplicate payments, we are proposing to
discontinue separate payment for CPT codes 94760, 94761, 94762, and
93770 and to list them in the physician fee schedule with a status code
of ``B'' for ``payment always bundled into payment for other
services.''

M. Removal of Requirement for X-Ray Before Chiropractic Manipulation

Section 1861(r)(5) of the Act defines a doctor of chiropractic as a
physician only for purpose of manual manipulation of the spine to
correct a subluxation demonstrated by x-ray to exist. Section 4513(a)
of the BBA eliminates the statutory provision that a spinal subluxation
be demonstrated by an x-ray. Thus, section 1861(r)(5) of the Act was
amended to allow Medicare payment for a chiropractor's manual
manipulation of the spine to correct subluxation without that
subluxation being demonstrated by an x-ray. This provision is effective
for services furnished on or after January 1, 2000.
In Sec. 410.22 (Limitations on services of a chiropractor),
paragraph (b)(1) states that Medicare Part B pays only for a
chiropractor's manual manipulation of the spine to correct a
subluxation if an x-ray demonstrates that a subluxation exists and if
the subluxation has resulted in a neuromusculoskeletal condition for
which manipulation is appropriate treatment.
In accordance with the BBA, we are deleting the x-ray requirement
from Sec. 410.22(b)(1). Thus, effective January 1, 2000,
Sec. 410.22(b)(1) will state that Medicare Part B pays only for a
chiropractor's manual manipulation of the spine to correct a
subluxation if the subluxation has resulted in a neuromusculoskeletal
condition for which manipulation is appropriate treatment.

N. Coverage of Prostate Cancer Screening Tests

Section 4103 of the BBA provides for Medicare coverage of certain
prostate cancer screening tests for all male beneficiaries, effective
January 1, 2000, subject to certain frequency and other limitations.
Effective January 1, 2000, the law provides for coverage for screening
digital rectal examinations (DRE) and screening prostate-specific
antigen blood tests. In addition, the law provides for coverage for
years beginning after 2002 of other procedures as we find appropriate
for the purpose of early detection of prostate cancer, taking into
account changes in technology and standards of medical practice,
availability, effectiveness, costs, and other factors as we consider
appropriate.
Current Medicare coverage policy allows payment for tests to
diagnose prostate cancer and related medically necessary services that
are furnished to beneficiaries. Under the policy, diagnostic prostate
cancer tests are covered if they are medically necessary to evaluate a
specific complaint or symptom that might indicate prostate cancer, or
to monitor an existing medical condition of an individual who has had a
history of prostate cancer. This coverage is based, in part, on section
1861(s)(3) of the Act, that provides for general Medicare coverage for
diagnostic x-ray, clinical laboratory, and other diagnostic tests.
Before the enactment of the BBA, prostate cancer screening tests have
been excluded from coverage based on section 1862(a)(7) of the Act,
that states that routine physical checkups are excluded services. This
exclusion is described in Sec. 411.15(a) (Particular services excluded
from services). In addition, prostate cancer screening tests have been
excluded from coverage based on section 1862(a)(1)(A) of the Act. This
section provides that items and services must be reasonable and
necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member as stated in
Sec. 411.15(k).
To conform the regulations to the statutory requirements of the
BBA, we are specifying an exception to the list of examples of routine
physical checkups excluded from coverage in Secs. 411.15(a)(1) and
411.15(k)(9) for prostate cancer screening tests that meet the
frequency limitations and the conditions for coverage that we are
specifying under Sec. 410.39 (Prostate cancer screening tests).
Coverage of prostate cancer screening is provided under Medicare Part B
only.
As provided in the law, this new coverage allows payment for one
screening DRE and one screening prostate-specific antigen blood test
every year.
We are proposing to add Sec. 410.39 (Prostate cancer screening
tests: Conditions for and limitations on coverage) to provide for
coverage of two types of prostate cancer screening tests. We are
proposing several definitions of terms that would be included to
implement the statutory provisions and to help the reader in
understanding the provisions of the regulation. These include
definitions of the terms--(1) prostate cancer screening tests, (2) a
screening DRE, (3) a screening prostate-specific antigen blood test,
(4) an attending physician, and (5) an attending physician assistant,
nurse practitioner, clinical nurse specialist or certified nurse
midwife. We are also proposing conditions of coverage for the two
prostate cancer screening tests

[[Page 39628]]

identified in the law for coverage effective January 1, 2000.
Section 4103(a) of the BBA defines the term ``prostate cancer
screening test'' to mean a test (among other things) that is ``provided
for the purpose of early detection of prostate cancer to a man over 50
years of age who has not had such a test during the preceding year.''
We have interpreted this language to mean that payment may be made for
a male beneficiary over 50 years of age or older (that is, starting at
least one day after he has attained age 50) for both an annual
screening DRE and an annual screening prostate-specific antigen test.
We have also interpreted the law to mean that payment may not be made
for such screening tests for an individual male beneficiary who is age
50 or younger.
Under our authority under the ``reasonable and necessary'' clause
of the Act, section 1862(a)(1)(A) of the Act, we are establishing
conditions under which we would cover prostate cancer screening tests.
To ensure that the screening digital rectal examinations are performed
as safely and accurately as possible, we are proposing to require, in
Sec. 410.39(b), that the examination must be performed by the
beneficiary's attending physician who is either a doctor of medicine or
osteopathy (as defined in section 1861(r)(1) of the Act), or by the
beneficiary's attending physician assistant, nurse practitioner,
clinical nurse specialist, or certified nurse midwife (as defined in
section 1861(aa) and section 1861(gg) of the Act) who is authorized
under State law to perform the examinations. In Sec. 410.39(c), we are
proposing that payment may not be made for screening DRE performed for
a man age 50 or younger. For an individual over 50 years of age,
payment may be made for a screening DRE only if the man has not had
such an examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening DRE
was performed. In Sec. 410.39(d) (Conditions for coverage of screening
prostate-specific antigen blood tests), we are specifying that coverage
is available for screening prostate-specific antigen blood tests only
if they are ordered by the beneficiary's attending physician, or by the
beneficiary's attending physician assistant, nurse practitioner,
clinical nurse specialist, or certified nurse midwife who is authorized
to order this test under State law. We are including this coverage
requirement to make certain that beneficiaries receive appropriate
information about the implications and possible results of having these
examinations performed. In Sec. 410.39(e) (Limitation on coverage of
screening prostate-specific antigen blood test), we are proposing that
payment may not be made for a screening prostate-specific antigen blood
test performed for a man age 50 or younger. For an individual over 50
years of age, payment may be made for a screening prostate-specific
antigen blood test only if the man has not had such an examination paid
for by Medicare during the preceding 11 months following the month in
which his last Medicare-covered screening prostate-specific antigen
blood test was performed.
We have created a new HCPCS code, G0102, prostate cancer screening
DRE, to be used for the screening DRE. A DRE is a relatively quick and
simple procedure and we have assigned it the same value as CPT code
99211, the lowest level E/M service. A DRE is usually provided as part
of an E/M service. We believe that it would be extremely rare for a DRE
to be the only service provided during a patient encounter. For this
reason, we are proposing to bundle the DRE into the payment for an E/M
service when a covered E/M service is provided on the same day as a
DRE. If the DRE is the only service provided or is provided as part of
an otherwise noncovered service, such as CPT code 99397, preventive
services visit, HCPCS code G0102 would be separately payable if all the
aforementioned coverage requirements are met.
We have created a new HCPCS code, G0103, prostate screening;
prostate specific antigen (PSA) to be used for the screening PSA test.
The PSA screening test is priced at the same payment rate as CPT code
85153, PSA; total and would be paid under the clinical diagnostic
laboratory fee schedule.

O. Diagnostic Tests

1. Supervision of Diagnostic Tests
On October 31, 1997, we published a final rule with comment period
(62 FR 59048) in the Federal Register that required that diagnostic
tests covered under section 1861(s)(3) of the Act and payable under the
physician fee schedule must be furnished under the appropriate level of
supervision by a physician as defined in section 1861(r) of the Act in
order to be considered reasonable and necessary and, therefore, covered
under Medicare. Medicare requires that physicians supervise diagnostic
testing to ensure the safety and effectiveness of the diagnostic
testing furnished to beneficiaries. The October 31, 1997 final rule
designated the level of physician supervision for most diagnostic tests
payable under the physician fee schedule. The physician supervision
requirement applied to tests performed by physician assistants (PAs),
nurse practitioners (NPs), clinical nurse specialists (CNSs), and other
nonphysician personnel.
Sections 4511 and 4512 of the BBA removed the restrictions on the
areas and settings in which NPs, CNSs, and PAs may be paid under the
physician fee schedule for services that would be physician services if
furnished by a physician.
Therefore, we are proposing to revise Sec. 410.32(b)(2), which
concerns diagnostic x-ray and other diagnostic tests. We are proposing
to add an exception that would specify that no physician supervision is
required for diagnostic tests performed by NPs and CNSs when they are
authorized by the State to perform these tests. In addition, we are
proposing to modify Sec. 410.32(b)(3) by means of a parenthetical
stating that diagnostic tests that a PA is legally authorized to
perform under State law require only a general level of physician
supervision.
This distinction is based on the fact that PAs are licensed to
practice with physician supervision. Also, for purposes of Medicare,
they must be either employees or contractors of physicians, and their
services may be billed only by the physicians (see section 1861(b)(6)
as modified by section 4512(b) of the BBA). For these reasons, we
believe it is appropriate to require that PAs furnish diagnostic tests
under the general supervision of those physicians.
We are also proposing to add an exception criterion at
Sec. 410.32(b)(2) so that the physician supervision rules would not
apply to pathology and laboratory codes in the 80000 series of the CPT
payable under the physician fee schedule. This family of codes is
within the ambit of the Clinical Laboratory Improvement Amendments of
1988 (CLIA) regulations (Part 493), and we have decided that it would
be unnecessarily confusing to apply another, separate set of
supervision rules to the performance of these procedures. We now
believe that the appropriate level of supervision of these pathology
and laboratory procedures (including the determination that there
should be no physician supervision at all) should be determined under
the CLIA regulations, and we would consider these matters beyond the
scope of Sec. 410.32.

[[Page 39629]]

2. Independent Diagnostic Testing Facilities (IDTFs)
Section 410.33, as adopted in the October 1997 final rule (62 FR
59099), establishes criteria for the operation of IDTFs. We are
proposing to modify the implementation date from July 1, 1998 to March
15, 1999 to reflect the actual implementation date.
Section 410.33(a) lists the types of entities the carrier may pay
for diagnostic tests under the physician fee schedule. We are proposing
to modify Sec. 410.33(a) to include NPs and CNSs who perform diagnostic
tests that the State authorizes them to perform in the list of entities
that may be paid directly by the carrier for diagnostic tests under the
physician fee schedule. This amendment would not authorize an NP or a
CNS to serve as the supervising physician for an IDTF under the
requirements set forth in Sec. 410.33(b).

P. New and Revised Relative Value Units for Calendar Year 1999

The AMA's RUC evaluated 16 new and revised 1999 CPT codes at its
September 1998 meeting. We received the RUC's recommendations for these
codes too late to incorporate them into our November 2, 1998, final
rule (63 FR 58814) on the 1999 physician fee schedule. We have
completed our evaluations of the codes, and we have included them below
for comment.
For twelve of the codes we propose accepting the RUC evaluations of
work. For two of the codes, 94620 and 94621 (pulmonary stress testing),
that represent revisions of existing codes, we revised the work RVUs
recommended by the RUC to achieve budget neutrality of work RVUs within
the family of codes. That is, we adjusted the work RVUs so that the sum
of the new or revised work RVUs (weighted by projected frequency of
use) for a family of codes would be the same as the sum of the current
work RVUs (weighted by their current frequency of use). We also
confirmed that the RUC's recommended changes to work RVUs were neutral
for two other sets of codes: (1) 31622, 31623, and 31624
(bronchoscopy); and (2) 69990 (use of operating microscope).
Finally, we are proposing specific payment policies apart from the
RUC recommendations. We summarize our adjustments for codes 33975,
33976, 69990, 94620, and 94621 below:

1. Ventricular Assist Device Implantations (CPT Codes 33975 and 33976)

In 1998, we requested that the AMA's RUC re-examine the work RVUs
for CPT codes 33975, 33976, 33977, and 33978 regarding implantation and
removal of ventricular assist devices. We made this request based on
information provided by the Society of Thoracic Surgeons (the Society)
that patients receiving these devices are now being maintained on them
for longer periods than in 1993, when the work was originally surveyed.
One suggestion of the Society was to decrease the global period from 90
days to 10 days. In September 1998, the RUC re-evaluated the work for
the implantation CPT codes 33975 and 33976 based on 10-day global
periods. The RUC recommended increasing the work RVUs despite the
reduction in the global period based on survey results that
intraservice work had increased and postoperative work had also
increased. The survey reported substantial time spent by the surgeon
attending the patient in the critical care unit post-operatively. We
did not incorporate the recommendations from the September 1998 RUC
meeting into the 1999 Medicare Physician Fee Schedule because we
received them too late to incorporate them into our 1998 final rule (63
FR 58814). We did reduce the global period for the implantation codes
to 10 days.
We note that the technology and indications for these devices are
evolving rapidly. Device and technique modifications are being
introduced and new, miniaturized devices have been developed and are
being tested in Europe that will decrease the time required for
implantation. Trials are being conducted or planned to extend the
indications from limited use as a short-term bridge to cardiac
transplant to maintenance of patients with end-stage heart failure.
With these changing indications, the patient population and the
procedure work will evolve.
Because of the evolving technology and indications and because much
critical care today is provided by critical care specialists rather
than by surgeons, we are proposing that there be no global period for
these codes until we have further evaluated the procedures. We have
estimated RVUs for these codes based on the RUC survey results for the
intraservice work, and we propose implementing them on an interim
basis. To enable evaluation of work trends, patient acuity, and medical
effectiveness and development of final work RVUs covering a global
period, we will require submission of the operative report, the
anesthesia record, and the hospital discharge summary along with the
claim for the implantation procedure. On an interim basis, we will
allow separate billing for all preoperative and postoperative work
performed by the surgeon or by other physicians subject to the existing
requirements for medical necessity, reasonableness, and documentation.
We estimated the work RVU values for these codes as intraservice
work only. We considered other alternatives such as using the average
work intensity for all physician time from the RUC survey, (that is,
total work RVUs divided by total physician time), but we rejected this
intensity as being too low and not adequately representing the greater
average intensity of the intraservice work compared to the pre-and
post-procedures work. We used the median intraservice times from the
RUC survey and the work intensity for a cardiac surgical procedure code
that does not include any pre or post service work, CPT code 33530,
reoperation for a coronary artery bypass procedure or a valve
procedure. We are proposing to assign work RVUs of 21 for CPT code
33975 and 23 for CPT code 33976. These values are slightly more than
half of the RUC recommendations for the codes including a 10-day global
period. We also note that the proposed value for CPT code 33975, which
represents only intraservice work, is approximately the same as the
value in 1999 when the code included a global period of 10 days and
prior to 1999 when the code included a global period of 90 days. We
will be examining the operative reports and anesthesia records in the
future to update the RUC survey estimates.

2. Use of Operating Microscope (CPT Code 69990)

CPT code 69990 replaced two previous codes, 61712 and 64830. These
previous codes were add-on codes that could be used only with certain
primary procedure codes. The RUC evaluated the work RVUs for code 69990
as a budget-neutral, weighted average of the RVUs for codes 61712 and
64830. However, code 69990 also replaces the use of a ``-20''
microsurgery modifier. The CPT modifier -20 could be used with a wide
range of primary procedure codes, but we have not paid additional
amounts when the CPT modifier -20 is submitted. No evidence was
presented at the RUC that the work has changed for those procedures
formerly qualified by the CPT microsurgery modifier -20 and now
associated with the code 69990. Therefore, we would pay separately for
code 69990 only if it is submitted as an add-on code to a primary
procedure for which the use of code 61712 or 64830 was acceptable. The
primary procedure codes for which we would pay separately for code
69990 are 61304 through 61711, 62010 through 62100, 63081 through
63308, 63704 through 63710, 64831, 64834 through

[[Page 39630]]

64836, 64840 through 64858, 64861 through 64870, 64885 through 64898,
and 64905 through 64907 (nervous system).

3. Pulmonary Stress Testing (CPT Codes 94620 and 94621)

CPT code 94620 previously included both simple and complex
pulmonary stress testing. For CPT 1999, complex testing was removed
from CPT code 94620 and assigned to a new CPT code 94621. We are
proposing to adjust the RUC recommendations to maintain budget
neutrality for work RVUs for these codes. Based on estimated
frequencies of 70 percent for CPT code 94620 and 30 percent for CPT
code 94621, the adjusted work RVUs are 0.64 for CPT code 94620 and 1.42
for CPT code 94621.
Our estimates for work neutrality in work values are based on the
frequencies with which we estimate the specific procedures will be done
and the codes billed. Typically, these estimates have been furnished by
the specialty society that proposed the new codes. If these estimates
are in error, our adjustments to maintain neutrality in work values
will also be erroneous. We are planning to examine the actual
frequencies with which the procedures are billed after the codes are
introduced for any codes for which we have made adjustments to achieve
neutrality in work values. If the reported frequencies confirm that the
original estimates were incorrect, we may propose an adjustment of the
work RVUs accordingly in a future year. This adjustment could either
increase or decrease the work RVUs.
Table 9 lists the 16 codes, the RUC recommendations, and the
results of our evaluation. This table includes the following
information:
<bullet> A ``#'' identifies a new code for 1999.
<bullet> CPT code. This is the CPT code for a service.
<bullet> Modifier. A ``26'' in this column indicates that the work
RVUs are for the professional component of the code.
<bullet> Description. This is an abbreviated version of the
narrative description of the code.
<bullet> RUC recommendations. This column identifies the work RVUs
recommended by the RUC.
<bullet> HCPAC recommendations. This column identifies work RVUs
recommended by the HCPAC.
<bullet> HCFA decision. This column indicates whether we agreed
with the RUC recommendation (``agree''); we established work RVUs that
are higher than the RUC recommendation (``increase''); or we
established work RVUs that were less than the RUC recommendation
(``decrease''). Codes for which we did not accept the RUC
recommendation are discussed in greater detail above. An ``(a)''
indicates that no RUC recommendation was provided. A discussion follows
the table.
<bullet> HCFA work RVUs. This column contains the RVUs for
physician work based on our reviews of the RUC recommendations.
<bullet> 1999 work RVUs. This column establishes the 1999 RVUs for
physician work.

Note: Because we did not receive these recommendations in time
for the November 2, 1998 final rule, they were not implemented for
CY 1999. We will implement these RUC recommendations in the CY 2000
physician fee schedule to be published later this year.

Table 9.--AMA RUC and HCPAC Recommendations and HCFA Decisions for New and Revised 1999 CPT Codes
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUC 1999 work
CPT* code MOD Description recommendation HCPAC recommendation HCFA decision HCFA work RVU RVU
--------------------------------------------------------------------------------------------------------------------------------------------------------
31622............. ......... Dx bronchoscope/wash 2.78 ......................... Agree................... 2.67............. 2.78
31623............. ......... Dx bronchoscope/ 2.88 ......................... Agree................... 3.07............. 2.88
brush.
31624............. ......... Dx bronchoscope/ 2.88 ......................... Agree................... 3.11............. 2.88
lavage.
32001............. ......... Total lung lavage... 6.00 ......................... Agree................... 5.71............. 6.00
33975............. ......... Inplant ventricular 39.00 ......................... Agree................... 21.00............ 21.00
device.
33976............. ......... Inplant ventricular 43.00 ......................... Agree................... 23.00............ 23.00
device.
35500............. ......... Harvest vein for 6.45 ......................... Agree................... Carrier.......... 6.45
bypass.
36823............. ......... Insert cannula(s)... 21.00 ......................... Agree................... Carrier.......... 21.00
38792............. ......... Identify sentinel 0.52 ......................... Agree................... Carrier.......... 0.52
node.
56321............. ......... Laparoscopy 20.00 ......................... Agree................... Carrier.......... 20.00
adrenalectomy.
56345............. ......... Laparoscopic 17.00 ......................... Agree................... Carrier.......... 17.00
splenectomy.
56347............. ......... Laparoscopic 9.78 ......................... Agree................... Carrier.......... 9.78
jejunostomy.
69990............. ......... Microsurgery add-on. 3.47 ......................... Agree................... 3.46............. 3.47
76977............. 26 Us bone density 0.05 ......................... Agree................... 0.22............. 0.05
measure.
94620............. ......... Pulmonary stress 0.67 ......................... Agree................... 0.64............. 0.64
test/simple.
94621............. ......... Pulm stress test/ 1.48 ......................... Agree................... 1.42............. 1.42
complex.
--------------------------------------------------------------------------------------------------------------------------------------------------------
* All numeric HCPCS CPT Copyright 1997 American Medical Association.

III. Collection of Information Requirements

This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).

IV. Response to Comments

Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will respond to the comments in the preamble to that
document.

V. Regulatory Impact Analysis

We have examined the impacts of this proposed rule as required by
Executive Order of 1993 (EO) 12866, the Unfunded Mandates Act of 1995
(EO) 12875, and the Regulatory Flexibility Act of 1980 (RFA) (Public
Law 96-354).
Executive Order 12866 directs agencies to assess all costs and
benefits

[[Page 39631]]

of available regulatory alternatives and, when regulation is necessary,
to select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety effects,
distributive impacts, and equity). A regulatory impact analysis (RIA)
must be prepared for major rules with economically significant effects
($100 million or more annually). While proposed changes in the Medicare
physician fee schedule are budget neutral for the most part, they may
involve redistribution of Medicare spending among procedures and
physician specialties that exceeds $100 million, so this proposed rule
is considered to be a major rule.
The Unfunded Mandates Reform Act of 1995 also requires (in section
202) that agencies prepare an assessment of anticipated costs and
benefits before proposing any rule that may result in an annual
expenditure by State, local, or tribal governments, in the aggregate,
or by the private sector, of $100 million or more. This proposed rule
will have no consequential effect on State, local, or tribal
governments. We believe the private sector cost of this rule falls
below these thresholds as well.
The Regulatory Flexibility requires that we analyze regulatory
options for small businesses and other small entities. We prepare a
Regulatory Flexibility Analysis (RFA) unless we certify that a rule
would not have a significant economic impact on a substantial number of
small entities. The RFA is to include a justification of why action is
being taken, the kinds and number of small entities the proposed rule
would affect, and an explanation of any considered meaningful options
that achieve the objectives and would lessen any significant adverse
economic impact on the small entities.
In addition, section 1102(b) of the Social Security 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 603 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital that is located outside of
a Metropolitan Statistical Area and has fewer than 50 beds.
For purposes of the RFA, all physicians are considered to be small
entities. There are about 700,000 physicians and other practitioners
who receive Medicare payment under the physician fee schedule. We have
prepared the following analysis, which, together with the rest of this
preamble, meets all three assessment requirements. It explains the
rationale for and purposes of the rule, details the costs and benefits
of the rule, analyzes alternatives, and presents the measures we
propose to minimize the burden on small entities.

A. Resource-Based Malpractice Relative Value Units

As explained earlier in this preamble, the resource-based
malpractice RVUs must be implemented in a budget-neutral manner. That
is, the total fee schedule malpractice RVUs must be the same under the
resource-based method as would have existed had the prior charge-based
malpractice RVUs been retained. This means that increases in RVUs for
some services will necessarily be offset by corresponding decreases in
values for other services. Table 10 shows, by specialty, the estimated
percentage changes in allowed charges for our proposed resource-based
malpractice RVUs.

Table 10.--Impact on Total Allowed Charges by Specialty of the Resource-
Based Malpractice Expense Relative Value Units
[Percent change]
------------------------------------------------------------------------
Allowed
charges Impact by
Specialty (in specialty
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY................................ 0.3 -0.1
CARDIAC SURGERY............................... 0.4 -1.0
CARDIOLOGY.................................... 3.7 -0.6
CLINICS....................................... 1.6 0.3
DERMATOLOGY................................... 1.3 0.1
EMERGENCY MEDICINE............................ 0.8 2.7
FAMILY PRACTICE............................... 3.0 0.5
GASTROENTEROLOGY.............................. 1.1 -0.1
GENERAL PRACTICE.............................. 1.1 0.6
GENERAL SURGERY............................... 2.2 -0.1
HEMATOLOGY ONCOLOGY........................... 0.6 0.3
INTERNAL MEDICINE............................. 6.4 0.4
NEPHROLOGY.................................... 0.9 1.3
NEUROLOGY..................................... 0.8 0.5
NEUROSURGERY.................................. 0.4 0.7
OBSTETRICS/GYNECOLOGY......................... 0.4 -0.6
OPHTHALMOLOGY................................. 3.8 -0.4
ORTHOPEDIC SURGERY............................ 2.3 -1.0
OTHER PHYSICIAN............................... 1.2 0.2
OTOLARYNGOLOGY................................ 0.6 -0.2
PATHOLOGY..................................... 0.5 -0.6
PLASTIC SURGERY............................... 0.2 -0.1
PSYCHIATRY.................................... 1.1 -0.1
PULMONARY..................................... 1.0 0.4
RADIATION ONCOLOGY............................ 0.6 -0.4
RADIOLOGY..................................... 2.8 -0.5
RHEUMATOLOGY.................................. 0.3 0.5
THORACIC SURGERY.............................. 0.7 -0.8
UROLOGY....................................... 1.3 0.1
VASCULAR SURGERY.............................. 0.3 -0.2

[[Page 39632]]

OTHERS:
CHIROPRACTOR.............................. 0.4 0.6
NONPHYSICIAN PRACTITIONER................. 0.9 -0.5
OPTOMETRIST............................... 0.6 0.1
PODIATRY.................................. 1.1 0.5
SUPPLIERS................................. 0.4 -0.3
---------------------------------------------------------------------
Table 11 shows the percentage change in total payment (in 1999 fee
schedule dollars) for selected high-volume procedures which would
result from the proposed change to resource-based malpractice RVUs.
As Tables 10 and 11 show, the effects on payments are very modest
and, in most cases, negligible. Of the 35 major payment specialties
shown in Table 10, 17 are estimated to experience payment increases and
18 are estimated to experience payment decreases. Only two specialties
are estimated to experience increases of more than 1 percent, emergency
medicine (2.7 percent) and nephrology (1.3 percent), with an estimated
median payment increase of 0.5 percent among the specialties which
receive an increase. No specialties are estimated to experience payment
decreases greater than 1 percent, with an estimated median payment
decrease of 0.4 percent among the specialties which receive a decrease.
The impact of the changes on the total revenue (Medicare and non-
Medicare) for a given specialty is less than the impact displayed in
Table 10 since physicians furnish services to both Medicare and non-
Medicare patients. The magnitude of the impact on Medicare payment for
a specialty depends generally on the mix of services a physician in the
specialty furnishes.

Table 11.--Total Payment for Selected Procedures Based Upon Resource Based Malpractice Expense

[robop...@us.govnews.org]

Archive-Name: gov/us/fed/nara/fed-register/1999/jul/22/64FR39607/part4

Posting-number: Volume 64, Issue 140, Page 39607, Part 1

--------------------------------------------------------------------------------------------------------------------------------------------------------
Resource Non-
Current Resource Facility Current non- based MP facility
Code Mod Description facility based MP percent facility non- percent
facility change facility change
--------------------------------------------------------------------------------------------------------------------------------------------------------
11721......................... ......... Debride nail, 6 or more........ $32.65 $32.65 0 $37.16 $37.16 0
17000......................... ......... Destroy benign/premal lesion... 30.56 30.91 1 46.89 47.23 1
27130......................... ......... Total hip replacement.......... 1,360.78 1,312.50 -4 1,360.78 1,312.50 -4
27236......................... ......... Repair of thigh fracture....... 1,060.70 1,046.11 -1 1,060.70 1,046.11 -1
27244......................... ......... Repair of thigh fracture....... 1,074.59 1,063.83 -1 1,074.59 1,063.83 -1
27447......................... ......... Total knee replacement......... 1,422.60 1,369.12 -4 1,422.60 1,369.12 -4
33533......................... ......... CABG, arterial, single......... 1,839.38 1,814.03 -1 1,839.38 1,814.03 -1
35301......................... ......... Rechanneling of artery......... 1,065.91 1,073.20 1 1,065.91 1,073.20 1
43239......................... ......... Upper GI endoscopy, biopsy..... 139.97 137.19 -2 258.40 255.62 -1
45385......................... ......... Colonscopy, lesion removal..... 277.50 275.07 -1 391.77 389.34 -1
66821......................... ......... After cataract laser surgery... 181.65 175.05 -4 191.37 184.77 -4
66984......................... ......... Remove cataract, insert lens... 663.72 653.65 -2 663.72 653.65 -2
67210......................... ......... Treatment of retinal lesion.... 516.80 516.46 0 563.34 563.00 0
71010......................... 26 Chest x-ray.................... 8.34 8.34 0 8.34 8.34 0
71020......................... ......... Chest x-ray.................... 33.34 33.34 0 33.34 33.34 0
71020......................... 26 Chest x-ray.................... 10.07 10.07 0 10.07 10.07 0
77430......................... ......... Weekly radiation therapy....... 170.88 169.49 -1 170.88 169.49 -1
78465......................... ......... Heart image (3D) multiple...... 514.37 513.33 0 514.37 513.33 0
88305......................... ......... Tissue exam by pathologist..... 58.35 58.00 -1 58.35 58.00 -1
88305......................... 26 Tissue exam by pathologist..... 38.20 37.86 -1 38.20 37.86 -1
90801......................... ......... Psy dx interview............... 135.45 135.80 0 136.15 136.49 0
90806......................... ......... Psytx, office (45-50).......... 91.00 90.65 0 92.73 92.39 0
90807......................... ......... Psytx, office (45-50) w/e&m.... 97.60 97.25 0 96.55 96.21 0
90862......................... ......... Medication management.......... 46.54 46.19 -1 47.23 46.89 -1
90921......................... ......... ESRD related services.......... 232.70 238.61 2 232.70 238.61 2
90935......................... ......... Hemodialysis, one evaluation... 66.34 66.34 0 66.34 66.34 0
92004......................... ......... Eye exam, new patient.......... 82.31 83.70 2 114.61 116.00 1
92012......................... ......... Eye exam established pt........ 34.38 34.38 0 71.89 71.89 0
92014......................... ......... Eye exam & treatment........... 55.92 56.61 1 83.36 84.05 1
92980......................... ......... Insert intracoronary stent..... 899.89 883.57 -2 899.89 883.57 -2
92982......................... ......... Coronary artery dilation....... 679.00 658.51 -3 679.00 658.51 -3
93000......................... ......... Electrocardiogram, complete.... 25.01 24.31 -3 25.01 24.31 -3
93010......................... ......... Electrocardiogram report....... 8.34 8.34 0 8.34 8.34 0
93015......................... ......... Cardiovascular stress test..... 101.07 97.25 -4 101.07 97.25 -4
93307......................... ......... Echo exam of heart............. 193.80 192.41 -1 193.80 192.41 -1
93307......................... 26 Echo exam of heart............. 47.23 45.85 -3 47.23 45.85 -3
93510......................... 26 Left heart catheterization..... 219.16 217.77 -1 219.16 217.77 -1
98941......................... ......... Chiropractic manipulation...... 28.83 29.17 1 32.99 33.34 1
99202......................... ......... Office/outpatient visit, new... 50.71 50.71 0 64.95 64.95 0

[[Page 39633]]

99203......................... ......... Office/outpatient visit, new... 73.98 74.67 1 92.04 92.73 1
99204......................... ......... Office/outpatient visit, new... 106.28 107.32 1 129.90 130.94 1
99205......................... ......... Office/outpatient visit, new... 137.88 139.27 1 161.15 162.54 1
99211......................... ......... Office/outpatient visit, est... 13.55 13.20 -3 21.88 21.53 -2
99212......................... ......... Office/outpatient visit, est... 26.74 26.74 0 34.73 34.73 0
99213......................... ......... Office/outpatient visit, est... 36.47 36.82 1 45.85 46.19 1
99214......................... ......... Office/outpatient visit, est... 59.04 59.39 1 72.24 72.59 0
99215......................... ......... Office/outpatient visit, est... 91.69 92.39 1 105.24 105.93 1
99221......................... ......... Initial hospital care.......... 68.77 68.77 0 68.77 68.77 0
99222......................... ......... Initial hospital care.......... 109.06 109.40 0 109.06 109.40 0
99223......................... ......... Initial hospital care.......... 149.35 151.08 1 149.35 151.08 1
99231......................... ......... Subsequent hospital care....... 32.30 32.30 0 32.30 32.30 0
99232......................... ......... Subsequent hospital care....... 52.10 52.44 1 52.10 54.22 1
99233......................... ......... Subsequent hospital care....... 74.33 74.67 0 74.33 74.67 0
99236......................... ......... Observ/hosp same date.......... 209.08 212.21 1 209.08 212.21 1
99238......................... ......... Hospital discharge day......... 65.30 65.99 1 65.30 65.99 1
99239......................... ......... Hospital discharge day......... 86.83 87.87 1 86.83 87.87 1
99241......................... ......... Office consultation............ 38.55 37.86 -2 54.18 53.49 -1
99242......................... ......... Office consultation............ 70.50 70.85 0 91.00 91.34 0
99243......................... ......... Office consultation............ 93.43 93.78 0 115.66 116.00 0
99244......................... ......... Office consultation............ 134.76 135.80 1 159.42 160.46 1
99245......................... ......... Office consultation............ 176.44 177.48 1 202.14 203.18 1
99251......................... ......... Initial inpatient consult...... 39.94 39.25 -2 39.94 39.25 -2
99252......................... ......... Initial inpatient consult...... 73.28 73.63 0 73.28 73.63 0
99253......................... ......... Initial inpatient consult...... 98.98 99.33 0 98.98 99.33 0
99254......................... ......... Initial inpatient consult...... 138.58 139.62 1 138.58 139.62 1
99255......................... ......... Initial inpatient consult...... 187.90 189.63 1 187.90 189.63 1
99261......................... ......... Follow-up inpatient consult.... 26.74 26.74 0 26.74 26.74 0
99262......................... ......... Follow-up inpatient consult.... 48.28 48.28 0 48.28 48.28 0
99263......................... ......... Follow-up inpatient conult..... 68.42 69.12 1 68.42 69.12 1
99282......................... ......... Emergency dept visit........... 26.40 26.74 1 26.40 26.74 1
99283......................... ......... Emergency dept visit........... 56.27 58.00 3 56.27 58.00 3
99284......................... ......... Emergency dept visit........... 87.52 89.95 3 87.52 89.95 3
99285......................... ......... Emergency dept visit........... 135.11 139.97 3 135.11 139.97 3
99291......................... ......... Critical care, first hour...... 189.98 192.41 1 191.37 193.80 1
99292......................... ......... Critical care, addl 30 min..... 95.51 97.25 2 96.55 98.29 2
99301......................... ......... Nursing facility care.......... 62.17 62.86 1 62.17 62.86 1
99302......................... ......... Nursing facility care.......... 82.31 83.36 1 82.31 83.36 1
99303......................... ......... Nursing facility care.......... 102.11 102.81 1 102.11 102.81 1
99311......................... ......... Nursing facility care, subseq.. 31.95 31.95 0 31.95 31.95 0
99312......................... ......... Nursing facility care, subseq.. 50.36 50.71 1 50.36 50.71 1
99313......................... ......... Nursing facility care, subseq.. 70.85 71.55 1 70.85 71.55 1
99348......................... ......... Home visit, estab patient...... 67.03 67.38 1 66.68 67.03 1
99350......................... ......... Home visit, estab patient...... 146.91 148.65 1 150.04 151.78 1
--------------------------------------------------------------------------------------------------------------------------------------------------------

B. Resource-Based Practice Expense

Revisions in resource-based practice expense RVUs for physicians'
services are also calculated to be budget neutral, that is, the total
practice expense RVUs for calendar year 2000 are calculated to be the
same as the total practice expense RVUs that we estimate would have
occurred without the changes proposed in this regulation. This also
means that increases in practice expense RVUs for some services will

necessarily be offset by corresponding decreases in values for other
services.

Table 12, ``Impact on Total Allowed Charges by Specialty of the
Fully Implemented Resource-Based Practice Expense Relative Value
Units'' shows, by specialty, the estimated percent changes in allowed
charges resulting from the practice expense proposals discussed earlier
in this proposed rule. This table shows the impact of proposed changes
on the fully implemented practice expense RVUs. That is, the table
compares payments using the fully implemented RVUs published in the
November 2, 1998 final rule (63 FR 58816) to the fully implemented RVUs
reflecting changes proposed in this rule.

Table 12.--Impact on Total Allowed Charges by Specialty of the Fully-
Implemented Resource-Based Practice Expense Relative Value Units
------------------------------------------------------------------------
Allowed Impact on
charges total
Specialty (in payments
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY................................ 1.7 -8

[[Page 39634]]

CARDIAC SURGERY............................... 0.3 -8
CARDIOLOGY.................................... 3.8 -2
CLINICS....................................... 1.7 -1
DERMATOLOGY................................... 1.3 2
EMERGENCY MEDICINE............................ 0.8 -1
FAMILY PRACTICE............................... 3.2 2
GASTROENTEROLOGY.............................. 1.1 -2
GENERAL PRACTICE.............................. 1.1 2
GENERAL SURGERY............................... 2.0 0
HEMATOLOGY ONCOLOGY........................... 0.6 1
INTERNAL MEDICINE............................. 6.7 0
NEPHROLOGY.................................... 0.9 0
NEUROLOGY..................................... 0.8 1
NEUROSURGERY.................................. 0.3 1
OBSTETRICS/GYNECOLOGY......................... 0.4 3
OPHTHALMOLOGY................................. 3.8 1
ORTHOPEDIC SURGERY............................ 2.2 3
OTHER PHYSICIAN............................... 1.2 0
OTOLARYNGOLOGY................................ 0.6 2
PATHOLOGY..................................... 0.5 2
PLASTIC SURGERY............................... 0.2 1
PSYCHIATRY.................................... 1.2 -1
PULMONARY..................................... 1.0 -2
RADIATION ONCOLOGY............................ 0.6 0
RADIOLOGY..................................... 2.9 0
RHEUMATOLOGY.................................. 0.3 5
THORACIC SURGERY.............................. 0.6 -6
UROLOGY....................................... 1.3 2
VASCULAR SURGERY.............................. 0.3 0
OTHERS:
CHIROPRACTOR.............................. 0.4 0
NONPHYSICIAN PRACTITIONER................. 0.8 2
OPTOMETRIST............................... 0.5 2
PODIATRY.................................. 1.1 2
SUPPLIERS................................. 0.5 1
------------------------------------------------------------------------

Table 13 shows the percentage change in total payment (in 1999
physician fee schedule dollars) for selected high-volume procedures
which would result from the change in payment related to the proposed
changes in practice expense RVUs.

Table 13.--Total Payment for Selected Procedures
--------------------------------------------------------------------------------------------------------------------------------------------------------
Non-
Current non- Proposed facility Current Proposed Facility
Code Mod Description faculity non- percent facility facility percent
facility change change
--------------------------------------------------------------------------------------------------------------------------------------------------------
11721......................... ......... Debride nail, 6 or more........ $37.16 $37.51 1 $32.65 $27.44 -16
17000......................... ......... Destroy benign/premal lesion... 46.89 47.93 2 30.56 30.56 0
27130......................... ......... Total hip replacement.......... NA NA NA 1,360.78 1,383.36 2
27236......................... ......... Repair of thigh fracture....... NA NA NA 1,060.70 1,061.39 0
27244......................... ......... Repair of thigh fracture....... NA NA NA 1,074.59 1,045.42 -3
27447......................... ......... Total knee replacement......... NA NA NA 1,422.60 1,443.44 1
33533......................... ......... CABG, arterial, single......... NA NA NA 1,839.38 1,699.06 -8
35301......................... ......... Rechanneling of artery......... NA NA NA 1,065.91 1,058.27 -1
43239......................... ......... Upper GI endoscopy, biopsy..... 258.40 280.28 8 139.97 134.76 -4
45385......................... ......... Colonscopy, lesion removal..... 391.77 431.02 10 277.50 264.31 -5
66821......................... ......... After cataract laser surgery... 191.37 196.23 3 181.65 171.57 -6
66984......................... ......... Remove cataract, insert lens... NA NA NA 663.72 645.66 -3
67210......................... ......... Treatment of retinal lesion.... 563.34 571.33 1 516.80 522.71 1
71010......................... 26 Chest x-ray.................... 8.34 8.34 0 8.34 8.34 0
71020......................... ......... Chest x-ray.................... 33.34 33.34 0 33.34 33.34 0
71020......................... 26 Chest x-ray.................... 10.07 10.07 0 10.07 10.07 0
77430......................... ......... Weeekly radiation therapy...... 170.88 171.57 0 170.88 171.57 0
78465......................... ......... Heat image (3D) multiple....... 514.37 517.50 1 514.37 517.50 1
88305......................... ......... Tissue exam by pathologist..... 58.35 59.04 1 58.35 59.04 1
88305......................... 26 Tissue exam by pathologist..... 38.20 38.90 2 38.20 38.90 2

[[Page 39635]]

90801......................... ......... Psy dx interview............... 136.15 138.93 2 135.45 131.29 -3
90806......................... ......... Psytx, office (45-50).......... 92.73 94.12 1 91.00 88.91 -2
90807......................... ......... Psytx, office (45-50) w/e&m.... 96.55 98.64 2 97.60 94.82 -3
90862......................... ......... Midication management.......... 47.23 48.97 4 46.54 44.46 -4
90921......................... ......... ESRD related services, month... 232.70 243.12 4 232.70 218.46 -6
90935......................... ......... Hemodialysis, one evaluation... NA NA NA 6634 58.35 -12
92004......................... ......... Eye exam, new patient.......... 114.61 116.70 2 82.31 82.66 0
92012......................... ......... Eye exam established pt........ 71.89 73.63 2 34.38 34.73 1
92104......................... ......... Eye exam & treatment........... 83.36 85.09 2 55.92 55.92 0
92980......................... ......... Insert intracoronary stent..... NA NA NA 899.89 766.18 -15
92982......................... ......... Coronary artery dilation....... NA NA NA 679.00 575.85 -15
93000......................... ......... Electrocardiogram, complete.... 25.01 25.70 3 25.01 25.70 3
93010......................... ......... Electrocardiogram report....... 8.34 8.34 0 8.34 8.34 0
93015......................... ......... Cardiovascular stress test..... 101.07 101.76 1 101.07 101.76 1
93307......................... ......... Echo exam of heart............. 193.80 194.84 1 193.80 194.84 1
93307......................... 26 Echo exam of heart............. 47.23 47.23 0 47.23 47.23 0
93510......................... 26 Left heart catheterization..... 219.16 219.50 0 219.16 219.50 0
90941......................... ......... Chiropractic manipulation...... 32.99 32.99 0 28.83 28.83 0
99202......................... ......... Office/outpatient visit, new... 64.73 67.73 4 50.71 43.07 -15
99203......................... ......... Office/outpatient visit, new... 92.04 95.86 4 73.98 65.30 -12
99204......................... ......... Office/outpatient visit, new... 129.90 136.15 5 106.28 96.55 -9
99205......................... ......... Office/outpatient visit, new... 161.15 169.14 5 137.88 127.46 -8
99211......................... ......... Office/outpatient visit, est... 21.88 24.66 13 13.55 8.68 -36
99212......................... ......... Office/outpatient visit, est... 34.73 36.82 6 26.74 21.88 -18
99213......................... ......... Office/outpatient visit, est... 45.85 48.97 7 36.47 31.95 -12
99214......................... ......... Office/outpatient visit, est... 72.24 76.06 5 59.04 52.79 -11
99215......................... ......... Office/outpatient visit, est... 105.24 109.40 4 91.69 84.74 -8
99221......................... ......... Initial hospital care.......... NA NA NA 68.77 61.82 -10
99222......................... ......... Initial hospital care.......... NA NA NA 109.06 102.11 -6
99223......................... ......... Initial hosptial care.......... NA NA NA 149.35 141.36 -5
99231......................... ......... Subsequent hosptial care....... NA NA NA 32.30 30.91 -4
99232......................... ......... Subsequent hospital care....... NA NA NA 52.10 50.36 -3
99233......................... ......... Subsequent hospital care....... NA NA NA 74.33 71.55 -4
99236......................... ......... Observ/hosp same date.......... NA NA NA 209.08 201.44 -4
99238......................... ......... Hospital discharge day......... NA NA NA 65.30 60.43 -7
99239......................... ......... Hospital discharge day......... NA NA NA 86.83 82.66 -5
99241......................... ......... Office consultation............ 54.18 59.39 10 38.55 31.26 -19
99242......................... ......... Office consultation............ 91.00 96.90 6 70.50 62.86 -11
99243......................... ......... Office consultation............ 115.66 123.30 7 93.43 84.05 -10
99244......................... ......... Office consultation............ 159.42 168.80 6 134.76 123.64 -8
99245......................... ......... Office consultation............ 202.14 213.60 6 176.44 164.63 -7
00251......................... ......... Initial inpatient consult...... NA NA NA 39.94 35.08 -12
99252......................... ......... Initial impatient consult...... NA NA NA 73.28 67.38 -8
99253......................... ......... Initial inpatient consult...... NA NA NA 98.98 91.69 -7
99254......................... ......... Initial inpatient consult...... NA NA NA 138.58 130.59 -6
99255......................... ......... Initial inpatient consult...... NA NA NA 187.90 178.87 -5
99261......................... ......... Follow-up inpatient consult.... NA NA NA 26.74 22.23 -17
99262......................... ......... Follow-up inpatient consult.... NA NA NA 48.28 43.07 -11
99263......................... ......... Follow-up inpatient consult.... NA NA NA 68.42 62.86 -8
99282......................... ......... Emergency dept visit........... NA NA NA 26.40 25.01 -5
99283......................... ......... Emergency dept visit........... NA NA NA 56.27 54.88 -2
99284......................... ......... Emergency dept visit........... NA NA NA 87.52 86.13 -2
99285......................... ......... Emergency dept visit........... NA NA NA 135.11 134.41 -1
99291......................... ......... Critical care, first hour...... 191.37 193.45 1 189.98 186.16 -2
99292......................... ......... Critical care, addl 30 min..... 96.55 98.29 2 95.51 92.73 -3
99301......................... ......... Nursing facility care.......... NA NA NA 62.17 56.61 -9
99302......................... ......... Nursing facility care.......... NA NA NA 82.31 75.71 -8
99303......................... ......... Nursing facility care.......... NA NA NA 102.11 94.47 -7
99311......................... ......... Nursing facility care, subseq.. NA NA NA 31.95 28.48 -11
99312......................... ......... Nursing facility care, subseq.. NA NA NA 50.36 46.89 -7
99313......................... ......... Nursing facility care, subseq.. NA NA NA 70.85 66.68 -6
99348......................... ......... Home visit, estab patient...... 66.68 68.07 2 67.03 62.86 -6
99350......................... ......... Home visit, establ patient..... 150.04 152.12 1 146.91 141.70 -4
--------------------------------------------------------------------------------------------------------------------------------------------------------

Table 14 shows the impact of using the 1999 resource-based practice
expense RVUs, updated to reflect the year 2000 transitions, compared to
the transitioned RVUs for the year 2000 which would result from
provisions in this proposed rule.

[[Page 39636]]

Table 14.--Impact on Total Allowed Charges by Specialty of the
Transitioned Resource-Based Practice Expense Relative Value Units
------------------------------------------------------------------------
Allowed Impact on
Specialty charges (in total payments
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................... 1.7 -4
CARDIAC SURGERY......................... 0.3 -4
CARDIOLOGY.............................. 3.8 -1
CLINICS................................. 1.6 0
DERMATOLOGY............................. 1.1 1
EMERGENCY MEDICINE...................... 0.8 -1
FAMILY PRACTICE......................... 2.9 1
GASTROENTEROLOGY........................ 1.1 -1
GENERAL PRACTICE........................ 1.0 1
GENERAL SURGERY......................... 2.0 0
HEMATOLOGY ONCOLOGY..................... 0.5 1
INTERNAL MEDICINE....................... 6.3 0
NEPHROLOGY.............................. 0.9 0
NEUROLOGY............................... 0.8 0
NEUROSURGERY............................ 0.3 0
OBSTETRICS/GYNECOLOGY................... 0.4 1
OPHTHHALMOLOGY.......................... 3.5 0
ORTHOPEDIC SURGERY...................... 2.0 1
OTHER PHYSICIAN......................... 1.2 0
OTOLARYNGOLOGY.......................... 0.6 1
PATHOLOGY............................... 0.5 1
PLASTIC SURGERY......................... 0.2 1
PSYCHIATRY.............................. 1.1 0
PULMONARY............................... 1.0 -1
RADIATION ONCOLOGY...................... 0.6 0
RADIOLOGY............................... 2.9 0
RHEUMATOLOGY............................ 0.3 3
THORACIC SURGERY........................ 0.6 -3
UROLOGY................................. 1.2 1
VASCULAR SURGERY........................ 0.3 0
OTHERS:
CHIROPRACTOR........................ 0.4 1
NONPHYSICIAN PRACTITIONER........... 0.8 1
OPTOMETRIST......................... 0.4 1
PODIATRY............................ 1.0 1
SUPPLIERS........................... 0.5 0
------------------------------------------------------------------------

Table 15 shows the combined impact of the proposed changes in the
malpractice RVUs and the fully implemented practice expense RVUs. The

impact of the changes on the total revenue (Medicare and non-Medicare)

for a given specialty is less than the impact displayed in these tables

since physicians furnish services to both Medicare and non-Medicare

patients. The magnitude of the impact that Medicare payment has on a

specialty depends generally on the mix of services a physician in the

specialty provides and the sites in which the services are performed.

Table 15.--Impact on Total Allowed Charges by Specialty of Proposed
Fully Implemented Practice Expense and Malpractice Relative Value Units
------------------------------------------------------------------------
Allowed Impact on
charges total
Specialty (in payments
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY................................ 1.6 -8
CARDIAC SURGERY............................... 0.3 -9
CARDIOLOGY.................................... 3.6 -3
CLINICS....................................... 1.6 0
DERMATOLOGY................................... 1.2 2
EMERGENCY MEDICINE............................ 0.8 1
FAMILY PRACTICE............................... 3.0 2
GASTROENTEROLOGY.............................. 1.0 -2
GENERAL PRACTICE.............................. 1.1 2
GENERAL SURGERY............................... 1.9 0
HEMATOLOGY ONCOLOGY........................... 0.6 1
INTERNAL MEDICINE............................. 6.4 1
NEPHROLOGY.................................... 0.9 1
NEUROLOGY..................................... 0.8 1
NEUROSURGERY.................................. 0.3 1
OBSTETRICS/GYNECOLOGY......................... 0.4 2
OPHTHALMOLOGY................................. 3.6 0

[[Page 39637]]

ORTHOPEDIC SURGERY............................ 2.0 2
OTHER PHYSICIAN............................... 1.2 0
OTOLARYNGOLOGY................................ 0.6 2
PATHOLOGY..................................... 0.5 1
PLASTIC SURGERY............................... 0.2 1
PSYCHIATRY.................................... 1.1 -1
PULMONARY..................................... 1.0 -1
RADIATION ONCOLOGY............................ 0.6 0
RADIOLOGY..................................... 2.7 -1
RHEUMATOLOGY.................................. 0.3 6
THORACIC SURGERY.............................. 0.5 -7
UROLOGY....................................... 1.2 2
VASCULAR SURGERY.............................. 0.3 0
OTHERS:
CHIROPRACTOR.............................. 0.4 1
NONPHYSICIAN PRACTITIONER................. 0.8 1
OPTOMETRIST............................... 0.5 3
PODIATRY.................................. 1.0 3
SUPPLIERS................................. 0.4 0
------------------------------------------------------------------------

C. Practice Expense for Physician Interpretation of Abnormal
Papanicolaou Smears

Currently, there are several codes for a physician's interpretation
of an abnormal pap smear (three HCFA Common Procedure Coding System
(HCPCS) codes and one CPT code). We evaluated the practice expense RVUs
for each of these codes in a slightly different manner, and the
practice expense RVUs assigned to HCPCS code G0141 were much lower than
those for the other codes. We believe it is more appropriate to have
the RVUs for all of these codes identical to those for CPT code 88141.
Any impact of this provision would be incorporated into the physician
fee schedule budget-neutrality calculation.

D. Technical Component of Physician Pathology Services and Independent
Laboratories

Independent laboratories usually bill for a combined service which
is the sum of the PC and TC services. These services can be furnished
to both hospital and nonhospital patients.
The claims processing instructions require the independent
laboratory to use the hospital as the place of service (POS) for TC
billing of hospital patients. However, our analysis of national claims
data indicates that independent laboratories are likely to use the
independent laboratory as the POS. Thus, we cannot directly calculate
the independent laboratory's billings for the combined service to
hospital inpatients.
Based on our knowledge of laboratory practice arrangements, we have
assumed that 60 percent of the allowed charges for independent
laboratories represent billings for hospital inpatients. We adjusted
this amount to remove PC billings because they would be billable
whether or not this proposal is finalized. We estimated the PC amount
by multiplying the total allowed charges for each code by the ratio of
the PC RVUs to total RVUs for that code. The remaining amount
represents the total allowed charges for TC services for hospital
inpatients.
We estimated that payment under the physician fee schedule for TC
billings by independent laboratories will decrease by $18 million.
The hospital is paid under the prospective payment system for the
technical component of a physician pathology service to hospital
inpatients. If the independent laboratory furnishes the technical
component service, it must enter into an arrangement with a hospital to
be paid appropriately for this service.

E. Discontinuous Anesthesia Time

If an anesthesia practitioner has not been billing for a block of
time before an interruption in services, under our proposal he or she
would be able to bill for that block of time and receive payment. It is
our understanding that, in most instances, a block of time before an
interruption is generally about fifteen minutes, or one time unit. On
the other hand, some anesthesia practitioners may have interpreted our
regulations as allowing them to bill for the block of time before an
interruption. If an anesthesia practitioner has billed in this manner,
then our proposed revision to the regulations would not have any
economic effect. We estimate that overall there would be no cost or
savings to Medicare.

F. Optometrist Services

The provision for optometrists' services would conform the
regulations to a provision of OBRA 1986 that expanded coverage for
services furnished by optometrists to include services otherwise

covered by Medicare that an optometrist is legally authorized to

perform as a doctor of optometry by the State in which the services are
performed. This provision has been implemented through program
instructions; therefore, this change in the regulations will have no
impact on the program.

G. Assisted Suicide

This rule would conform the regulations to a provision in the
Assisted Suicide Funding Act of 1997. This Act prohibits the use of

Federal funds to furnish or pay for any health care service or health
benefit coverage for the purpose of causing, or assisting to cause, the

death of any individual. We believe that this regulation change would
have no program costs or savings given the limited occurrence of
assisted suicide and the exclusion from Medicare payment of expenses
for these services under section 1862(a)(1)(A) of the Act. This section
of the Act states that no payment may be made under Part A or Part B
for any expenses incurred for items or services that are not reasonable
or necessary for the

[[Page 39638]]

diagnosis or treatment of illness or injury or to improve the

functioning of a malformed body member.

H. CPT Modifier -25

Under our proposed policy for procedures when the global surgery

rules do not apply (for example, the global code is ``XXX'' in the

database), a physician may bill only for a separately identifiable E/M
service with the use of the CPT modifier -25. This proposal would

assist carriers in claims adjudication and eliminate unnecessary

denials when physicians appropriately attach modifier -25 to E/M
services if they are significant and separately identifiable from the
procedure. We estimate a savings of $10 million due to this proposal.

I. Nurse Practioner Qualifications

The proposed NP qualifications provide a mechanism that would
grandfather those individuals who have Medicare NP billing numbers
before January 1, 2001; they could continue to bill as NPs. Therefore,
an individual who may not have been nationally certified as an NP or
who does not have a master's degree in nursing would be permitted to
continue to bill under the Medicare program. However, after January 1,
2003, to obtain a Medicare NP billing number, a new applicant would be
required to possess a master's degree in nursing, State authorization
to practice as an NP, and national certification as an NP. By this
time, the advanced nursing profession would have been furnished ample
notification and time to acquire these credentials. There are no
Medicare program costs or savings associated with this provision.
Further, these requirements are consistent with our understanding of
certification and training requirements being implemented by NP groups.

J. Relative Value Units for Pediatric Services

This proposal would correct our use of the wrong data in
establishing the work RVUs for certain pediatric surgical services.
Since pediatric services are a small portion of services under
Medicare, this change would have a negligible impact on the Medicare
program.

K. Percutaneous Thrombectomy of an Arteriovenous Fistula

We are proposing to establish payment for a new HCPCS code that
more accurately describes the activities regarding percutaneous
thrombectomy of a dialysis graft or fistula. Since this is basically a
coding change we do not anticipate any costs or savings.

L. Pulse Oximetry, Temperature Gradient Studies, and Venous Pressure
Determinations

We are proposing to discontinue separate payment for CPT codes
94760 (noninvasive ear or pulse oximetry for oxygen saturation; single
determination); 94761 (non-invasive ear or pulse oximetry for oxygen
saturation; multiple determinations); 94762 (noninvasive ear or pulse
oximetry for oxygen saturation; by continuous overnight monitoring);
93740 (temperature gradient studies); and 93770 (determination of
venous pressure). Payment for these codes would be bundled into payment
for other services. Any savings from this provision would be
incorporated into the physician fee schedule budget-neutrality
calculation.

M. Removal of Requirement for X-ray Before Chiropractic Manipulation

This rule will conform the regulations to section 4513(a) of the
BBA. We expect that removal of the requirement will encourage increased
billing for chiropractic manipulation. The impact of this BBA provision
is shown in the table below.

Estimated Costs
[$ millions]
------------------------------------------------------------------------

------------------------------------------------------------------------
FY 2000.................................................... $20
FY 2001.................................................... 40
FY 2002.................................................... 50
------------
Total.................................................. 110
------------------------------------------------------------------------

N. Coverage of Prostate Cancer Screening Tests

Section 4103 of the BBA authorizes coverage of certain prostate
cancer screening tests, effective January 1, 2000, subject to certain
frequency and payment limitations. The new tests include: (1) Screening
DREs, and (2) screening prostate-specific antigen tests. Based on the
projected utilization of these screening services and related medically
necessary follow-up tests and treatment that may be required for the
beneficiaries screened, we estimate that this BBA provision will result
in an increase in Medicare payments as described in the table below for
fiscal years 2000 through 2002. These payments will be made to many
urologists, primary care physicians, and other practitioners (involved
in screening DREs), and to clinical laboratories (involved in screening
prostate-specific antigen tests) nationally.

Estimated Medicare Costs
[$ million]
------------------------------------------------------------------------
Part A Part B
------------------------------------------------------------------------
FY 2000....................................... $170 $590
FY 2001....................................... 300 1,100
FY 2002....................................... 400 1,270
-------------------------
Total..................................... 870 2,960
------------------------------------------------------------------------

We believe that the effect of the rule will be positive. Prostate
cancer is the most commonly diagnosed cancer in men and the second
leading cause of cancer death for American men. The American Cancer
Society estimates that in 1999 about 179,000 new cases of prostate
cancer will be diagnosed in the United States, and about 37,000 will
die directly from the disease. According to the American Urological
Association, the use of a screening prostate-specific antigen blood
test in combination with a screening DRE is the best method for
detecting prostate cancer when the disease is localized and potentially
curable. Although coverage of prostate cancer screening should improve
access to this service for Medicare beneficiaries, the benefits of such
screening, based on the available medical literature, are not entirely
clear. The literature on the benefits of cancer detection especially
among men over 70 indicates that screening for prostate cancer does not
necessarily lead to the prolongation of life or improvement in the
quality of life. However, when prostate cancer is found early, there is
evidence that it can often be treated successfully. Through early
detection of prostate cancer made possible under the new benefit and
the use of appropriate treatment measures, our expectation is that the
harmful effects of this serious disease among the Medicare population
will be reduced in the future.

O. Diagnostic Tests

1. Supervision of Diagnostic Test

This proposal would conform the requirements of the physician
supervision policy in Sec. 410.32(b) with BBA provisions relating to
PAs, NPs, and CNSs. We would clarify that the level of physician
supervision for diagnostic tests performed by PAs, when they are
authorized by the State to perform these tests, is general. This means
that we would not require that the supervising physician for the
diagnostic test be on the premises when the test is performed. It will
mean that no level of physician supervision is required for diagnostic

tests performed by NPs and CNSs when they are authorized by the State

to perform these tests. The proposal would not affect the

[[Page 39639]]

scope of services for which PAs, NPs or CNs could bill; therefore, we
do not expect any significant costs or savings.
2. Independent Diagnostic Testing Facilities (IDTF)
The IDTF proposal would clarify Sec. 410.33 to the effect that NPs
and CNSs are included among the entities that may bill carriers
directly for diagnostic tests. This proposal is a technical one and
would not have a significant effect on costs or savings.

P. New and Revised Relative Value Units for Calender Year 1999

1. Ventricular Assist Device Implantations

This proposal would suspend the global period and allow the surgeon
to bill all postoperative E/M visits. Although, we anticipate an
increase in billing for these codes, the anticipated economic impact on
the Medicare program is negligible because of the minimal use of these
services.

2. Use of Operating Microscope

CPT code 69990 replaced two previous codes that were add-on codes
(61712 and 64830) and also replaced use of a ``-20'' microsurgery
modifier. For clarification purposes, we are identifying the primary
procedure codes for which we would pay separately for code 69990 since
this is limited to those primary procedures for which the use of
previous codes 61712 or 64830 was acceptable. There are no costs or
savings associated with this proposal because it is a clarification in
coding rather than a change in value.
3. Pulmonary Stress Testing
For 1999, the work RVUs established for CPT 94620 (simple pulmonary
stress testing) were 0.88; the same work RVUs were assigned to the
newly created code 94621, complex pulmonary stress testing. We are
proposing to establish the work RVUs at 0.64 for CPT code 94620 and at
1.42 for CPT code 94621 based on the estimated frequencies. This
proposal would not impact costs or savings to the Medicare program but
would maintain budget neutrality for work RVUs for these codes.

Q. Budget-Neutrality

Each year since the fee schedule has been implemented, our
actuaries have determined any adjustments needed to meet the budget-
neutrality requirement of the statute. A component of the actuarial
determination of budget-neutrality involves estimating the impact of
changes in the volume-and-intensity of physicians' services provided to
Medicare beneficiaries as a result of the proposed changes. Consistent
with the provision in the November 2, 1999 final rule, the actuaries
would use a model that assumes a 30 percent volume-and-intensity
response to price reductions.

R. Impact on Beneficiaries

Although changes in physicians' payments when the physician fee
schedule was implemented in 1992 were large, we detected no problems
with beneficiary access to care. Furthermore, because there is a four-
year transition of the resource-based practice expense system, we
expect minimal impact on beneficiaries.
We are currently conducting substantial research to evaluate
beneficiary access to physicians. This research includes, but is not
limited to, augmenting the beneficiary survey questionnaire to further
clarify access problems, conducting a survey of Medicare physicians to
identify physician specialties and procedures by geographic areas, and
tracking claims data in ``vulnerable populations''.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 410

Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Rural areas, X-rays.

42 CFR Part 411

Kidney diseases, Medicare, Reporting and recordkeeping
requirements.

42 CFR Part 414

Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.

42 CFR Part 415

Health facilities, Health professions, Medicare and Reporting and
recordkeeping requirements.

For the reasons set forth in the preamble, 42 CFR chapter IV would
be amended as follows:

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

A. Part 410 is amended as set forth below:
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).

2. In Sec. 410.22, paragraph (b)(1) is revised to read as follows:

Sec. 410.22. Limitations on services of a chiropractor.

* * * * *
(b) Limitations on services. (1) Medicare Part B pays only for a

chiropractor's manual manipulation of the spine to correct a
subluxation if the subluxation has resulted in a neuromusculoskeletal

condition for which manual manipulation is appropriate treatment.
* * * * *
3. Section 410.23 is revised to read as follows:

Sec. 410.23 Limitations on services of an optometrist.

Medicare Part B pays for the services of a doctor of optometry,
acting within the scope of his or her license, if the services would be
covered as physicians' services when performed by a doctor of medicine
or osteopathy.

4. In Sec. 410.32, the introductory text to paragraph (b)(2) is
republished for the convenience of the reader, paragraph (b)(2) is
amended by adding new paragraphs (b)(2)(v) and (b)(2)(vi), and the
introductory text to paragraph (b)(3) is revised to read as follows:

Sec. 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and
other diagnostic tests: Conditions.

* * * * *
(b) Diagnostic x-ray and other diagnostic tests. * * *
(2) Exceptions. The following diagnostic tests payable under the
physician fee schedule are excluded from the basic rule set forth in
paragraph (b)(1) of this section:
* * * * *
(v) Diagnostic tests performed by a nurse practitioner or clinical
nurse specialist authorized to perform the tests under applicable State
laws.
(vi) Pathology and laboratory procedures listed in the 80000 series
of the Current Procedural Terminology published by the American Medical
Association.
(3) Levels of supervision. Except where otherwise indicated, all
diagnostic x-ray and other diagnostic tests subject to this provision
and payable under the physician fee schedule must be furnished under at
least a general level of physician supervision as defined in paragraph
(b)(3)(i) of this section. In addition, some of these tests also
require either direct or personal supervision as defined in paragraphs
(b)(3)(ii) or (b)(3)(iii) of this section, respectively. (However,
diagnostic tests a physician

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assistant is legally authorized to perform under State law require only
a general level of physician supervision.) When direct or personal
supervision is required, physician supervision at the specified level
is required throughout the performance of the test.

* * * * *

5. In Sec. 410.33, paragraph (a)(1) is revised to read as follows:

Sec. 410.33 Independent diagnostic testing facility.

(a) General rule. (1) Effective for diagnostic procedures performed
on or after March 15, 1999, carriers will pay for diagnostic procedures
under the physician fee schedule only when performed by a physician, a
group practice of physicians, an approved supplier of portable x-ray
services, a nurse practitioner or a clinical nurse specialist when he
or she performs a test he or she is authorized by the State to perform,
or an independent diagnostic testing facility (IDTF). An IDTF may be a
fixed location, a mobile entity, or an individual nonphysician
practitioner. It is independent of a physician's office or hospital;
however, these rules apply when an IDTF furnishes diagnostic procedures
in a physician's office.

* * * * *

6. A new Sec. 410.39 is added to read as follows:

Sec. 410.39 Prostate cancer screening tests: Conditions for and
limitations on coverage.

(a) Definitions. As used in this section, the following definitions
apply:
(1) Prostate cancer screening tests means any of the following
procedures furnished to an individual for the purpose of early
detection of prostate cancer:
(i) A screening digital rectal examination.
(ii) A screening prostate-specific antigen blood test.
(iii) For years beginning after 2002, other procedures HCFA finds

appropriate for the purpose of early detection of prostate cancer,
taking into account changes in technology and standards of medical

practice, availability, effectiveness, costs, and other factors HCFA
considers appropriate.
(2) A screening digital rectal examination means a clinical
examination of an individual's prostate for nodules or other
abnormalities of the prostate.
(3) A screening prostate-specific antigen blood test means a test
that measures the level of prostate-specific antigen in an individual's
blood.
(4) An attending physician for purposes of this provision means a

doctor of medicine or osteopathy (as defined in section 1861(r)(1) of

the Act) who is fully knowledgeable about the beneficiary's medical
condition, and who would be responsible for using the results of any
examination performed in the overall management of the beneficiary's
specific medical problem.
(5) An attending physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife, for purposes of this
provision means a physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife (as defined in sections
1861(aa) and 1861(gg) of the Act) who is fully knowledgeable about the
beneficiary's medical condition, and who would be responsible for using
the results of any examination performed in the overall management of
the beneficiary's specific medical problem.
(b) Condition for coverage of screening digital rectal
examinations. Medicare Part B pays for a screening digital rectal
examination if it is performed by the beneficiary's attending

physician, or by the beneficiary's attending physician assistant, nurse

practitioner, clinical nurse specialist, or certified nurse midwife as
defined in paragraphs (a)(4) or (a)(5) of this section who is
authorized to perform this service under State law.
(c) Limitation on coverage of screening digital rectal
examinations. (1) Payment may not be made for a screening digital
rectal examination performed for a man age 50 or younger.
(2) For an individual over 50 years of age, payment may be made for
a screening digital rectal examination only if the man has not had such

an examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening

digital rectal examination was performed.
(d) Condition for coverage of screening prostate-specific antigen
blood tests. Medicare Part B pays for a screening prostate-specific
antigen blood test if it is ordered by the beneficiary's attending

physician, or by the beneficiary's attending physician assistant, nurse

practitioner, clinical nurse specialist, or certified nurse midwife as
defined in paragraphs (a)(4) or (a)(5) of this section who is

authorized to order this test under State law.

(e) Limitation on coverage of screening prostate-specific antigen
blood test. (1) Payment may not be made for a screening prostate-
specific antigen blood test performed for a man under age 50.
(2) For an individual over 50 years of age, payment may be made for
a screening prostate-specific antigen blood test only if the man has

not had such an examination paid for by Medicare during the preceding
11 months following the month in which his last Medicare-covered

screening prostate-specific antigen blood test was performed.
7. In Sec. 410.75, paragraph (b) is revised to read as follows:

Sec. 410.75 Nurse practitioner's services.

* * * * *

(b) Qualifications. For Medicare Part B coverage of his or her
services, a nurse practitioner must--

(1)(i) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(2) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000.

(3) On or after January 1, 2001, nurse practitioners applying for a
Medicare billing number for the first time must meet the standards for

nurse practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this
section.

(4) On or after January 1, 2003, nurse practitioners applying for a
Medicare billing number for the first time must possess a master's

degree in nursing and meet the standards for nurse practitioners in
paragraphs (b)(1)(i) and (b)(1)(ii) of this section.

* * * * *

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE
PAYMENT

B. Part 411 is amended as set forth below:
1. The authority citation for part 411 continues to read as
follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).

2. In Sec. 411.15, the introductory text to the section is revised,
the introductory text to paragraph (a) is republished, paragraph (a)(1)
is revised, the introductory text to paragraph (k) is republished, and
new paragraphs (k)(9) and (q) are added to read as follows:

Sec. 411.15 Particular services excluded from coverage.

The following services are excluded from coverage:

[[Page 39641]]

(a) Routine physical checkups such as:
(1) Examinations performed for a purpose other than treatment or
diagnosis of a specific illness, symptoms, complaint, or injury, except
for screening mammography, colorectal cancer screening tests, screening
pelvic examinations, or prostate cancer screening tests that meet the
criteria specified in paragraphs (k)(6) through (k)(9) of this section.

* * * * *

(k) Any services that are not reasonable and necessary for one of
the following purposes:

* * * * *

(9) In the case of prostate cancer screening tests, for the purpose
of early detection of prostate cancer, subject to the conditions and
limitations specified in Sec. 410.39 of this chapter.

* * * * *

(q) Assisted suicide. Any health care service used for the purpose
of causing, or assisting to cause, the death of any individual. This
does not pertain to the withholding or withdrawing of medical treatment
or care, nutrition or hydration or to the provision of a service for
the purpose of alleviating pain or discomfort, even if the use may
increase the risk of death, so long as the service is not furnished for
the specific purpose of causing death.

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

C. Part 414 is amended as set forth below:
1. The authority citation for part 414 continues to read as
follows:

Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social
Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1).

2. In Sec. 414.22, the introductory text is republished, paragraph
(b)(5)(i) is revised, and a new paragraph (c)(3) is added to read as
follows:

Sec. 414.22 Relative value units (RVUs).

HCFA establishes RVUs for physicians' work, practice expense, and
malpractice insurance.

* * * * *

(b) Practice expense RVUs. * * *
(5) * * *
(i) Usually one of two levels of practice expense RVUs can be
applied to each code. The lower facility practice expense RVUs apply to
services furnished to hospital, skilled nursing facility, or ambulatory
surgical center patients. The higher non-facility practice expense RVUs
apply to services performed in a physician's office, services furnished
to patients in a nursing facility, in a facility or institution other
than a hospital, skilled nursing facility, or ambulatory surgical
center, or in the home. The facility practice expense RVUs for a
particular code may not be greater than the non-facility RVUs for that
code.

* * * * *

(c) Malpractice insurance RVUs. * * *
(3) For services furnished in the year 2000 and subsequent years,

the malpractice RVUs are based on the relative malpractice insurance

resources.
3. In Sec. 414.46, the introductory texts to paragraphs (a) and (b)
are republished, paragraphs (a)(1) and (a)(2) are revised, paragraph
(a)(3) is added, and paragraphs (b)(1) and (b)(2) are revised to read
as follows:

Sec. 414.46 Additional rules for payment of anesthesia services.

(a) Definitions. For purposes of this section, the following
definitions apply:
(1) Base unit means the value for each anesthesia code that
reflects all activities other than anesthesia time. These activities
include usual preoperative and postoperative visits, the administration
of fluids and blood incident to anesthesia care, and monitoring
services.
(2) Anesthesia practitioner, for the purpose of anesthesia time,
means a physician who performs the anesthesia service alone, a CRNA who
is not medically directed who performs the anesthesia service alone, or
a medically directed CRNA.
(3) Anesthesia time means the time during which an anesthesia
practitioner is present with the patient. It starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services and
ends when the anesthesia practitioner is no longer furnishing
anesthesia services to the beneficiary, that is, when the beneficiary
may be placed safely under postoperative care. Anesthesia time is a
continuous time period from the start of anesthesia to the end of an
anesthesia service. In counting anesthesia time, the anesthesia
practitioner can add blocks of anesthesia time around an interruption
in anesthesia time as long as the anesthesia practitioner is furnishing
continuous anesthesia care within the time periods around the
interruption.
(b) Determinations of payment amount--Basic rule. For anesthesia
services performed, medically directed, or medically supervised by a
physician, the carrier pays the lesser of the actual charge or the
anesthesia fee schedule amount.
(1) The carrier bases the physician fee schedule amount for an
anesthesia service on the product of the sum of allowable base and time
units and an anesthesia-specific CF. The carrier calculates the time
units from the anesthesia time reported by the anesthesia practitioner
for the anesthesia procedure. The physician who fulfills the conditions
for medical direction in Sec. 415.110 (Conditions for payment:
Anesthesiology services) reports the same anesthesia time as the
medically-directed CRNA.
(2) HCFA furnishes the carrier with the base units for each
anesthesia procedure code. The base units are derived from the 1988
American Society of Anesthesiologists' Relative Value Guide except that
the number of base units recognized for anesthesia services furnished
during cataract or iridectomy surgery is four units.

* * * * *

4. In Sec. 414.60, the introductory text of paragraph (a) is

revised to read as follows:

Sec. 414.60 Payment for the services of CRNAs.

(a) Basis for payment. The allowance for the anesthesia service
furnished by a CRNA, medically directed or not medically directed, is
based on allowable base and time units as defined in Sec. 414.46(a).
Beginning with CY 1994--

* * * * *

PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS,
SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN
CERTAIN SETTINGS

D. Part 415 is amended as set forth below:
1. The authority citation for part 415 continues to read as
follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).

2. Section 415.130(c) is revised to read as follows:

Sec. 415.130 Conditions for payment; Physician pathology services.

* * * * *

(c) Physician pathology services furnished by an independent
laboratory. The technical component of physician pathology services, as
described in paragraph (a) of this section, furnished to a hospital
inpatient before January 1, 2000, or to an outpatient can be paid on a
fee schedule basis under this subpart. On or after January 1, 2000,
payment is made only to the hospital for the technical component of
physician

[[Page 39642]]

pathology services furnished to a hospital inpatient.

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)

(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

Dated: May 27, 1999.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.

Dated: June 29, 1999.
Donna E. Shalala,
Secretary.

Note: These addenda will not appear in the Code of Federal
Regulations.

Addendum A--Explanation and Use of Addenda B

The addenda on the following pages provide various data
pertaining to the Medicare fee schedule for physicians' services
furnished in 2000. Addendum B contains the RVUs for work, non-
facility practice expense, facility practice expense, and
malpractice expense, and other information for all services included
in the physician fee schedule.

Addendum B--2000 Relative Value Units and Related Information Used in
Determining Medicare Payments for 2000

This addendum contains the following information for each CPT
code and alphanumeric HCPCS code, except for alphanumeric codes
beginning with B (enteral and parenteral therapy), E (durable
medical equipment), K (temporary codes for nonphysicians' services
or items), or L (orthotics), and codes for anesthesiology.
1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number
for the service. Alphanumeric HCPCS codes are included at the end of
this addendum.
2. Modifier. A modifier is shown if there is a technical
component (modifier TC) and a professional component (PC) (modifier
-26) for the service. If there is a PC and a TC for the service,
Addendum B contains three entries for the code: One for the global
values (both professional and technical); one for modifier -26 (PC);
and one for modifier TC. The global service is not designated by a
modifier, and physicians must bill using the code without a modifier
if the physician furnishes both the PC and the TC of the service.
Modifier -53 is shown for a discontinued procedure. There will
be RVUs for the code (CPT code 45378) with this modifier.
3. Status indicator. This indicator shows whether the CPT/HCPCS
code is in the physician fee schedule and whether it is separately
payable if the service is covered.
A = Active code. These codes are separately payable under the
fee schedule if covered. There will be RVUs for codes with this
status. The presence of an ``A'' indicator does not mean that
Medicare has made a national decision regarding the coverage of the
service. Carriers remain responsible for coverage decisions in the
absence of a national Medicare policy.
B = Bundled code. Payment for covered services is always bundled
into payment for other services not specified. If RVUs are shown,
they are not used for Medicare payment. If these services are
covered, payment for them is subsumed by the payment for the
services to which they are incident. (An example is a telephone call
from a hospital nurse regarding care of a patient.)
C = Carrier-priced code. Carriers will establish RVUs and
payment amounts for these services, generally on a case-by-case
basis following review of documentation, such as an operative
report.
D = Deleted code. These codes are deleted effective with the
beginning of the calendar year.
E = Excluded from physician fee schedule by regulation. These
codes are for items or services that we chose to exclude from the
physician fee schedule payment by regulation. No RVUs are shown, and
no payment may be made under the physician fee schedule for these
codes. Payment for them, if they are covered, continues under
reasonable charge or other payment procedures.
G = Code not valid for Medicare purposes. Medicare does not
recognize codes assigned this status. Medicare uses another code for
reporting of, and payment for, these services.
N = Noncovered service. These codes are noncovered services.
Medicare payment may not be made for these codes. If RVUs are shown,
they are not used for Medicare payment.
P = Bundled or excluded code. There are no RVUs for these
services. No separate payment should be made for them under the
physician fee schedule.

--If the item or service is covered as incident to a physician's
service and is furnished on the same day as a physician's service,
payment for it is bundled into the payment for the physician's
service to which it is incident (an example is an elastic bandage
furnished by a physician incident to a physician's service).
--If the item or service is covered as other than incident to a
physician's service, it is excluded from the physician fee schedule
(for example, colostomy supplies) and is paid under the other
payment provisions of the Act.

R = Restricted coverage. Special coverage instructions apply. If
the service is covered and no RVUs are shown, it is carrier-priced.
T = Injections. There are RVUs for these services, but they are
only paid if there are no other services payable under the physician
fee schedule billed on the same date by the same provider. If any
other services payable under the physician fee schedule are billed
on the same date by the same provider, these services are bundled
into the service(s) for which payment is made.
X = Exclusion by law. These codes represent an item or service
that is not within the definition of ``physicians' services'' for
physician fee schedule payment purposes. No RVUs are shown for these
codes, and no payment may be made under the physician fee schedule.
(Examples are ambulance services and clinical diagnostic laboratory
services.)
4. Description of code. This is an abbreviated version of the

narrative description of the code.

5. Physician work RVUs. These are the RVUs for the physician
work for this service in 2000. Codes that are not used for Medicare
payment are identified with a ``+.''
6. Fully implemented non-facility practice expense RVUs. These
are the fully implemented resource-based practice expense RVUs for
non-facility settings.
7. Year 2000 Transition non-facility practice expense RVUs.
Blended non-facility practice expense RVUs for use in 2000.
8. Fully implemented facility practice expense RVUs. These are
the fully implemented resource-based practice expense RVUs for
facility settings.
9. Year 2000 transition facility practice expense RVUs. Blended
facility practice expense RVUs for use in 2000.
10. Malpractice expense RVUs. These are the RVUs for the
malpractice expense for the service for 2000.
11. Fully implemented non-facility total. This is the sum of the
work, fully implemented non-facility practice expense, and
malpractice expense RVUs.
12. Year 2000 transition non-facility total. This is the sum of
the work, transition non-facility practice expense, and malpractice
expense RVUs for use in 2000.
13. Fully implemented facility total. This is the sum of the
work, fully implemented facility practice expense, and malpractice
expense RVUs.
14. Year 2000 transition facility total. This is the sum of the
work, transition facility practice expense, and malpractice expense
RVUs for use in 2000.
15. Global period. This indicator shows the number of days in
the global period for the code (0, 10, or 90 days). An explanation
of the alpha codes follows:
MMM = The code describes a service furnished in uncomplicated
maternity cases including antepartum care, delivery, and postpartum
care. The usual global surgical concept does not apply. See the 1999
Physicians' Current Procedural Terminology for specific definitions.
XXX = The global concept does not apply.
YYY = The global period is to be set by the carrier (for
example, unlisted surgery codes).
ZZZ = The code is part of another service and falls within the
global period for the other service.

Addendum B--2000 Relative Value Units and Related Information Used in
Determining Medicare Payments for 2000

<hbond><hbond><hbond><hbond><hbond><hbond><hbond><hbond><hbond><hbond>
<hbond><hbond>\4\ PE RVUs = Practice Expense Relative Value
Units.

\5\ # Indicates new CPT/HCPCS codes which were not factored into budget
neutrality adjustments.

[[Page 39643]]

Addendum B.--Relative Value Units (RVUs) and Related Information
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Fully Fully
Physician implemented Year 2000 Fully Year 2000 implemented Year 2000 Fully Year 2000
CPT\1\/ MOD Status Description work non- transitional implemented transitional Malpractice non- transitional implemented transitional Global
HCPCS\2\ RVUs<SUP>3,</SUP>\<SUP>5</SUP> facility PE non-facility facility PE facility PE RVUs facility non-facility facility facility
RVUs PE RVUs RVUs RVUs total total total total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10040 ......... A Acne surgery of 1.18 1.31 0.83 0.54 0.36 0.05 2.54 2.06 1.77 1.59 010
skin abscess.
10060 ......... A Drainage of skin 1.17 1.20 0.84 0.60 0.42 0.08 2.45 2.09 1.85 1.67 010
abscess.
10061 ......... A Drainage of skin 2.40 1.84 1.27 1.11 0.73 0.17 4.41 3.84 3.68 3.30 010
abscess.
10080 ......... A Drainage of 1.17 1.83 1.19 0.66 0.47 0.09 3.09 2.45 1.92 1.73 010
pilonidal cyst.
10081 ......... A Drainage of 2.45 2.47 1.84 1.43 1.02 0.21 5.13 4.50 4.09 3.68 010
pilonidal cyst.
10120 ......... A Remove foreign 1.22 1.65 1.08 0.66 0.46 0.10 2.97 2.40 1.98 1.78 010
body.
10121 ......... A Remove foreign 2.69 2.62 1.86 1.70 1.13 0.25 5.56 4.80 4.64 4.07 010
body.
10140 ......... A Drainage of 1.53 1.27 0.90 0.81 0.54 0.11 2.91 2.54 2.45 2.18 010
hematoma/fluid.
10160 ......... A Puncture drainage 1.20 1.43 0.92 0.70 0.46 0.10 2.73 2.22 2.00 1.76 010
of lesion.
10180 ......... A Complex drainage, 2.25 1.31 1.23 1.24 1.19 0.24 3.80 3.72 3.73 3.68 010
wound.
11000 ......... A Debride infected 0.60 0.51 0.47 0.23 0.23 0.04 1.15 1.11 0.87 0.87 000
skin.
11001 ......... A Debride infect 0.30 0.28 0.28 0.12 0.13 0.02 0.60 0.60 0.44 0.45 ZZZ
skin add-on.
11010 ......... A Debride skin, fx.. 4.20 2.14 3.22 1.88 3.09 0.38 6.72 7.80 6.46 7.67 010
11011 ......... A Debride skin/ 4.95 3.48 4.30 2.56 3.84 0.51 8.94 9.76 8.02 9.30 000
muscle, fx.
11012 ......... A Debride skin/ 6.88 4.88 6.00 3.98 5.55 0.74 12.50 13.62 11.60 13.17 000
muscle/bone, fx.
11040 ......... A Debride skin 0.50 0.46 0.45 0.19 0.21 0.03 0.99 0.98 0.72 0.74 000
partial.
11041 ......... A Debride skin full. 0.82 0.61 0.61 0.32 0.32 0.06 1.49 1.49 1.20 1.20 000
11042 ......... A Debride skin/ 1.12 0.86 0.79 0.44 0.40 0.09 2.07 2.00 1.65 1.61 000
tissue.
11043 ......... A Debride tissue/ 2.38 2.25 2.11 1.34 1.65 0.23 4.86 4.72 3.95 4.26 010
muscle.
11044 ......... A Debride tissue/ 3.06 2.95 3.01 1.78 2.42 0.31 6.32 6.38 5.15 5.79 010
muscle/bone.
11055 ......... R Trim skin lesion.. 0.27 0.34 0.31 0.11 0.13 0.02 0.63 0.60 0.40 0.42 000
11056 ......... R Trim 2 to 4 skin 0.39 0.38 0.38 0.15 0.17 0.03 0.80 0.80 0.57 0.59 000
lesions.
11057 ......... R Trim over 4 skin 0.50 0.42 0.36 0.20 0.18 0.03 0.95 0.89 0.73 0.71 000
lesions.
11100 ......... A Biopsy of skin 0.81 1.27 0.91 0.37 0.33 0.04 2.12 1.76 1.22 1.18 000
lesion.
11101 ......... A Biopsy, skin add- 0.41 0.56 0.44 0.19 0.18 0.02 0.99 0.87 0.62 0.61 ZZZ
on.
11200 ......... A Removal of skin 0.77 0.97 0.72 0.32 0.28 0.04 1.78 1.53 1.13 1.09 010
tags.
11201 ......... A Remove skin tags 0.29 0.37 0.28 0.13 0.11 0.02 0.68 0.59 0.44 0.42 ZZZ
add-on.
11300 ......... A Shave skin lesion. 0.51 0.88 0.73 0.22 0.26 0.03 1.42 1.27 0.76 0.80 000
11301 ......... A Shave skin lesion. 0.85 0.96 0.85 0.40 0.39 0.04 1.85 1.74 1.29 1.28 000
11302 ......... A Shave skin lesion. 1.05 1.06 1.02 0.49 0.49 0.05 2.16 2.12 1.59 1.59 000
11303 ......... A Shave skin lesion. 1.24 1.17 1.33 0.55 0.65 0.06 2.47 2.63 1.85 1.95 000
11305 ......... A Shave skin lesion. 0.67 0.77 0.67 0.28 0.28 0.04 1.48 1.38 0.99 0.99 000
11306 ......... A Shave skin lesion. 0.99 0.97 0.87 0.44 0.42 0.05 2.01 1.91 1.48 1.46 000
11307 ......... A Shave skin lesion. 1.14 1.05 1.04 0.51 0.51 0.06 2.25 2.24 1.71 1.71 000
11308 ......... A Shave skin lesion. 1.41 1.17 1.35 0.62 0.69 0.08 2.66 2.84 2.11 2.18 000
11310 ......... A Shave skin lesion. 0.73 0.97 0.86 0.34 0.36 0.04 1.74 1.63 1.11 1.13 000
11311 ......... A Shave skin lesion. 1.05 1.07 1.00 0.51 0.49 0.05 2.17 2.10 1.61 1.59 000
11312 ......... A Shave skin lesion. 1.20 1.13 1.18 0.58 0.60 0.06 2.39 2.44 1.84 1.86 000
11313 ......... A Shave skin lesion. 1.62 1.39 1.51 0.78 0.80 0.08 3.09 3.21 2.48 2.50 000
11400 ......... A Removal of skin 0.91 2.11 1.35 0.68 0.49 0.07 3.09 2.33 1.66 1.47 010
lesion.
11401 ......... A Removal of skin 1.32 2.14 1.44 0.92 0.65 0.10 3.56 2.86 2.34 2.07 010
lesion.
11402 ......... A Removal of skin 1.61 2.24 1.61 0.92 0.71 0.12 3.97 3.34 2.65 2.44 010
lesion.
11403 ......... A Removal of skin 1.92 2.05 1.66 1.06 0.85 0.16 4.13 3.74 3.14 2.93 010
lesion.
11404 ......... A Removal of skin 2.20 2.20 1.85 1.15 0.95 0.19 4.59 4.24 3.54 3.34 010
lesion.
11406 ......... A Removal of skin 2.76 2.96 2.50 1.38 1.71 0.26 5.98 5.52 4.40 4.73 010
lesion.
11420 ......... A Removal of skin 1.06 1.80 1.18 0.73 0.51 0.08 2.94 2.32 1.87 1.65 010
lesion.
11421 ......... A Removal of skin 1.53 2.10 1.44 0.93 0.66 0.11 3.74 3.08 2.57 2.30 010
lesion.
11422 ......... A Removal of skin 1.76 2.23 1.63 1.00 0.76 0.13 4.12 3.52 2.89 2.65 010
lesion.
11423 ......... A Removal of skin 2.17 2.17 1.80 1.20 0.96 0.18 4.52 4.15 3.55 3.31 010
lesion.
11424 ......... A Removal of skin 2.62 2.33 1.92 1.37 1.07 0.21 5.16 4.75 4.20 3.90 010
lesion.
11426 ......... A Removal of skin 3.78 3.39 2.69 1.84 1.92 0.34 7.51 6.81 5.96 6.04 010
lesion.
11440 ......... A Removal of skin 1.15 2.20 1.48 0.88 0.63 0.08 3.43 2.71 2.11 1.86 010
lesion.
11441 ......... A Removal of skin 1.61 2.34 1.63 1.08 0.77 0.11 4.06 3.35 2.80 2.49 010
lesion.
11442 ......... A Removal of skin 1.87 2.43 1.83 1.18 0.90 0.14 4.44 3.84 3.19 2.91 010
lesion.
11443 ......... A Removal of skin 2.49 2.90 2.24 1.50 1.15 0.19 5.58 4.92 4.18 3.83 010
lesion.
11444 ......... A Removal of skin 3.42 2.93 2.27 1.94 1.37 0.26 6.61 5.95 5.62 5.05 010
lesion.
11446 ......... A Removal of skin 4.49 3.92 2.93 2.41 1.69 0.34 8.75 7.76 7.24 6.52 010
lesion.
11450 ......... A Removal, sweat 2.73 3.71 3.31 0.90 1.91 0.24 6.68 6.28 3.87 4.88 090
gland lesion.
11451 ......... A Removal, sweat 3.95 4.26 3.71 1.63 2.39 0.39 8.60 8.05 5.97 6.73 090
gland lesion.
11462 ......... A Removal, sweat 2.51 3.48 3.05 0.99 1.81 0.24 6.23 5.80 3.74 4.56 090
gland lesion.
11463 ......... A Removal, sweat 3.95 4.91 3.54 1.62 1.90 0.41 9.27 7.90 5.98 6.26 090
gland lesion.
11470 ......... A Removal, sweat 3.25 4.43 3.73 1.30 2.16 0.32 8.00 7.30 4.87 5.73 090
gland lesion.
11471 ......... A Removal, sweat 4.41 5.24 3.96 1.81 2.24 0.44 10.09 8.81 6.66 7.09 090
gland lesion.
11600 ......... A Removal of skin 1.41 2.28 1.76 1.07 0.85 0.10 3.79 3.27 2.58 2.36 010
lesion.
11601 ......... A Removal of skin 1.93 2.19 1.85 0.83 0.80 0.12 4.24 3.90 2.88 2.85 010
lesion.
11602 ......... A Removal of skin 2.09 2.35 2.17 1.23 1.11 0.13 4.57 4.39 3.45 3.33 010
lesion.
11603 ......... A Removal of skin 2.35 2.19 2.32 1.31 1.27 0.16 4.70 4.83 3.82 3.78 010
lesion.
11604 ......... A Removal of skin 2.58 2.33 2.57 1.40 1.41 0.19 5.10 5.34 4.17 4.18 010
lesion.
11606 ......... A Removal of skin 3.43 3.20 3.29 1.72 2.55 0.30 6.93 7.02 5.45 6.28 010
lesion.
11620 ......... A Removal of skin 1.34 2.22 1.84 0.97 0.85 0.09 3.65 3.27 2.40 2.28 010
lesion.
11621 ......... A Removal of skin 1.97 2.33 2.12 1.23 1.09 0.12 4.42 4.21 3.32 3.18 010
lesion.
11622 ......... A Removal of skin 2.34 2.49 2.44 1.39 1.30 0.15 4.98 4.93 3.88 3.79 010
lesion.
11623 ......... A Removal of skin 2.93 2.48 2.64 1.65 1.53 0.21 5.62 5.78 4.79 4.67 010
lesion.
11624 ......... A Removal of skin 3.43 2.79 3.14 1.87 1.81 0.26 6.48 6.83 5.56 5.50 010
lesion.
11626 ......... A Removal of skin 4.30 3.65 3.68 2.27 2.99 0.36 8.31 8.34 6.93 7.65 010
lesion.
11640 ......... A Removal of skin 1.53 2.28 2.04 1.10 1.00 0.10 3.91 3.67 2.73 2.63 010
lesion.
11641 ......... A Removal of skin 2.44 2.59 2.43 1.54 1.34 0.15 5.18 5.02 4.13 3.93 010
lesion.
11642 ......... A Removal of skin 2.93 2.56 2.68 1.78 1.59 0.19 5.68 5.80 4.90 4.71 010
lesion.
11643 ......... A Removal of skin 3.50 2.89 3.08 2.05 1.85 0.25 6.64 6.83 5.80 5.60 010
lesion.
11644 ......... A Removal of skin 4.55 3.51 3.66 2.58 2.25 0.34 8.40 8.55 7.47 7.14 010
lesion.
11646 ......... A Removal of skin 5.95 4.67 4.68 3.30 4.00 0.48 11.10 11.11 9.73 10.43 010
lesion.
11719 ......... R Trim nail(s)...... 0.11 0.43 0.35 0.04 0.09 0.01 0.55 0.47 0.16 0.21 000
11720 ......... A Debride nail, 1-5. 0.32 0.40 0.38 0.13 0.16 0.02 0.74 0.72 0.47 0.50 000
11721 ......... A Debride nail, 6 or 0.54 0.50 0.55 0.21 0.26 0.04 1.08 1.13 0.79 0.84 000
more.

[[Page 39644]]

11730 ......... A Removal of nail 1.13 0.71 0.60 0.44 0.35 0.08 1.92 1.81 1.65 1.56 000
plate.
11732 ......... A Remove additional 0.57 0.27 0.27 0.23 0.19 0.04 0.88 0.88 0.84 0.80 ZZZ
nail plate.
11740 ......... A Drain blood from 0.37 0.61 0.52 0.13 0.17 0.03 1.01 0.92 0.53 0.57 000
under nail.
11750 ......... A Removal of nail 1.86 1.44 1.86 0.77 0.96 0.13 3.43 3.85 2.76 2.95 010
bed.
11752 ......... A Remove nail bed/ 2.67 1.79 2.43 1.61 1.57 0.22 4.68 5.32 4.50 4.46 010
finger tip.
11755 ......... A Biopsy, nail unit. 1.31 1.01 1.04 0.54 0.81 0.08 2.40 2.43 1.93 2.20 000
11760 ......... A Reconstruction of 1.58 1.42 1.22 1.08 0.80 0.14 3.14 2.94 2.80 2.52 010
nail bed.
11762 ......... A Reconstruction of 2.89 1.87 2.33 1.68 1.54 0.21 4.97 5.43 4.78 4.64 010
nail bed.
11765 ......... A Excision of nail 0.69 0.89 0.72 0.41 0.35 0.05 1.63 1.46 1.15 1.09 010
fold, toe.
11770 ......... A Removal of 2.61 2.52 2.71 1.26 2.08 0.25 5.38 5.57 4.12 4.94 010
pilonidal lesion.
11771 ......... A Removal of 5.74 5.00 4.96 3.80 4.36 0.58 11.32 11.28 10.12 10.68 090
pilonidal lesion.
11772 ......... A Removal of 6.98 5.93 5.58 4.24 4.74 0.73 13.64 13.29 11.95 12.45 090
pilonidal lesion.
11900 ......... A Injection into 0.52 0.62 0.45 0.21 0.18 0.02 1.16 0.99 0.75 0.72 000
skin lesions.
11901 ......... A Added skin lesions 0.80 0.74 0.59 0.34 0.28 0.03 1.57 1.42 1.17 1.11 000
injection.
11920 ......... R Correct skin color 1.61 1.91 1.60 0.85 1.07 0.18 3.70 3.39 2.64 2.86 000
defects.
11921 ......... R Correct skin color 1.93 2.12 1.82 1.02 1.27 0.22 4.27 3.97 3.17 3.42 000
defects.
11922 ......... R Correct skin color 0.49 0.34 0.37 0.26 0.33 0.06 0.89 0.92 0.81 0.88 ZZZ
defects.
11950 ......... R Therapy for 0.84 1.01 1.15 0.41 0.85 0.06 1.91 2.05 1.31 1.75 000
contour defects.
11951 ......... R Therapy for 1.19 1.45 1.37 0.50 0.90 0.10 2.74 2.66 1.79 2.19 000
contour defects.
11952 ......... R Therapy for 1.69 1.02 1.16 1.01 1.15 0.12 2.83 2.97 2.82 2.96 000
contour defects.
11954 ......... R Therapy for 1.85 1.61 1.45 0.98 1.14 0.21 3.67 3.51 3.04 3.20 000
contour defects.
11960 ......... A Insert tissue 9.08 NA NA 9.43 8.91 0.93 NA NA 19.44 18.92 090
expander(s).
11970 ......... A Replace tissue 7.06 NA NA 4.63 6.53 0.79 NA NA 12.48 14.38 090
expander.
11971 ......... A Remove tissue 2.13 5.06 3.78 3.13 2.82 0.23 7.42 6.14 5.49 5.18 090
expander(s).
11975 ......... N Insert +1.48 1.39 1.27 0.57 0.86 0.12 2.99 2.87 2.17 2.46 XXX
contraceptive cap.
11976 ......... R Removal of 1.78 1.52 1.46 0.68 1.04 0.15 3.45 3.39 2.61 2.97 XXX
contraceptive cap.
11977 ......... N Removal/reinsert +3.30 2.09 2.33 1.26 1.91 0.27 5.66 5.90 4.83 5.48 XXX
contra cap.
12001 ......... A Repair superficial 1.70 2.17 1.40 0.78 0.70 0.15 4.02 3.25 2.63 2.55 010
wound(s).
12002 ......... A Repair superficial 1.86 2.25 1.56 0.82 0.84 0.17 4.28 3.59 2.85 2.87 010
wound(s).
12004 ......... A Repair superficial 2.24 2.42 1.83 0.94 1.09 0.21 4.87 4.28 3.39 3.54 010
wound(s).
12005 ......... A Repair superficial 2.86 2.85 2.23 1.19 1.40 0.27 5.98 5.36 4.32 4.53 010
wound(s).
12006 ......... A Repair superficial 3.67 3.80 2.87 1.86 1.90 0.35 7.82 6.89 5.88 5.92 010
wound(s).
12007 ......... A Repair superficial 4.12 4.26 3.11 2.16 2.06 0.40 8.78 7.63 6.68 6.58 010
wound(s).
12011 ......... A Repair superficial 1.76 2.24 1.52 0.79 0.80 0.16 4.16 3.44 2.71 2.72 010
wound(s).
12013 ......... A Repair superficial 1.99 2.38 1.75 0.84 0.98 0.19 4.56 3.93 3.02 3.16 010
wound(s).
12014 ......... A Repair superficial 2.46 2.69 1.99 1.03 1.16 0.23 5.38 4.68 3.72 3.85 010
wound(s).
12015 ......... A Repair superficial 3.19 3.11 2.44 1.23 1.50 0.30 6.60 5.93 4.72 4.99 010
wound(s).
12016 ......... A Repair superficial 3.93 3.34 2.90 1.46 1.96 0.38 7.65 7.21 5.77 6.27 010
wound(s).
12017 ......... A Repair superficial 4.71 4.96 4.31 2.16 2.91 0.46 10.13 9.48 7.33 8.08 010
wound(s).
12018 ......... A Repair superficial 5.53 5.66 5.63 2.73 4.16 0.48 11.67 11.64 8.74 10.17 010
wound(s).
12020 ......... A Closure of split 2.62 2.42 1.86 1.42 1.36 0.24 5.28 4.72 4.28 4.22 010
wound.
12021 ......... A Closure of split 1.84 1.93 1.30 1.06 0.70 0.16 3.93 3.30 3.06 2.70 010
wound.
12031 ......... A Layer closure of 2.15 2.45 1.62 1.11 0.75 0.16 4.76 3.93 3.42 3.06 010
wound(s).
12032 ......... A Layer closure of 2.47 2.46 1.80 1.19 0.88 0.17 5.10 4.44 3.83 3.52 010
wound(s).
12034 ......... A Layer closure of 2.92 2.71 2.16 1.35 1.48 0.25 5.88 5.33 4.52 4.65 010
wound(s).
12035 ......... A Layer closure of 3.43 2.80 2.44 1.63 1.86 0.33 6.56 6.20 5.39 5.62 010
wound(s).
12036 ......... A Layer closure of 4.05 4.60 3.56 2.32 2.42 0.42 9.07 8.03 6.79 6.89 010
wound(s).
12037 ......... A Layer closure of 4.67 4.96 4.16 2.85 3.10 0.46 10.09 9.29 7.98 8.23 010
wound(s).
12041 ......... A Layer closure of 2.37 2.75 1.83 1.16 0.81 0.18 5.30 4.38 3.71 3.36 010
wound(s).
12042 ......... A Layer closure of 2.74 2.68 1.98 1.33 0.99 0.19 5.61 4.91 4.26 3.92 010
wound(s).
12044 ......... A Layer closure of 3.14 2.83 2.30 1.48 1.62 0.27 6.24 5.71 4.89 5.03 010
wound(s).
12045 ......... A Layer closure of 3.64 3.28 2.80 1.77 2.04 0.34 7.26 6.78 5.75 6.02 010
wound(s).
12046 ......... A Layer closure of 4.25 4.89 3.98 2.40 2.73 0.38 9.52 8.61 7.03 7.36 010
wound(s).
12047 ......... A Layer closure of 4.65 5.38 4.87 2.79 3.58 0.46 10.49 9.98 7.90 8.69 010
wound(s).
12051 ......... A Layer closure of 2.47 2.66 1.88 1.27 0.91 0.18 5.31 4.53 3.92 3.56 010
wound(s).
12052 ......... A Layer closure of 2.77 2.58 2.09 1.25 1.03 0.19 5.54 5.05 4.21 3.99 010
wound(s).
12053 ......... A Layer closure of 3.12 2.73 2.32 1.40 1.66 0.24 6.09 5.68 4.76 5.02 010
wound(s).
12054 ......... A Layer closure of 3.46 3.05 2.94 1.53 2.18 0.30 6.81 6.70 5.29 5.94 010
wound(s).
12055 ......... A Layer closure of 4.43 4.00 3.76 2.11 2.82 0.41 8.84 8.60 6.95 7.66 010
wound(s).
12056 ......... A Layer closure of 5.24 5.41 5.28 2.94 4.04 0.45 11.10 10.97 8.63 9.73 010
wound(s).
12057 ......... A Layer closure of 5.96 4.93 5.49 3.90 4.97 0.52 11.41 11.97 10.38 11.45 010
wound(s).
13100 ......... A Repair of wound or 3.12 3.02 2.13 1.73 1.18 0.23 6.37 5.48 5.08 4.53 010
lesion.
13101 ......... A Repair of wound or 3.92 3.20 2.73 2.17 1.65 0.25 7.37 6.90 6.34 5.82 010
lesion.
13120 ......... A Repair of wound or 3.30 3.10 2.29 1.75 1.25 0.26 6.66 5.85 5.31 4.81 010
lesion.
13121 ......... A Repair of wound or 4.33 3.41 3.15 2.24 1.84 0.28 8.02 7.76 6.85 6.45 010
lesion.
13131 ......... A Repair of wound or 3.79 3.37 2.76 2.10 1.59 0.28 7.44 6.83 6.17 5.66 010
lesion.
13132 ......... A Repair of wound or 5.95 4.15 4.56 3.12 2.80 0.36 10.46 10.87 9.43 9.11 010
lesion.
13150 ......... A Repair of wound or 3.81 4.50 3.21 2.48 2.20 0.31 8.62 7.33 6.60 6.32 010
lesion.
13151 ......... A Repair of wound or 4.45 4.47 3.57 2.85 2.09 0.31 9.23 8.33 7.61 6.85 010
lesion.
13152 ......... A Repair of wound or 6.33 5.22 5.40 3.77 3.28 0.43 11.98 12.16 10.53 10.04 010
lesion.
13160 ......... A Late closure of 10.48 NA NA 6.18 4.90 1.14 NA NA 17.80 16.52 090
wound.
13300 ......... A Repair of wound or 5.27 3.95 5.08 2.89 4.55 0.46 9.68 10.81 8.62 10.28 010
lesion.
14000 ......... A Skin tissue 5.89 6.28 4.99 4.20 3.03 0.48 12.65 11.36 10.57 9.40 090
rearrangement.
14001 ......... A Skin tissue 8.47 7.56 6.36 5.52 5.34 0.70 16.73 15.53 14.69 14.51 090
rearrangement.
14020 ......... A Skin tissue 6.59 6.66 5.99 4.82 5.07 0.53 13.78 13.11 11.94 12.19 090
rearrangement.
14021 ......... A Skin tissue 10.06 8.07 7.41 6.60 6.67 0.76 18.89 18.23 17.42 17.49 090
rearrangement.
14040 ......... A Skin tissue 7.87 7.07 7.21 5.55 4.62 0.57 15.51 15.65 13.99 13.06 090
rearrangement.
14041 ......... A Skin tissue 11.49 8.72 8.64 7.45 5.87 0.73 20.94 20.86 19.67 18.09 090
rearrangement.
14060 ......... A Skin tissue 8.50 7.58 8.00 6.32 7.37 0.63 16.71 17.13 15.45 16.50 090
rearrangement.
14061 ......... A Skin tissue 12.29 9.64 10.51 8.36 7.03 0.79 22.72 23.59 21.44 20.11 090
rearrangement.
14300 ......... A Skin tissue 11.76 8.89 10.58 7.78 10.03 0.97 21.62 23.31 20.51 22.76 090
rearrangement.
14350 ......... A Skin tissue 9.61 NA NA 5.97 6.28 0.96 NA NA 16.54 16.85 090
rearrangement.
15000 ......... A Skin graft........ 4.00 2.30 2.32 1.95 2.14 0.38 6.68 6.70 6.33 6.52 000
15001 ......... A Skin graft add-on. 1.00 0.49 0.49 0.48 0.48 0.10 1.59 1.59 1.58 1.58 ZZZ

[robop...@us.govnews.org]

Archive-Name: gov/us/fed/nara/fed-register/1999/jul/22/64FR39607/part6

Posting-number: Volume 64, Issue 140, Page 39607, Part 1

[[Page 39645]]

15050 ......... A Skin pinch graft.. 4.30 4.52 3.23 3.52 2.73 0.43 9.25 7.96 8.25 7.46 090
15100 ......... A Skin split graft.. 9.05 5.83 5.38 5.79 5.36 0.98 15.86 15.41 15.82 15.39 090
15101 ......... A Skin split graft 1.72 1.17 1.45 0.78 1.26 0.18 3.07 3.35 2.68 3.16 ZZZ
add-on.
15120 ......... A Skin split graft.. 9.83 7.34 6.96 6.50 6.54 0.84 18.01 17.63 17.17 17.21 090
15121 ......... A Skin split graft 2.67 1.67 2.42 1.28 2.22 0.27 4.61 5.36 4.22 5.16 ZZZ
add-on.
15200 ......... A Skin full graft... 8.03 7.96 6.22 5.25 4.87 0.75 16.74 15.00 14.03 13.65 090
15201 ......... A Skin full graft 1.32 0.94 1.38 0.63 1.10 0.14 2.40 2.84 2.09 2.56 ZZZ
add-on.
15220 ......... A Skin full graft... 7.87 8.03 6.64 5.71 5.48 0.71 16.61 15.22 14.29 14.06 090
15221 ......... A Skin full graft 1.19 0.81 1.27 0.61 1.02 0.13 2.13 2.59 1.93 2.34 ZZZ
add-on.
15240 ......... A Skin full graft... 9.04 7.82 7.22 6.44 6.53 0.82 17.68 17.08 16.30 16.39 090
15241 ......... A Skin full graft 1.86 1.29 1.94 0.96 1.59 0.18 3.33 3.98 3.00 3.63 ZZZ
add-on.
15260 ......... A Skin full graft... 10.06 7.97 8.04 7.05 7.58 0.68 18.71 18.78 17.79 18.32 090
15261 ......... A Skin full graft 2.23 1.42 2.26 1.17 1.92 0.18 3.83 4.67 3.58 4.33 ZZZ
add-on.
15350 ......... A Skin homograft.... 4.00 6.92 4.63 3.96 3.15 0.42 11.34 9.05 8.38 7.57 090
15351 ......... A Skin homograft add- 1.00 0.42 0.42 0.42 0.42 0.09 1.51 1.51 1.51 1.51 ZZZ
on.
15400 ......... A Skin heterograft.. 4.00 3.84 2.50 3.84 2.50 0.36 8.20 6.86 8.20 6.86 090
15401 ......... A Skin heterograft 1.00 0.42 0.42 0.42 0.42 0.09 1.51 1.51 1.51 1.51 ZZZ
add-on.
15570 ......... A Form skin pedicle 9.21 7.18 6.58 5.72 5.85 0.95 17.34 16.74 15.88 16.01 090
flap.
15572 ......... A Form skin pedicle 9.27 7.05 6.45 6.08 5.96 0.92 17.24 16.64 16.27 16.15 090
flap.
15574 ......... A Form skin pedicle 9.88 7.34 6.60 6.42 6.14 0.91 18.13 17.39 17.21 16.93 090
flap.
15576 ......... A Form skin pedicle 8.69 7.79 5.59 5.92 4.66 0.75 17.23 15.03 15.36 14.10 090
flap.
15580 ......... A Attach skin 9.46 NA NA 6.64 5.66 1.05 NA NA 17.15 16.17 090
pedicle graft.
15600 ......... A Skin graft........ 1.91 4.83 3.78 1.96 2.12 0.20 6.94 5.89 4.07 4.23 090
15610 ......... A Skin graft........ 2.42 4.28 3.67 2.24 2.57 0.26 6.96 6.35 4.92 5.25 090
15620 ......... A Skin graft........ 2.94 5.23 4.48 2.95 3.23 0.28 8.45 7.70 6.17 6.45 090
15625 ......... A Skin graft........ 1.91 NA NA 2.20 2.24 0.21 NA NA 4.32 4.36 090
15630 ......... A Skin graft........ 3.27 5.03 4.47 3.13 3.52 0.30 8.60 8.04 6.70 7.09 090
15650 ......... A Transfer skin 3.97 5.05 4.90 3.22 3.98 0.36 9.38 9.23 7.55 8.31 090
pedicle flap.
15732 ......... A Muscle-skin graft, 17.84 NA NA 11.10 13.95 1.55 NA NA 30.49 33.34 090
head/neck.
15734 ......... A Muscle-skin graft, 17.79 NA NA 10.72 15.68 1.96 NA NA 30.47 35.43 090
trunk.
15736 ......... A Muscle-skin graft, 16.27 NA NA 10.09 13.84 1.82 NA NA 28.18 31.93 090
arm.
15738 ......... A Muscle-skin graft, 17.92 NA NA 10.70 12.35 2.01 NA NA 30.63 32.28 090
leg.
15740 ......... A Island pedicle 10.25 7.62 9.45 6.64 8.96 0.68 18.55 20.38 17.57 19.89 090
flap graft.
15750 ......... A Neurovascular 11.41 NA NA 7.87 10.43 1.24 NA NA 20.52 23.08 090
pedicle graft.
15756 ......... A Free muscle flap, 35.23 NA NA 21.01 26.84 3.77 NA NA 60.01 65.84 090
microvasc.
15757 ......... A Free skin flap, 35.23 NA NA 21.51 27.09 3.53 NA NA 60.27 65.85 090
microvasc.
15758 ......... A Free fascial flap, 35.10 NA NA 21.67 27.17 3.58 NA NA 60.35 65.85 090
microvasc.
15760 ......... A Composite skin 8.74 7.82 7.87 6.34 7.13 0.76 17.32 17.37 15.84 16.63 090
graft.
15770 ......... A Derma-fat-fascia 7.52 NA NA 5.80 6.95 0.85 NA NA 14.17 15.32 090
graft.
15775 ......... R Hair transplant 3.96 2.83 2.98 1.51 2.32 0.45 7.24 7.39 5.92 6.73 000
punch grafts.
15776 ......... R Hair transplant 5.54 3.63 4.00 2.93 3.65 0.63 9.80 10.17 9.10 9.82 000
punch grafts.
15780 ......... A Abrasion treatment 7.29 6.41 4.04 6.22 3.53 0.58 14.28 11.91 14.09 11.40 090
of skin.
15781 ......... A Abrasion treatment 4.85 4.30 4.20 4.30 3.18 0.30 9.45 9.35 9.45 8.33 090
of skin.
15782 ......... A Abrasion treatment 4.32 3.72 2.51 3.30 1.98 0.29 8.33 7.12 7.91 6.59 090
of skin.
15783 ......... A Abrasion treatment 4.29 3.89 2.95 3.76 2.39 0.28 8.46 7.52 8.33 6.96 090
of skin.
15786 ......... A Abrasion, lesion, 2.03 1.54 1.11 1.23 0.79 0.12 3.69 3.26 3.38 2.94 010
single.
15787 ......... A Abrasion, lesions, 0.33 0.24 0.25 0.15 0.14 0.02 0.59 0.60 0.50 0.49 ZZZ
add-on.
15788 ......... R Chemical peel, 2.09 2.44 2.03 1.00 1.31 0.10 4.63 4.22 3.19 3.50 090
face, epiderm.
15789 ......... R Chemical peel, 4.92 5.15 3.38 3.25 2.43 0.32 10.39 8.62 8.49 7.67 090
face, dermal.
15792 ......... R Chemical peel, 1.86 2.39 1.47 2.39 1.47 0.12 4.37 3.45 4.37 3.45 090
nonfacial.
15793 ......... A Chemical peel, 3.74 NA NA 2.80 1.67 0.17 NA NA 6.71 5.58 090
nonfacial.
15810 ......... A Salabrasion....... 4.74 2.82 3.47 2.82 3.47 0.41 7.97 8.62 7.97 8.62 090
15811 ......... A Salabrasion....... 5.39 5.55 4.81 4.36 4.21 0.62 11.56 10.82 10.37 10.22 090
15819 ......... A Plastic surgery, 9.38 NA NA 6.51 7.60 0.87 NA NA 16.76 17.85 090
neck.
15820 ......... A Revision of lower 5.15 9.06 7.61 6.11 6.13 0.31 14.52 13.07 11.57 11.59 090
eyelid.
15821 ......... A Revision of lower 5.72 9.41 8.12 6.38 6.61 0.31 15.44 14.15 12.41 12.64 090
eyelid.
15822 ......... A Revision of upper 4.45 8.22 6.77 5.71 5.52 0.24 12.91 11.46 10.40 10.21 090
eyelid.
15823 ......... A Revision of upper 7.05 9.52 8.95 6.96 7.67 0.35 16.92 16.35 14.36 15.07 090
eyelid.
15824 ......... R Removal of 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
forehead wrinkles.
15825 ......... R Removal of neck 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15826 ......... R Removal of brow 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15828 ......... R Removal of face 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15829 ......... R Removal of skin 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15831 ......... A Excise excessive 12.40 NA NA 7.33 9.01 1.30 NA NA 21.03 22.71 090
skin tissue.
15832 ......... A Excise excessive 11.59 NA NA 6.88 7.94 1.24 NA NA 19.71 20.77 090
skin tissue.
15833 ......... A Excise excessive 10.64 NA NA 6.98 6.87 1.36 NA NA 18.98 18.87 090
skin tissue.
15834 ......... A Excise excessive 10.85 NA NA 7.20 7.50 1.31 NA NA 19.36 19.66 090
skin tissue.
15835 ......... A Excise excessive 11.67 NA NA 6.64 7.12 1.43 NA NA 19.74 20.22 090
skin tissue.
15836 ......... A Excise excessive 9.34 NA NA 5.63 5.96 1.00 NA NA 15.97 16.30 090
skin tissue.
15837 ......... A Excise excessive 8.43 6.54 6.51 5.84 6.16 0.88 15.85 15.82 15.15 15.47 090
skin tissue.
15838 ......... A Excise excessive 7.13 NA NA 5.52 5.95 0.55 NA NA 13.20 13.63 090
skin tissue.
15839 ......... A Excise excessive 9.38 6.99 4.82 5.73 4.19 0.84 17.21 15.04 15.95 14.41 090
skin tissue.
15840 ......... A Graft for face 13.26 NA NA 9.33 12.58 1.11 NA NA 23.70 26.95 090
nerve palsy.
15841 ......... A Graft for face 23.26 NA NA 14.41 16.36 2.66 NA NA 40.33 42.28 090
nerve palsy.
15842 ......... A Graft for face 37.96 NA NA 20.67 26.07 4.74 NA NA 63.37 68.77 090
nerve palsy.
15845 ......... A Skin and muscle 12.57 NA NA 8.45 11.73 0.91 NA NA 21.93 25.21 090
repair, face.
15850 ......... B Removal of sutures 0.78 1.26 0.83 0.30 0.35 0.05 2.09 1.66 1.13 1.18 XXX
15851 ......... A Removal of sutures 0.86 1.51 0.92 0.32 0.25 0.06 2.43 1.84 1.24 1.17 000
15852 ......... A Dressing 0.86 1.61 1.05 0.37 0.31 0.08 2.55 1.99 1.31 1.25 000
change,not for
burn.
15860 ......... A Test for blood 1.95 1.04 1.26 0.80 1.14 0.20 3.19 3.41 2.95 3.29 000
flow in graft.
15876 ......... R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15877 ......... R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15878 ......... R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15879 ......... R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.

[[Page 39646]]

15920 ......... A Removal of tail 7.95 NA NA 5.17 4.19 0.80 NA NA 13.92 12.94 090
bone ulcer.
15922 ......... A Removal of tail 9.90 NA NA 6.77 6.63 1.07 NA NA 17.74 17.60 090
bone ulcer.
15931 ......... A Remove sacrum 9.24 NA NA 5.29 4.24 0.99 NA NA 15.52 14.47 090
pressure sore.
15933 ......... A Remove sacrum 10.85 NA NA 7.57 7.54 1.18 NA NA 19.60 19.57 090
pressure sore.
15934 ......... A Remove sacrum 12.69 NA NA 7.94 8.02 1.40 NA NA 22.03 22.11 090
pressure sore.
15935 ......... A Remove sacrum 14.57 NA NA 9.24 10.72 1.62 NA NA 25.43 26.91 090
pressure sore.
15936 ......... A Remove sacrum 12.38 NA NA 8.29 9.72 1.33 NA NA 22.00 23.43 090
pressure sore.
15937 ......... A Remove sacrum 14.21 NA NA 9.43 12.03 1.58 NA NA 25.22 27.82 090
pressure sore.
15940 ......... A Removal of 9.34 NA NA 5.65 4.75 1.02 NA NA 16.01 15.11 090
pressure sore.
15941 ......... A Removal of 11.43 NA NA 8.81 8.23 1.26 NA NA 21.50 20.92 090
pressure sore.
15944 ......... A Removal of 11.46 NA NA 7.92 8.99 1.24 NA NA 20.62 21.69 090
pressure sore.
15945 ......... A Removal of 12.69 NA NA 8.58 10.34 1.38 NA NA 22.65 24.41 090
pressure sore.
15946 ......... A Removal of 21.57 NA NA 13.41 15.72 2.25 NA NA 37.23 39.54 090
pressure sore.
15950 ......... A Remove thigh 7.54 NA NA 4.66 3.97 0.81 NA NA 13.01 12.32 090
pressure sore.
15951 ......... A Remove thigh 10.72 NA NA 7.60 7.95 1.15 NA NA 19.47 19.82 090
pressure sore.
15952 ......... A Remove thigh 11.39 NA NA 7.05 7.40 1.25 NA NA 19.69 20.04 090
pressure sore.
15953 ......... A Remove thigh 12.63 NA NA 7.94 8.90 1.38 NA NA 21.95 22.91 090
pressure sore.
15956 ......... A Remove thigh 15.52 NA NA 9.81 14.17 1.67 NA NA 27.00 31.36 090
pressure sore.
15958 ......... A Remove thigh 15.48 NA NA 9.84 14.16 1.69 NA NA 27.01 31.33 090
pressure sore.
15999 ......... C Removal of 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
pressure sore.
16000 ......... A Initial treatment 0.89 0.95 0.67 0.23 0.21 0.07 1.91 1.63 1.19 1.17 000
of burn(s).
16010 ......... A Treatment of 0.87 1.04 0.70 0.32 0.25 0.07 1.98 1.64 1.26 1.19 000
burn(s).
16015 ......... A Treatment of 2.35 2.82 2.52 0.88 1.55 0.22 5.39 5.09 3.45 4.12 000
burn(s).
16020 ......... A Treatment of 0.80 1.10 0.74 0.24 0.22 0.06 1.96 1.60 1.10 1.08 000
burn(s).
16025 ......... A Treatment of 1.85 1.62 1.06 0.67 0.46 0.17 3.64 3.08 2.69 2.48 000
burn(s).
16030 ......... A Treatment of 2.08 2.66 1.61 0.86 0.71 0.20 4.94 3.89 3.14 2.99 000
burn(s).
16035 ......... A Incision of burn 4.82 2.84 2.44 1.99 2.02 0.50 8.16 7.76 7.31 7.34 090
scab.
17000 ......... A Destroy benign/ 0.60 0.76 0.61 0.26 0.25 0.03 1.39 1.24 0.89 0.88 010
premal lesion.
17003 ......... A Destroy 2-14 0.15 0.56 0.35 0.07 0.07 0.01 0.72 0.51 0.23 0.23 ZZZ
lesions.
17004 ......... A Destroy 15 & more 2.79 1.86 2.15 1.31 1.27 0.12 4.77 5.06 4.22 4.18 010
lesions.
17106 ......... A Destruction of 4.59 3.49 2.79 2.67 1.86 0.28 8.36 7.66 7.54 6.73 090
skin lesions.
17107 ......... A Destruction of 9.16 5.93 4.98 4.96 3.49 0.54 15.63 14.68 14.66 13.19 090
skin lesions.
17108 ......... A Destruction of 13.20 8.29 9.20 7.17 8.64 0.81 22.30 23.21 21.18 22.65 090
skin lesions.
17110 ......... A Destruct lesion, 1- 0.65 0.92 0.68 0.26 0.24 0.04 1.61 1.37 0.95 0.93 010
14.
17111 ......... A Destruct lesion, 0.92 1.13 0.89 0.37 0.35 0.06 2.11 1.87 1.35 1.33 010
15 or more.
17250 ......... A Chemical cautery, 0.50 0.63 0.50 0.19 0.19 0.04 1.17 1.04 0.73 0.73 000
tissue.
17260 ......... A Destruction of 0.91 1.07 1.15 0.42 0.52 0.04 2.02 2.10 1.37 1.47 010
skin lesions.
17261 ......... A Destruction of 1.17 1.17 1.34 0.55 0.66 0.05 2.39 2.56 1.77 1.88 010
skin lesions.
17262 ......... A Destruction of 1.58 1.37 1.68 0.74 0.87 0.06 3.01 3.32 2.38 2.51 010
skin lesions.
17263 ......... A Destruction of 1.79 1.47 1.96 0.82 1.02 0.07 3.33 3.82 2.68 2.88 010
skin lesions.
17264 ......... A Destruction of 1.94 1.55 2.18 0.88 1.15 0.08 3.57 4.20 2.90 3.17 010
skin lesions.
17266 ......... A Destruction of 2.34 1.75 2.57 0.98 1.34 0.11 4.20 5.02 3.43 3.79 010
skin lesions.
17270 ......... A Destruction of 1.32 1.27 1.36 0.61 0.67 0.06 2.65 2.74 1.99 2.05 010
skin lesions.
17271 ......... A Destruction of 1.49 1.33 1.62 0.70 0.83 0.06 2.88 3.17 2.25 2.38 010
skin lesions.
17272 ......... A Destruction of 1.77 1.46 1.93 0.84 1.02 0.07 3.30 3.77 2.68 2.86 010
skin lesions.
17273 ......... A Destruction of 2.05 1.60 2.20 0.95 1.18 0.09 3.74 4.34 3.09 3.32 010
skin lesions.
17274 ......... A Destruction of 2.59 1.87 2.68 1.18 1.46 0.11 4.57 5.38 3.88 4.16 010
skin lesions.
17276 ......... A Destruction of 3.20 2.19 2.95 1.63 1.74 0.16 5.55 6.31 4.99 5.10 010
skin lesions.
17280 ......... A Destruction of 1.17 1.19 1.49 0.52 0.71 0.05 2.41 2.71 1.74 1.93 010
skin lesions.
17281 ......... A Destruction of 1.72 1.44 1.86 0.82 0.98 0.07 3.23 3.65 2.61 2.77 010
skin lesions.
17282 ......... A Destruction of 2.04 1.60 2.20 0.97 1.19 0.08 3.72 4.32 3.09 3.31 010
skin lesions.
17283 ......... A Destruction of 2.64 1.89 2.58 1.27 1.46 0.11 4.64 5.33 4.02 4.21 010
skin lesions.
17284 ......... A Destruction of 3.21 2.17 2.99 1.55 1.73 0.14 5.52 6.34 4.90 5.08 010
skin lesions.
17286 ......... A Destruction of 4.44 2.83 3.76 2.41 2.38 0.23 7.50 8.43 7.08 7.05 010
skin lesions.
17304 ......... A Chemosurgery of 7.60 6.84 5.60 3.65 2.92 0.33 14.77 13.53 11.58 10.85 000
skin lesion.
17305 ......... A 2nd stage 2.85 2.61 2.53 1.37 1.30 0.12 5.58 5.50 4.34 4.27 000
chemosurgery.
17306 ......... A 3rd stage 2.85 2.62 2.07 1.38 1.07 0.12 5.59 5.04 4.35 4.04 000
chemosurgery.
17307 ......... A Followup skin 2.85 2.61 2.11 1.39 1.10 0.12 5.58 5.08 4.36 4.07 000
lesion therapy.
17310 ......... A Extensive skin 0.95 1.05 0.60 0.47 0.27 0.05 2.05 1.60 1.47 1.27 000
chemosurgery.
17340 ......... A Cryotherapy of 0.76 1.19 0.75 0.25 0.20 0.05 2.00 1.56 1.06 1.01 010
skin.
17360 ......... A Skin peel therapy. 1.43 1.30 0.80 0.71 0.43 0.07 2.80 2.30 2.21 1.93 010
17380 ......... R Hair removal by 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
electrolysis.
17999 ......... C Skin tissue 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
19000 ......... A Drainage of breast 0.84 1.47 0.94 0.24 0.23 0.07 2.38 1.85 1.15 1.14 000
lesion.
19001 ......... A Drain breast 0.42 1.11 0.69 0.12 0.13 0.03 1.56 1.14 0.57 0.58 ZZZ
lesion add-on.
19020 ......... A Incision of breast 3.57 6.19 3.86 3.14 2.33 0.36 10.12 7.79 7.07 6.26 090
lesion.
19030 ......... A Injection for 1.53 10.96 5.75 0.42 0.48 0.07 12.56 7.35 2.02 2.08 000
breast x-ray.
19100 ......... A Biopsy of breast.. 1.27 3.46 2.08 0.39 0.37 0.09 4.82 3.44 1.75 1.73 000
19101 ......... A Biopsy of breast.. 3.18 8.71 5.63 3.78 3.16 0.24 12.13 9.05 7.20 6.58 010
19110 ......... A Nipple exploration 4.30 7.68 5.18 4.10 3.39 0.43 12.41 9.91 8.83 8.12 090
19112 ......... A Excise breast duct 3.67 7.87 5.21 2.92 2.73 0.37 11.91 9.25 6.96 6.77 090
fistula.
19120 ......... A Removal of breast 5.56 4.16 3.66 3.45 3.30 0.57 10.29 9.79 9.58 9.43 090
lesion.
19125 ......... A Excision, breast 6.06 4.70 3.93 3.65 3.40 0.63 11.39 10.62 10.34 10.09 090
lesion.
19126 ......... A Excision,addl 2.93 NA NA 1.11 1.34 0.30 NA NA 4.34 4.57 ZZZ
breast lesion.
19140 ......... A Removal of breast 5.14 8.33 6.50 3.49 4.08 0.54 14.01 12.18 9.17 9.76 090
tissue.
19160 ......... A Removal of breast 5.99 NA NA 4.25 4.37 0.61 NA NA 10.85 10.97 090
tissue.
19162 ......... A Remove breast 13.53 NA NA 7.91 9.05 1.38 NA NA 22.82 23.96 090
tissue, nodes.
19180 ......... A Removal of breast. 8.80 NA NA 5.84 5.97 0.90 NA NA 15.54 15.67 090
19182 ......... A Removal of breast. 7.73 NA NA 4.91 5.75 0.80 NA NA 13.44 14.28 090
19200 ......... A Removal of breast. 15.49 NA NA 8.96 10.03 1.57 NA NA 26.02 27.09 090
19220 ......... A Removal of breast. 15.72 NA NA 8.74 10.19 1.57 NA NA 26.03 27.48 090
19240 ......... A Removal of breast. 16.00 NA NA 8.79 9.52 1.64 NA NA 26.43 27.16 090
19260 ......... A Removal of chest 15.44 NA NA 9.89 7.69 1.76 NA NA 27.09 24.89 090
wall lesion.
19271 ......... A Revision of chest 18.90 NA NA 12.43 13.79 2.23 NA NA 33.56 34.92 090
wall.

[[Page 39647]]

19272 ......... A Extensive chest 21.55 NA NA 12.76 13.22 2.46 NA NA 36.77 37.23 090
wall surgery.
19290 ......... A Place needle wire, 1.27 5.50 2.99 0.35 0.42 0.06 6.83 4.32 1.68 1.75 000
breast.
19291 ......... A Place needle wire, 0.63 1.52 0.90 0.17 0.22 0.03 2.18 1.56 0.83 0.88 ZZZ
breast.
19316 ......... A Suspension of 10.69 NA NA 7.10 9.93 1.19 NA NA 18.98 21.81 090
breast.
19318 ......... A Reduction of large 15.62 NA NA 9.66 12.53 1.75 NA NA 27.03 29.90 090
breast.
19324 ......... A Enlarge breast.... 5.85 NA NA 3.77 3.67 0.65 NA NA 10.27 10.17 090
19325 ......... A Enlarge breast 8.45 NA NA 5.95 6.16 0.96 NA NA 15.36 15.57 090
with implant.
19328 ......... A Removal of breast 5.68 NA NA 4.09 4.09 0.64 NA NA 10.41 10.41 090
implant.
19330 ......... A Removal of implant 7.59 NA NA 4.82 4.52 0.85 NA NA 13.26 12.96 090
material.
19340 ......... A Immediate breast 6.33 NA NA 3.24 5.40 0.71 NA NA 10.28 12.44 ZZZ
prosthesis.
19342 ......... A Delayed breast 11.20 NA NA 7.26 9.50 1.26 NA NA 19.72 21.96 090
prosthesis.
19350 ......... A Breast 8.92 11.28 9.48 6.18 6.93 1.00 21.20 19.40 16.10 16.85 090
reconstruction.
19355 ......... A Correct inverted 7.57 13.04 9.20 4.74 5.05 0.78 21.39 17.55 13.09 13.40 090
nipple(s).
19357 ......... A Breast 18.16 NA NA 12.72 12.96 2.04 NA NA 32.92 33.16 090
reconstruction.
19361 ......... A Breast 19.26 NA NA 11.41 16.63 2.16 NA NA 32.83 38.05 090
reconstruction.
19364 ......... A Breast 41.00 NA NA 23.94 21.02 4.44 NA NA 69.38 66.46 090
reconstruction.
19366 ......... A Breast 21.28 NA NA 11.21 14.51 2.26 NA NA 34.75 38.05 090
reconstruction.
19367 ......... A Breast 25.73 NA NA 14.59 18.22 2.85 NA NA 43.17 46.80 090
reconstruction.
19368 ......... A Breast 32.42 NA NA 18.57 20.21 3.68 NA NA 54.67 56.31 090
reconstruction.
19369 ......... A Breast 29.82 NA NA 17.58 19.72 3.33 NA NA 50.73 52.87 090
reconstruction.
19370 ......... A Surgery of breast 8.05 NA NA 5.52 6.11 0.91 NA NA 14.48 15.07 090
capsule.
19371 ......... A Removal of breast 9.35 NA NA 6.51 7.55 1.05 NA NA 16.91 17.95 090
capsule.
19380 ......... A Revise breast 9.14 NA NA 6.41 7.61 1.02 NA NA 16.57 17.77 090
reconstruction.
19396 ......... A Design custom 2.17 4.23 2.97 0.83 1.27 0.25 6.65 5.39 3.25 3.69 000
breast implant.
19499 ......... C Breast surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
20000 ......... A Incision of 2.12 1.86 1.39 1.06 0.76 0.16 4.14 3.67 3.34 3.04 010
abscess.
20005 ......... A Incision of deep 3.42 2.65 2.32 2.07 2.03 0.32 6.39 6.06 5.81 5.77 010
abscess.
20100 ......... A Explore wound, 10.08 5.35 5.37 4.85 5.12 0.98 16.41 16.43 15.91 16.18 010
neck.
20101 ......... A Explore wound, 3.22 2.29 2.00 1.74 1.72 0.31 5.82 5.53 5.27 5.25 010
chest.
20102 ......... A Explore wound, 3.94 3.05 2.57 1.90 1.99 0.41 7.40 6.92 6.25 6.34 010
abdomen.
20103 ......... A Explore wound, 5.30 3.96 3.39 2.99 2.90 0.55 9.81 9.24 8.84 8.75 010
extremity.
20150 ......... A Excise epiphyseal 13.69 NA NA 7.51 10.49 1.11 NA NA 22.31 25.29 090
bar.
20200 ......... A Muscle biopsy..... 1.46 1.60 1.41 0.61 0.92 0.17 3.23 3.04 2.24 2.55 000
20205 ......... A Deep muscle biopsy 2.35 3.82 2.93 0.97 1.51 0.29 6.46 5.57 3.61 4.15 000
20206 ......... A Needle biopsy, 0.99 2.99 2.02 0.31 0.68 0.06 4.04 3.07 1.36 1.73 000
muscle.
20220 ......... A Bone biopsy, 1.27 3.45 2.44 2.01 1.72 0.06 4.78 3.77 3.34 3.05 000
trocar/needle.
20225 ......... A Bone biopsy, 1.87 0.65 1.62 0.65 1.45 0.10 2.62 3.59 2.62 3.42 000
trocar/needle.
20240 ......... A Bone biopsy, 3.23 NA NA 3.52 2.78 0.29 NA NA 7.04 6.30 010
excisional.
20245 ......... A Bone biopsy, 3.95 NA NA 4.15 4.02 0.38 NA NA 8.48 8.35 010
excisional.
20250 ......... A Open bone biopsy.. 5.03 NA NA 3.73 4.62 0.49 NA NA 9.25 10.14 010
20251 ......... A Open bone biopsy.. 5.56 NA NA 4.47 5.41 0.71 NA NA 10.74 11.68 010
20500 ......... A Injection of sinus 1.23 4.94 2.67 4.39 2.30 0.09 6.26 3.99 5.71 3.62 010
tract.
20501 ......... A Inject sinus tract 0.76 12.94 6.64 0.20 0.27 0.03 13.73 7.43 0.99 1.06 000
for x-ray.
20520 ......... A Removal of foreign 1.85 4.30 2.54 2.85 1.62 0.16 6.31 4.55 4.86 3.63 010
body.
20525 ......... A Removal of foreign 3.50 5.46 3.94 3.64 3.03 0.36 9.32 7.80 7.50 6.89 010
body.
20550 ......... A Inj tendon/ 0.86 2.17 1.29 0.18 0.20 0.06 3.09 2.21 1.10 1.12 000
ligament/cyst.
20600 ......... A Drain/inject joint/ 0.66 1.15 0.83 0.26 0.26 0.05 1.86 1.54 0.97 0.97 000
bursa.
20605 ......... A Drain/inject joint/ 0.68 1.44 0.97 0.27 0.26 0.05 2.17 1.70 1.00 0.99 000
bursa.
20610 ......... A Drain/inject joint/ 0.79 1.79 1.14 0.31 0.28 0.07 2.65 2.00 1.17 1.14 000
bursa.
20615 ......... A Treatment of bone 2.28 3.52 2.03 2.33 1.30 0.18 5.98 4.49 4.79 3.76 010
cyst.
20650 ......... A Insert and remove 2.23 4.07 2.62 2.78 1.98 0.18 6.48 5.03 5.19 4.39 010
bone pin.
20660 ......... A Apply,remove 2.51 NA NA 1.32 1.51 0.47 NA NA 4.30 4.49 000
fixation device.
20661 ......... A Application of 4.89 NA NA 6.08 5.12 0.85 NA NA 11.82 10.86 090
head brace.
20662 ......... A Application of 6.07 NA NA 4.76 5.93 0.59 NA NA 11.42 12.59 090
pelvis brace.
20663 ......... A Application of 5.43 NA NA 3.82 4.43 0.51 NA NA 9.76 10.37 090
thigh brace.
20664 ......... A Halo brace 8.06 NA NA 7.76 5.96 1.42 NA NA 17.24 15.44 090
application.
20665 ......... A Removal of 1.31 2.23 1.39 1.16 0.85 0.18 3.72 2.88 2.65 2.34 010
fixation device.
20670 ......... A Removal of support 1.74 4.73 2.77 3.31 1.86 0.18 6.65 4.69 5.23 3.78 010
implant.
20680 ......... A Removal of support 3.35 4.12 3.87 4.12 3.87 0.36 7.83 7.58 7.83 7.58 090
implant.
20690 ......... A Apply bone 3.52 NA NA 1.67 2.82 0.35 NA NA 5.54 6.69 090
fixation device.
20692 ......... A Apply bone 6.41 NA NA 3.36 4.67 0.68 NA NA 10.45 11.76 090
fixation device.
20693 ......... A Adjust bone 5.86 NA NA 12.71 7.71 0.70 NA NA 19.27 14.27 090
fixation device.
20694 ......... A Remove bone 4.16 7.20 5.01 5.65 4.24 0.46 11.82 9.63 10.27 8.86 090
fixation device.
20802 ......... A Replantation, arm, 41.15 NA NA 24.95 32.95 3.68 NA NA 69.78 77.78 090
complete.
20805 ......... A Replant forearm, 50.00 NA NA 41.90 46.01 3.83 NA NA 95.73 99.84 090
complete.
20808 ......... A Replantation, 61.65 NA NA 39.11 50.70 5.83 NA NA 106.59 118.18 090
hand, complete.
20816 ......... A Replantation 30.94 NA NA 41.00 35.86 3.26 NA NA 75.20 70.06 090
digit, complete.
20822 ......... A Replantation 25.59 NA NA 37.88 31.63 2.69 NA NA 66.16 59.91 090
digit, complete.
20824 ......... A Replantation 30.94 NA NA 36.32 33.52 3.48 NA NA 70.74 67.94 090
thumb, complete.
20827 ......... A Replantation 26.41 NA NA 37.45 31.78 2.90 NA NA 66.76 61.09 090
thumb, complete.
20838 ......... A Replantation, 41.41 NA NA 31.69 36.32 5.27 NA NA 78.37 83.00 090
foot, complete.
20900 ......... A Removal of bone 5.58 5.21 4.13 5.21 4.13 0.58 11.37 10.29 11.37 10.29 090
for graft.
20902 ......... A Removal of bone 7.55 NA NA 7.90 6.64 0.83 NA NA 16.28 15.02 090
for graft.
20910 ......... A Remove cartilage 5.34 6.70 3.78 5.69 3.28 0.46 12.50 9.58 11.49 9.08 090
for graft.
20912 ......... A Remove cartilage 6.35 NA NA 6.13 5.57 0.59 NA NA 13.07 12.51 090
for graft.
20920 ......... A Removal of fascia 5.31 NA NA 4.71 4.49 0.54 NA NA 10.56 10.34 090
for graft.
20922 ......... A Removal of fascia 6.61 7.58 6.17 6.03 5.40 0.88 15.07 13.66 13.52 12.89 090
for graft.
20924 ......... A Removal of tendon 6.48 NA NA 6.12 6.02 0.72 NA NA 13.32 13.22 090
for graft.
20926 ......... A Removal of tissue 5.53 NA NA 5.44 4.13 0.76 NA NA 11.73 10.42 090
for graft.
20930 ......... B Spinal bone 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
allograft.
20931 ......... A Spinal bone 1.81 NA NA 0.97 1.43 0.32 NA NA 3.10 3.56 ZZZ
allograft.
20936 ......... B Spinal bone 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
autograft.
20937 ......... A Spinal bone 2.79 NA NA 1.49 2.19 0.36 NA NA 4.64 5.34 ZZZ
autograft.
20938 ......... A Spinal bone 3.02 NA NA 1.61 2.37 0.47 NA NA 5.10 5.86 ZZZ
autograft.

[[Page 39648]]

20950 ......... A Record fluid 1.26 NA NA 1.65 1.42 0.14 NA NA 3.05 2.82 000
pressure,muscle.
20955 ......... A Fibula bone graft, 39.21 NA NA 26.94 32.92 4.10 NA NA 70.25 76.23 090
microvasc.
20956 ......... A Iliac bone graft, 39.27 NA NA 26.85 28.02 4.97 NA NA 71.09 72.26 090
microvasc.
20957 ......... A Mt bone graft, 40.65 NA NA 20.91 25.58 5.14 NA NA 66.70 71.37 090
microvasc.
20962 ......... A Other bone graft, 39.27 NA NA 26.13 27.66 4.54 NA NA 69.94 71.47 090
microvasc.
20969 ......... A Bone/skin graft, 43.92 NA NA 29.05 36.30 4.30 NA NA 77.27 84.52 090
microvasc.
20970 ......... A Bone/skin graft, 43.06 NA NA 27.33 35.00 4.46 NA NA 74.85 82.52 090
iliac crest.
20972 ......... A Bone-skin graft, 42.99 NA NA 20.08 31.54 4.18 NA NA 67.25 78.71 090
metatarsal.
20973 ......... A Bone-skin graft, 45.76 NA NA 26.92 36.39 5.06 NA NA 77.74 87.21 090
great toe.
20974 ......... A Electrical bone 0.62 0.34 2.03 0.32 1.09 0.05 1.01 2.70 0.99 1.76 000
stimulation.
20975 ......... A Electrical bone 2.60 NA NA 1.38 2.24 0.32 NA NA 4.30 5.16 000
stimulation.
20999 ......... C Musculoskeletal 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
21010 ......... A Incision of jaw 10.14 NA NA 6.10 8.61 0.53 NA NA 16.77 19.28 090
joint.
21015 ......... A Resection of 5.29 NA NA 5.73 6.03 0.55 NA NA 11.57 11.87 090
facial tumor.
21025 ......... A Excision of bone, 10.06 7.44 5.97 6.34 4.30 0.82 18.32 16.85 17.22 15.18 090
lower jaw.
21026 ......... A Excision of facial 4.85 5.43 4.42 4.34 3.03 0.41 10.69 9.68 9.60 8.29 090
bone(s).
21029 ......... A Contour of face 7.71 7.28 8.24 5.25 4.93 0.66 15.65 16.61 13.62 13.30 090
bone lesion.
21030 ......... A Removal of face 6.46 5.54 4.59 4.27 3.05 0.50 12.50 11.55 11.23 10.01 090
bone lesion.
21031 ......... A Remove exostosis, 3.24 3.66 3.83 1.96 1.98 0.26 7.16 7.33 5.46 5.48 090
mandible.
21032 ......... A Remove exostosis, 3.24 3.66 3.94 3.65 2.88 0.26 7.16 7.44 7.15 6.38 090
maxilla.
21034 ......... A Removal of face 16.17 10.17 8.88 9.89 8.74 1.40 27.74 26.45 27.46 26.31 090
bone lesion.
21040 ......... A Removal of jaw 2.11 3.36 3.18 1.57 1.54 0.17 5.64 5.46 3.85 3.82 090
bone lesion.
21041 ......... A Removal of jaw 6.71 5.77 6.01 3.99 3.56 0.52 13.00 13.24 11.22 10.79 090
bone lesion.
21044 ......... A Removal of jaw 11.86 NA NA 7.54 8.95 0.94 NA NA 20.34 21.75 090
bone lesion.
21045 ......... A Extensive jaw 16.17 NA NA 9.78 12.40 1.31 NA NA 27.26 29.88 090
surgery.
21050 ......... A Removal of jaw 10.77 NA NA 10.91 11.89 0.79 NA NA 22.47 23.45 090
joint.
21060 ......... A Remove jaw joint 10.23 NA NA 8.61 10.41 0.83 NA NA 19.67 21.47 090
cartilage.
21070 ......... A Remove coronoid 8.20 NA NA 5.22 6.31 0.76 NA NA 14.18 15.27 090
process.
21076 ......... A Prepare face/oral 13.42 9.45 12.74 7.11 7.56 1.01 23.88 27.17 21.54 21.99 010
prosthesis.
21077 ......... A Prepare face/oral 33.75 23.77 32.04 17.88 19.02 2.63 60.15 68.42 54.26 55.40 090
prosthesis.
21079 ......... A Prepare face/oral 22.34 16.80 23.56 12.37 13.77 1.62 40.76 47.52 36.33 37.73 090
prosthesis.
21080 ......... A Prepare face/oral 25.10 18.88 26.47 13.89 15.46 1.87 45.85 53.44 40.86 42.43 090
prosthesis.
21081 ......... A Prepare face/oral 22.88 17.20 24.12 12.66 14.09 1.72 41.80 48.72 37.26 38.69 090
prosthesis.
21082 ......... A Prepare face/oral 20.87 14.70 19.81 11.05 11.76 1.58 37.15 42.26 33.50 34.21 090
prosthesis.
21083 ......... A Prepare face/oral 19.30 14.52 20.36 10.68 11.89 1.41 35.23 41.07 31.39 32.60 090
prosthesis.
21084 ......... A Prepare face/oral 22.51 16.93 23.74 12.46 13.87 1.71 41.15 47.96 36.68 38.09 090
prosthesis.
21085 ......... A Prepare face/oral 9.00 6.34 8.54 4.77 5.07 0.71 16.05 18.25 14.48 14.78 010
prosthesis.
21086 ......... A Prepare face/oral 24.92 18.74 26.28 13.79 15.35 1.98 45.64 53.18 40.69 42.25 090
prosthesis.
21087 ......... A Prepare face/oral 24.92 17.55 23.65 13.20 14.04 1.95 44.42 50.52 40.07 40.91 090
prosthesis.
21088 ......... C Prepare face/oral 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
prosthesis.
21089 ......... C Prepare face/oral 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
prosthesis.
21100 ......... A Maxillofacial 4.22 6.34 3.75 3.49 2.32 0.26 10.82 8.23 7.97 6.80 090
fixation.
21110 ......... A Interdental 5.21 5.31 5.66 3.64 3.32 0.37 10.89 11.24 9.22 8.90 090
fixation.
21116 ......... A Injection, jaw 0.81 7.68 4.24 0.25 0.52 0.05 8.54 5.10 1.11 1.38 000
joint x-ray.

[robop...@us.govnews.org]

Archive-Name: gov/us/fed/nara/fed-register/1999/jul/22/64FR39607/part7

Posting-number: Volume 64, Issue 140, Page 39607, Part 1

21120 ......... A Reconstruction of 4.93 9.30 6.60 6.37 5.14 0.42 14.65 11.95 11.72 10.49 090
chin.
21121 ......... A Reconstruction of 7.64 7.46 6.80 5.46 5.80 0.64 15.74 15.08 13.74 14.08 090
chin.
21122 ......... A Reconstruction of 8.52 NA NA 6.61 6.69 0.76 NA NA 15.89 15.97 090
chin.
21123 ......... A Reconstruction of 11.16 NA NA 6.75 7.79 0.96 NA NA 18.87 19.91 090
chin.
21125 ......... A Augmentation lower 10.62 10.13 7.63 7.17 6.15 0.86 21.61 19.11 18.65 17.63 090
jaw bone.
21127 ......... A Augmentation lower 11.12 9.12 8.85 7.58 8.08 0.98 21.22 20.95 19.68 20.18 090
jaw bone.
21137 ......... A Reduction of 9.82 NA NA 6.83 7.28 0.90 NA NA 17.55 18.00 090
forehead.
21138 ......... A Reduction of 12.19 NA NA 7.96 8.79 1.12 NA NA 21.27 22.10 090
forehead.
21139 ......... A Reduction of 14.61 NA NA 7.49 9.52 1.35 NA NA 23.45 25.48 090
forehead.
21141 ......... A Reconstruct 18.10 NA NA 9.52 12.54 1.53 NA NA 29.15 32.17 090
midface, lefort.
21142 ......... A Reconstruct 18.81 NA NA 10.63 13.37 1.86 NA NA 31.30 34.04 090
midface, lefort.
21143 ......... A Reconstruct 19.58 NA NA 10.53 13.62 1.30 NA NA 31.41 34.50 090
midface, lefort.
21145 ......... A Reconstruct 19.94 NA NA 10.52 13.04 1.57 NA NA 32.03 34.55 090
midface, lefort.
21146 ......... A Reconstruct 20.71 NA NA 11.41 13.76 1.73 NA NA 33.85 36.20 090
midface, lefort.
21147 ......... A Reconstruct 21.77 NA NA 11.31 14.01 1.63 NA NA 34.71 37.41 090
midface, lefort.
21150 ......... A Reconstruct 25.24 NA NA 16.00 18.02 1.97 NA NA 43.21 45.23 090
midface, lefort.
21151 ......... A Reconstruct 28.30 NA NA 16.74 19.59 3.44 NA NA 48.48 51.33 090
midface, lefort.
21154 ......... A Reconstruct 30.52 NA NA 18.04 21.04 3.35 NA NA 51.91 54.91 090
midface, lefort.
21155 ......... A Reconstruct 34.45 NA NA 17.04 22.15 3.78 NA NA 55.27 60.38 090
midface, lefort.
21159 ......... A Reconstruct 42.38 NA NA 22.97 28.32 4.04 NA NA 69.39 74.74 090
midface, lefort.
21160 ......... A Reconstruct 46.44 NA NA 20.19 28.53 3.78 NA NA 70.41 78.75 090
midface, lefort.
21172 ......... A Reconstruct orbit/ 27.80 NA NA 14.71 18.37 2.05 NA NA 44.56 48.22 090
forehead.
21175 ......... A Reconstruct orbit/ 33.17 NA NA 20.13 23.29 4.00 NA NA 57.30 60.46 090
forehead.
21179 ......... A Reconstruct entire 22.25 NA NA 15.57 16.60 2.60 NA NA 40.42 41.45 090
forehead.
21180 ......... A Reconstruct entire 25.19 NA NA 15.04 17.54 2.26 NA NA 42.49 44.99 090
forehead.
21181 ......... A Contour cranial 9.90 NA NA 7.13 7.43 1.04 NA NA 18.07 18.37 090
bone lesion.
21182 ......... A Reconstruct 32.19 NA NA 20.93 23.29 2.86 NA NA 55.98 58.34 090
cranial bone.
21183 ......... A Reconstruct 35.31 NA NA 21.61 24.83 3.33 NA NA 60.25 63.47 090
cranial bone.
21184 ......... A Reconstruct 38.24 NA NA 23.02 26.74 6.92 NA NA 68.18 71.90 090
cranial bone.
21188 ......... A Reconstruction of 22.46 NA NA 14.45 16.04 2.00 NA NA 38.91 40.50 090
midface.
21193 ......... A Reconstruct lower 17.15 NA NA 9.82 11.59 1.52 NA NA 28.49 30.26 090
jaw bone.
21194 ......... A Reconstruct lower 19.84 NA NA 12.40 13.94 1.72 NA NA 33.96 35.50 090
jaw bone.
21195 ......... A Reconstruct lower 17.24 NA NA 11.11 12.25 1.42 NA NA 29.77 30.91 090
jaw bone.
21196 ......... A Reconstruct lower 18.91 NA NA 11.96 13.37 1.58 NA NA 32.45 33.86 090
jaw bone.
21198 ......... A Reconstruct lower 14.16 NA NA 9.86 12.97 1.09 NA NA 25.11 28.22 090
jaw bone.
21206 ......... A Reconstruct upper 14.10 NA NA 8.87 9.94 1.08 NA NA 24.05 25.12 090
jaw bone.
21208 ......... A Augmentation of 10.23 8.54 10.38 7.40 9.81 0.85 19.62 21.46 18.48 20.89 090
facial bones.
21209 ......... A Reduction of 6.72 7.24 6.11 5.22 5.10 0.59 14.55 13.42 12.53 12.41 090
facial bones.
21210 ......... A Face bone graft... 10.23 8.49 10.35 7.19 6.65 0.80 19.52 21.38 18.22 17.68 090
21215 ......... A Lower jaw bone 10.77 8.49 10.68 6.51 6.47 0.84 20.10 22.29 18.12 18.08 090
graft.

[[Page 39649]]

21230 ......... A Rib cartilage 10.77 NA NA 8.58 9.92 0.99 NA NA 20.34 21.68 090
graft.
21235 ......... A Ear cartilage 6.72 10.70 9.36 7.09 7.56 0.56 17.98 16.64 14.37 14.84 090
graft.
21240 ......... A Reconstruction of 14.05 NA NA 10.14 13.46 1.16 NA NA 25.35 28.67 090
jaw joint.
21242 ......... A Reconstruction of 12.95 NA NA 9.55 12.51 1.16 NA NA 23.66 26.62 090
jaw joint.
21243 ......... A Reconstruction of 20.79 NA NA 12.49 14.06 1.64 NA NA 34.92 36.49 090
jaw joint.
21244 ......... A Reconstruction of 11.86 NA NA 8.31 11.24 1.00 NA NA 21.17 24.10 090
lower jaw.
21245 ......... A Reconstruction of 11.86 12.05 12.25 8.96 10.71 0.95 24.86 25.06 21.77 23.52 090
jaw.
21246 ......... A Reconstruction of 12.47 9.55 9.57 9.55 9.57 1.02 23.04 23.06 23.04 23.06 090
jaw.
21247 ......... A Reconstruct lower 22.63 NA NA 13.95 20.48 1.74 NA NA 38.32 44.85 090
jaw bone.
21248 ......... A Reconstruction of 11.48 8.73 11.22 7.14 7.00 0.91 21.12 23.61 19.53 19.39 090
jaw.
21249 ......... A Reconstruction of 17.52 11.16 16.04 9.66 10.06 1.43 30.11 34.99 28.61 29.01 090
jaw.
21255 ......... A Reconstruct lower 16.72 NA NA 10.84 15.40 1.76 NA NA 29.32 33.88 090
jaw bone.
21256 ......... A Reconstruction of 16.19 NA NA 11.85 15.59 1.45 NA NA 29.49 33.23 090
orbit.
21260 ......... A Revise eye sockets 16.52 NA NA 8.69 14.21 0.71 NA NA 25.92 31.44 090
21261 ......... A Revise eye sockets 31.49 NA NA 14.10 16.70 2.56 NA NA 48.15 50.75 090
21263 ......... A Revise eye sockets 28.42 NA NA 12.67 23.30 1.18 NA NA 42.27 52.90 090
21267 ......... A Revise eye sockets 18.90 NA NA 13.78 14.82 1.18 NA NA 33.86 34.90 090
21268 ......... A Revise eye sockets 24.48 NA NA 15.76 16.21 4.10 NA NA 44.34 44.79 090
21270 ......... A Augmentation cheek 10.23 9.59 10.01 8.19 9.31 0.95 20.77 21.19 19.37 20.49 090
bone.
21275 ......... A Revision 11.24 NA NA 9.79 9.75 1.09 NA NA 22.12 22.08 090
orbitofacial
bones.
21280 ......... A Revision of eyelid 6.03 NA NA 5.84 6.52 0.30 NA NA 12.17 12.85 090
21282 ......... A Revision of eyelid 3.49 NA NA 4.60 4.39 0.21 NA NA 8.30 8.09 090
21295 ......... A Revision of jaw 1.53 NA NA 3.29 2.17 0.12 NA NA 4.94 3.82 090
muscle/bone.
21296 ......... A Revision of jaw 4.25 NA NA 3.81 3.87 0.38 NA NA 8.44 8.50 090
muscle/bone.
21299 ......... C Cranio/ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
maxillofacial
surgery.
21300 ......... A Treatment of skull 0.72 4.45 2.73 0.24 0.55 0.08 5.25 3.53 1.04 1.35 000
fracture.
21310 ......... A Treatment of nose 0.58 3.59 2.20 0.15 0.42 0.05 4.22 2.83 0.78 1.05 000
fracture.
21315 ......... A Treatment of nose 1.51 4.04 3.00 1.16 1.48 0.13 5.68 4.64 2.80 3.12 010
fracture.
21320 ......... A Treatment of nose 1.85 4.10 3.32 1.80 2.01 0.15 6.10 5.32 3.80 4.01 010
fracture.
21325 ......... A Repair of nose 3.77 NA NA 3.15 3.80 0.32 NA NA 7.24 7.89 090
fracture.
21330 ......... A Repair of nose 5.38 NA NA 4.79 5.61 0.49 NA NA 10.66 11.48 090
fracture.
21335 ......... A Repair of nose 8.61 NA NA 6.69 8.49 0.68 NA NA 15.98 17.78 090
fracture.
21336 ......... A Repair nasal 5.72 NA NA 5.11 4.78 0.49 NA NA 11.32 10.99 090
septal fracture.
21337 ......... A Repair nasal 2.70 5.38 4.22 2.75 2.91 0.24 8.32 7.16 5.69 5.85 090
septal fracture.
21338 ......... A Repair nasoethmoid 6.46 NA NA 5.22 5.33 0.57 NA NA 12.25 12.36 090
fracture.
21339 ......... A Repair nasoethmoid 8.09 NA NA 5.70 6.70 0.69 NA NA 14.48 15.48 090
fracture.
21340 ......... A Repair of nose 10.77 NA NA 7.75 8.71 0.73 NA NA 19.25 20.21 090
fracture.
21343 ......... A Repair of sinus 12.95 NA NA 9.02 9.49 1.26 NA NA 23.23 23.70 090
fracture.
21344 ......... A Repair of sinus 19.72 NA NA 12.67 11.31 1.89 NA NA 34.28 32.92 090
fracture.
21345 ......... A Repair of nose/jaw 8.16 10.69 9.63 6.95 7.76 0.68 19.53 18.47 15.79 16.60 090
fracture.
21346 ......... A Repair of nose/jaw 10.61 NA NA 8.81 9.51 0.88 NA NA 20.30 21.00 090
fracture.
21347 ......... A Repair of nose/jaw 12.69 NA NA 9.04 10.14 1.14 NA NA 22.87 23.97 090
fracture.
21348 ......... A Repair of nose/jaw 16.69 NA NA 10.63 11.47 1.54 NA NA 28.86 29.70 090
fracture.
21355 ......... A Repair cheek bone 3.77 5.57 3.63 1.96 1.83 0.33 9.67 7.73 6.06 5.93 010
fracture.
21356 ......... A Repair cheek bone 4.15 NA NA 3.07 4.02 0.36 NA NA 7.58 8.53 010
fracture.
21360 ......... A Repair cheek bone 6.46 NA NA 4.94 6.33 0.55 NA NA 11.95 13.34 090
fracture.
21365 ......... A Repair cheek bone 14.95 NA NA 10.41 11.91 1.35 NA NA 26.71 28.21 090
fracture.
21366 ......... A Repair cheek bone 17.77 NA NA 12.23 12.67 1.59 NA NA 31.59 32.03 090
fracture.
21385 ......... A Repair eye socket 9.16 NA NA 7.42 8.92 0.70 NA NA 17.28 18.78 090
fracture.
21386 ......... A Repair eye socket 9.16 NA NA 7.19 8.52 0.80 NA NA 17.15 18.48 090
fracture.
21387 ......... A Repair eye socket 9.70 NA NA 7.27 7.68 0.83 NA NA 17.80 18.21 090
fracture.
21390 ......... A Repair eye socket 10.13 NA NA 7.85 9.97 0.79 NA NA 18.77 20.89 090
fracture.
21395 ......... A Repair eye socket 12.68 NA NA 9.08 9.77 1.20 NA NA 22.96 23.65 090
fracture.
21400 ......... A Treat eye socket 1.40 4.63 3.22 0.92 1.30 0.13 6.16 4.75 2.45 2.83 090
fracture.
21401 ......... A Repair eye socket 3.26 4.41 3.61 2.41 2.61 0.26 7.93 7.13 5.93 6.13 090
fracture.
21406 ......... A Repair eye socket 7.01 NA NA 5.99 5.82 0.64 NA NA 13.64 13.47 090
fracture.
21407 ......... A Repair eye socket 8.61 NA NA 7.06 7.38 0.73 NA NA 16.40 16.72 090
fracture.
21408 ......... A Repair eye socket 12.38 NA NA 8.51 8.86 1.27 NA NA 22.16 22.51 090
fracture.
21421 ......... A Treat mouth roof 5.14 7.10 6.88 4.73 5.43 0.41 12.65 12.43 10.28 10.98 090
fracture.
21422 ......... A Repair mouth roof 8.32 NA NA 6.50 8.22 0.73 NA NA 15.55 17.27 090
fracture.
21423 ......... A Repair mouth roof 10.40 NA NA 6.83 8.74 0.87 NA NA 18.10 20.01 090
fracture.
21431 ......... A Treat craniofacial 7.05 NA NA 6.16 6.35 0.58 NA NA 13.79 13.98 090
fracture.
21432 ......... A Repair 8.61 NA NA 6.12 6.73 0.99 NA NA 15.72 16.33 090
craniofacial
fracture.
21433 ......... A Repair 25.35 NA NA 16.31 17.90 2.18 NA NA 43.84 45.43 090
craniofacial
fracture.
21435 ......... A Repair 17.25 NA NA 11.14 12.76 1.42 NA NA 29.81 31.43 090
craniofacial
fracture.
21436 ......... A Repair 28.04 NA NA 14.69 15.30 1.99 NA NA 44.72 45.33 090
craniofacial
fracture.
21440 ......... A Repair dental 2.70 5.27 4.30 3.04 3.13 0.22 8.19 7.22 5.96 6.05 090
ridge fracture.
21445 ......... A Repair dental 5.38 6.39 6.51 4.21 5.32 0.45 12.22 12.34 10.04 11.15 090
ridge fracture.
21450 ......... A Treat lower jaw 2.97 5.26 4.17 2.31 2.70 0.25 8.48 7.39 5.53 5.92 090
fracture.
21451 ......... A Treat lower jaw 4.87 6.14 6.24 4.65 5.24 0.40 11.41 11.51 9.92 10.51 090
fracture.
21452 ......... A Treat lower jaw 1.98 8.07 4.79 3.31 2.41 0.16 10.21 6.93 5.45 4.55 090
fracture.
21453 ......... A Treat lower jaw 5.54 7.00 7.11 5.27 5.94 0.47 13.01 13.12 11.28 11.95 090
fracture.
21454 ......... A Treat lower jaw 6.46 NA NA 4.75 6.24 0.51 NA NA 11.72 13.21 090
fracture.
21461 ......... A Repair lower jaw 8.09 8.33 9.00 6.69 8.18 0.69 17.11 17.78 15.47 16.96 090
fracture.
21462 ......... A Repair lower jaw 9.79 9.59 10.64 7.19 9.44 0.81 20.19 21.24 17.79 20.04 090
fracture.
21465 ......... A Repair lower jaw 11.91 NA NA 7.09 8.13 1.02 NA NA 20.02 21.06 090
fracture.
21470 ......... A Repair lower jaw 15.34 NA NA 9.88 14.10 1.29 NA NA 26.51 30.73 090
fracture.
21480 ......... A Reset dislocated 0.61 2.08 1.47 0.18 0.46 0.05 2.74 2.13 0.84 1.12 000
jaw.
21485 ......... A Reset dislocated 3.99 4.07 3.23 2.87 2.03 0.29 8.35 7.51 7.15 6.31 090
jaw.
21490 ......... A Repair dislocated 11.86 NA NA 6.72 6.79 0.90 NA NA 19.48 19.55 090
jaw.
21493 ......... A Treat hyoid bone 1.27 0.49 1.07 0.49 1.01 0.10 1.86 2.44 1.86 2.38 090
fracture.
21494 ......... A Repair hyoid bone 6.28 2.40 5.28 2.40 5.28 0.48 9.16 12.04 9.16 12.04 090
fracture.
21495 ......... A Repair hyoid bone 5.69 NA NA 4.39 4.81 0.43 NA NA 10.51 10.93 090
fracture.
21497 ......... A Interdental wiring 3.86 4.76 4.54 3.54 3.93 0.31 8.93 8.71 7.71 8.10 090

[[Page 39650]]

21499 ......... C Head surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
21501 ......... A Drain neck/chest 3.81 3.83 2.91 3.32 2.65 0.39 8.03 7.11 7.52 6.85 090
lesion.
21502 ......... A Drain chest lesion 7.12 NA NA 7.94 6.26 0.81 NA NA 15.87 14.19 090
21510 ......... A Drainage of bone 5.74 NA NA 6.89 5.52 0.65 NA NA 13.28 11.91 090
lesion.
21550 ......... A Biopsy of neck/ 2.06 1.96 1.44 1.19 0.83 0.13 4.15 3.63 3.38 3.02 010
chest.
21555 ......... A Remove lesion neck/ 4.35 3.92 2.83 2.49 2.12 0.41 8.68 7.59 7.25 6.88 090
chest.
21556 ......... A Remove lesion neck/ 5.57 NA NA 3.24 3.68 0.53 NA NA 9.34 9.78 090
chest.
21557 ......... A Remove tumor, neck 8.88 NA NA 7.41 8.32 0.85 NA NA 17.14 18.05 090
or chest.
21600 ......... A Partial removal of 6.89 NA NA 7.57 6.23 0.83 NA NA 15.29 13.95 090
rib.
21610 ......... A Partial removal of 14.61 NA NA 10.26 7.94 2.03 NA NA 26.90 24.58 090
rib.
21615 ......... A Removal of rib.... 9.87 NA NA 8.61 9.80 1.38 NA NA 19.86 21.05 090
21616 ......... A Removal of rib and 12.04 NA NA 9.19 8.54 1.56 NA NA 22.79 22.14 090
nerves.
21620 ......... A Partial removal of 6.79 NA NA 8.26 7.85 0.83 NA NA 15.88 15.47 090
sternum.
21627 ......... A Sternal 6.81 NA NA 13.05 9.26 0.87 NA NA 20.73 16.94 090
debridement.
21630 ......... A Extensive sternum 17.38 NA NA 13.37 13.68 2.07 NA NA 32.82 33.13 090
surgery.
21632 ......... A Extensive sternum 18.14 NA NA 13.30 12.91 2.41 NA NA 33.85 33.46 090
surgery.
21700 ......... A Revision of neck 6.19 6.82 5.67 6.47 5.49 0.78 13.79 12.64 13.44 12.46 090
muscle.
21705 ......... A Revision of neck 9.60 NA NA 8.59 6.93 1.36 NA NA 19.55 17.89 090
muscle/rib.
21720 ......... A Revision of neck 5.68 7.41 5.79 6.00 5.09 0.87 13.96 12.34 12.55 11.64 090
muscle.
21725 ......... A Revision of neck 6.99 NA NA 6.20 5.73 0.68 NA NA 13.87 13.40 090
muscle.
21740 ......... A Reconstruction of 16.50 NA NA 14.54 12.15 2.05 NA NA 33.09 30.70 090
sternum.
21750 ......... A Repair of sternum 10.77 NA NA 12.44 10.20 1.41 NA NA 24.62 22.38 090
separation.
21800 ......... A Treatment of rib 0.96 1.81 1.33 0.92 0.88 0.09 2.86 2.38 1.97 1.93 090
fracture.
21805 ......... A Treatment of rib 2.75 NA NA 4.10 2.79 0.30 NA NA 7.15 5.84 090
fracture.
21810 ......... A Treatment of rib 6.86 NA NA 6.74 7.35 0.60 NA NA 14.20 14.81 090
fracture(s).
21820 ......... A Treat sternum 1.28 2.17 1.83 1.30 1.39 0.13 3.58 3.24 2.71 2.80 090
fracture.
21825 ......... A Repair sternum 7.41 NA NA 11.08 9.29 1.01 NA NA 19.50 17.71 090
fracture.
21899 ......... C Neck/chest surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
21920 ......... A Biopsy soft tissue 2.06 1.99 1.43 0.77 0.60 0.10 4.15 3.59 2.93 2.76 010
of back.
21925 ......... A Biopsy soft tissue 4.49 9.79 5.96 4.24 3.18 0.45 14.73 10.90 9.18 8.12 090
of back.
21930 ......... A Remove lesion, 5.00 4.19 3.57 2.66 2.81 0.49 9.68 9.06 8.15 8.30 090
back or flank.
21935 ......... A Remove tumor of 17.96 NA NA 11.75 9.45 1.88 NA NA 31.59 29.29 090
back.
22100 ......... A Remove part of 9.73 NA NA 8.15 8.22 1.41 NA NA 19.29 19.36 090
neck vertebra.
22101 ......... A Remove part, 9.81 NA NA 8.42 8.56 1.28 NA NA 19.51 19.65 090
thorax vertebra.
22102 ......... A Remove part, 9.81 NA NA 8.14 6.51 1.38 NA NA 19.33 17.70 090
lumbar vertebra.
22103 ......... A Remove extra spine 2.34 NA NA 1.25 1.84 0.35 NA NA 3.94 4.53 ZZZ
segment.
22110 ......... A Remove part of 12.74 NA NA 10.16 10.36 1.98 NA NA 24.88 25.08 090
neck vertebra.
22112 ......... A Remove part, 12.81 NA NA 9.91 10.33 1.67 NA NA 24.39 24.81 090
thorax vertebra.
22114 ......... A Remove part, 12.81 NA NA 12.27 10.07 1.46 NA NA 26.54 24.34 090
lumbar vertebra.
22116 ......... A Remove extra spine 2.32 NA NA 1.24 1.82 0.35 NA NA 3.91 4.49 ZZZ
segment.
22210 ......... A Revision of neck 23.82 NA NA 16.48 15.75 3.65 NA NA 43.95 43.22 090
spine.
22212 ......... A Revision of thorax 19.42 NA NA 14.05 16.41 2.14 NA NA 35.61 37.97 090
spine.
22214 ......... A Revision of lumbar 19.45 NA NA 14.61 15.51 2.48 NA NA 36.54 37.44 090
spine.
22216 ......... A Revise, extra 6.04 NA NA 3.21 4.36 0.87 NA NA 10.12 11.27 ZZZ
spine segment.
22220 ......... A Revision of neck 21.37 NA NA 15.12 16.59 3.31 NA NA 39.80 41.27 090
spine.
22222 ......... A Revision of thorax 21.52 NA NA 10.44 12.61 1.07 NA NA 33.03 35.20 090
spine.
22224 ......... A Revision of lumbar 21.52 NA NA 15.27 15.60 2.60 NA NA 39.39 39.72 090
spine.
22226 ......... A Revise, extra 6.04 NA NA 3.22 4.36 0.78 NA NA 10.04 11.18 ZZZ
spine segment.
22305 ......... A Treat spine 2.05 2.67 2.56 1.70 2.08 0.22 4.94 4.83 3.97 4.35 090
process fracture.
22310 ......... A Treat spine 2.61 3.87 3.30 2.96 2.85 0.29 6.77 6.20 5.86 5.75 090
fracture.
22315 ......... A Treat spine 8.84 NA NA 9.48 7.73 1.20 NA NA 19.52 17.77 090
fracture.
22325 ......... A Repair of spine 18.30 NA NA 13.78 11.41 2.42 NA NA 34.50 32.13 090
fracture.
22326 ......... A Repair neck spine 19.59 NA NA 15.33 16.31 3.33 NA NA 38.25 39.23 090
fracture.
22327 ......... A Repair thorax 19.20 NA NA 14.05 15.68 2.77 NA NA 36.02 37.65 090
spine fracture.
22328 ......... A Repair each add 4.61 NA NA 2.38 3.58 0.71 NA NA 7.70 8.90 ZZZ
spine fx.
22505 ......... A Manipulation of 1.87 10.53 5.98 10.17 5.80 0.14 12.54 7.99 12.18 7.81 010
spine.
22548 ......... A Neck spine fusion. 25.82 NA NA 17.49 21.09 4.90 NA NA 48.21 51.81 090
22554 ......... A Neck spine fusion. 18.62 NA NA 13.68 17.59 3.29 NA NA 35.59 39.50 090
22556 ......... A Thorax spine 23.46 NA NA 16.26 19.90 3.36 NA NA 43.08 46.72 090
fusion.
22558 ......... A Lumbar spine 22.28 NA NA 15.38 18.64 2.76 NA NA 40.42 43.68 090
fusion.
22585 ......... A Additional spinal 5.53 NA NA 2.91 4.39 0.89 NA NA 9.33 10.81 ZZZ
fusion.
22590 ......... A Spine & skull 20.51 NA NA 15.02 19.22 3.49 NA NA 39.02 43.22 090
spinal fusion.
22595 ......... A Neck spinal fusion 19.39 NA NA 14.19 18.67 3.38 NA NA 36.96 41.44 090
22600 ......... A Neck spine fusion. 16.14 NA NA 12.35 15.81 2.63 NA NA 31.12 34.58 090
22610 ......... A Thorax spine 16.02 NA NA 12.22 15.67 2.34 NA NA 30.58 34.03 090
fusion.
22612 ......... A Lumbar spine 21.00 NA NA 15.15 18.76 2.77 NA NA 38.92 42.53 090
fusion.
22614 ......... A Spine fusion, 6.44 NA NA 3.44 4.79 0.87 NA NA 10.75 12.10 ZZZ
extra segment.
22630 ......... A Lumbar spine 20.84 NA NA 15.69 17.85 3.23 NA NA 39.76 41.92 090
fusion.
22632 ......... A Spine fusion, 5.23 NA NA 2.78 4.10 0.75 NA NA 8.76 10.08 ZZZ
extra segment.
22800 ......... A Fusion of spine... 18.25 NA NA 13.46 17.63 2.23 NA NA 33.94 38.11 090
22802 ......... A Fusion of spine... 30.88 NA NA 20.46 25.60 3.60 NA NA 54.94 60.08 090
22804 ......... A Fusion of spine... 36.27 NA NA 23.14 26.94 4.09 NA NA 63.50 67.30 090
22808 ......... A Fusion of spine... 26.27 NA NA 17.77 18.88 3.94 NA NA 47.98 49.09 090
22810 ......... A Fusion of spine... 30.27 NA NA 19.32 19.65 3.73 NA NA 53.32 53.65 090
22812 ......... A Fusion of spine... 32.70 NA NA 20.23 24.19 3.85 NA NA 56.78 60.74 090
22818 ......... A Kyphectomy, 1-2 31.83 NA NA 20.83 25.75 4.55 NA NA 57.21 62.13 090
segments.
22819 ......... A Kyphectomy, 3 & 36.44 NA NA 22.98 26.82 5.20 NA NA 64.62 68.46 090
more segment.
22830 ......... A Exploration of 10.85 NA NA 9.51 11.24 1.38 NA NA 21.74 23.47 090
spinal fusion.
22840 ......... A Insert spine 12.54 NA NA 8.17 7.33 1.71 NA NA 22.42 21.58 ZZZ
fixation device.
22841 ......... B Insert spine 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
fixation device.
22842 ......... A Insert spine 12.58 NA NA 6.69 7.07 1.72 NA NA 20.99 21.37 ZZZ
fixation device.
22843 ......... A Insert spine 13.46 NA NA 8.61 8.95 1.73 NA NA 23.80 24.14 ZZZ
fixation device.
22844 ......... A Insert spine 16.44 NA NA 10.23 10.79 1.88 NA NA 28.55 29.11 ZZZ
fixation device.
22845 ......... A Insert spine 11.96 NA NA 7.88 7.04 2.04 NA NA 21.88 21.04 ZZZ
fixation device.

[[Page 39651]]

22846 ......... A Insert spine 12.42 NA NA 8.17 8.37 2.09 NA NA 22.68 22.88 ZZZ
fixation device.
22847 ......... A Insert spine 13.80 NA NA 8.53 9.03 1.75 NA NA 24.08 24.58 ZZZ
fixation device.
22848 ......... A Insert pelvic 6.00 NA NA 4.53 5.37 0.69 NA NA 11.22 12.06 ZZZ
fixationdevice.
22849 ......... A Reinsert spinal 18.51 NA NA 13.25 13.01 2.35 NA NA 34.11 33.87 090
fixation.
22850 ......... A Remove spine 9.52 NA NA 8.32 9.14 1.25 NA NA 19.09 19.91 090
fixation device.
22851 ......... A Apply spine prosth 6.71 NA NA 5.06 6.01 0.98 NA NA 12.75 13.70 ZZZ
device.
22852 ......... A Remove spine 9.01 NA NA 8.16 9.40 1.15 NA NA 18.32 19.56 090
fixation device.
22855 ......... A Remove spine 15.13 NA NA 11.23 9.67 2.47 NA NA 28.83 27.27 090
fixation device.
22899 ......... C Spine surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
22900 ......... A Remove abdominal 5.80 NA NA 4.18 3.74 0.59 NA NA 10.57 10.13 090
wall lesion.
22999 ......... C Abdomen surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
23000 ......... A Removal of calcium 4.36 6.73 5.13 5.99 4.76 0.43 11.52 9.92 10.78 9.55 090
deposits.
23020 ......... A Release shoulder 8.93 NA NA 9.20 8.55 0.99 NA NA 19.12 18.47 090
joint.
23030 ......... A Drain shoulder 3.43 4.69 3.52 3.70 3.02 0.36 8.48 7.31 7.49 6.81 010
lesion.
23031 ......... A Drain shoulder 2.74 4.76 2.65 3.46 1.87 0.27 7.77 5.66 6.47 4.88 010
bursa.
23035 ......... A Drain shoulder 8.61 NA NA 14.03 10.39 0.94 NA NA 23.58 19.94 090
bone lesion.
23040 ......... A Exploratory 9.20 NA NA 10.19 10.13 1.01 NA NA 20.40 20.34 090
shoulder surgery.
23044 ......... A Exploratory 7.12 NA NA 9.08 8.29 0.78 NA NA 16.98 16.19 090
shoulder surgery.
23065 ......... A Biopsy shoulder 2.27 2.23 1.48 1.31 1.02 0.12 4.62 3.87 3.70 3.41 010
tissues.
23066 ......... A Biopsy shoulder 4.16 6.42 3.85 5.27 3.28 0.44 11.02 8.45 9.87 7.88 090
tissues.
23075 ......... A Removal of 2.39 4.31 3.07 2.73 2.28 0.25 6.95 5.71 5.37 4.92 010
shoulder lesion.
23076 ......... A Removal of 7.63 NA NA 7.17 5.51 0.82 NA NA 15.62 13.96 090
shoulder lesion.
23077 ......... A Remove tumor of 16.09 NA NA 15.11 11.56 1.66 NA NA 32.86 29.31 090
shoulder.
23100 ......... A Biopsy of shoulder 6.03 NA NA 7.97 7.59 0.65 NA NA 14.65 14.27 090
joint.
23101 ......... A Shoulder joint 5.58 NA NA 7.28 6.97 0.62 NA NA 13.48 13.17 090
surgery.
23105 ......... A Remove shoulder 8.23 NA NA 9.01 9.42 0.90 NA NA 18.14 18.55 090
joint lining.
23106 ......... A Incision of 5.96 NA NA 7.67 6.41 0.69 NA NA 14.32 13.06 090
collarbone joint.
23107 ......... A Explore,treat 8.62 NA NA 9.50 9.90 0.94 NA NA 19.06 19.46 090
shoulder joint.
23120 ......... A Partial removal, 7.11 NA NA 8.83 6.92 0.78 NA NA 16.72 14.81 090
collar bone.
23125 ......... A Removal of 9.39 NA NA 9.44 9.33 1.04 NA NA 19.87 19.76 090
collarbone.
23130 ......... A Partial 7.55 NA NA 9.13 8.39 0.82 NA NA 17.50 16.76 090
removal,shoulderb
one.
23140 ......... A Removal of bone 6.89 NA NA 7.32 5.92 0.72 NA NA 14.93 13.53 090
lesion.
23145 ......... A Removal of bone 9.09 NA NA 9.60 9.21 0.87 NA NA 19.56 19.17 090
lesion.
23146 ......... A Removal of bone 7.83 NA NA 8.99 7.34 0.82 NA NA 17.64 15.99 090
lesion.
23150 ......... A Removal of humerus 8.48 NA NA 8.73 7.97 0.89 NA NA 18.10 17.34 090
lesion.
23155 ......... A Removal of humerus 10.35 NA NA 10.29 9.92 1.16 NA NA 21.80 21.43 090
lesion.
23156 ......... A Removal of humerus 8.68 NA NA 8.72 8.51 0.96 NA NA 18.36 18.15 090
lesion.
23170 ......... A Remove collarbone 6.86 NA NA 8.94 7.08 0.77 NA NA 16.57 14.71 090
lesion.
23172 ......... A Remove shoulder 6.90 NA NA 8.53 7.07 0.78 NA NA 16.21 14.75 090
blade lesion.
23174 ......... A Remove humerus 9.51 NA NA 12.18 10.73 1.01 NA NA 22.70 21.25 090
lesion.
23180 ......... A Remove collar bone 8.53 NA NA 13.60 9.14 0.94 NA NA 23.07 18.61 090
lesion.
23182 ......... A Remove shoulder 8.15 NA NA 13.94 10.54 0.88 NA NA 22.97 19.57 090
blade lesion.
23184 ......... A Remove humerus 9.38 NA NA 14.49 12.04 1.02 NA NA 24.89 22.44 090
lesion.
23190 ......... A Partial removal of 7.24 NA NA 7.70 7.15 0.79 NA NA 15.73 15.18 090
scapula.
23195 ......... A Removal of head of 9.81 NA NA 9.35 9.51 1.06 NA NA 20.22 20.38 090
humerus.
23200 ......... A Removal of collar 12.08 NA NA 13.26 11.61 1.28 NA NA 26.62 24.97 090
bone.
23210 ......... A Removal of 12.49 NA NA 12.65 11.22 1.31 NA NA 26.45 25.02 090
shoulderblade.
23220 ......... A Partial removal of 14.56 NA NA 13.20 13.14 1.56 NA NA 29.32 29.26 090
humerus.
23221 ......... A Partial removal of 17.74 NA NA 13.63 16.66 1.35 NA NA 32.72 35.75 090
humerus.
23222 ......... A Partial removal of 23.92 NA NA 19.62 17.96 2.57 NA NA 46.11 44.45 090
humerus.
23330 ......... A Remove shoulder 1.85 4.48 2.54 3.27 1.79 0.19 6.52 4.58 5.31 3.83 010
foreign body.
23331 ......... A Remove shoulder 7.38 NA NA 8.32 5.39 0.81 NA NA 16.51 13.58 090
foreign body.
23332 ......... A Remove shoulder 11.62 NA NA 10.99 10.77 1.28 NA NA 23.89 23.67 090
foreign body.
23350 ......... A Injection for 1.00 10.12 5.34 0.27 0.42 0.04 11.16 6.38 1.31 1.46 000
shoulder x-ray.
23395 ......... A Muscle 16.85 NA NA 12.64 12.36 1.85 NA NA 31.34 31.06 090
transfer,shoulder/
arm.
23397 ......... A Muscle transfers.. 16.13 NA NA 12.88 14.02 1.81 NA NA 30.82 31.96 090
23400 ......... A Fixation of 13.54 NA NA 12.70 11.69 1.52 NA NA 27.76 26.75 090
shoulder blade.
23405 ......... A Incision of tendon 8.37 NA NA 8.24 8.19 0.92 NA NA 17.53 17.48 090
& muscle.
23406 ......... A Incise tendon(s) & 10.79 NA NA 10.05 10.13 1.21 NA NA 22.05 22.13 090
muscle(s).
23410 ......... A Repair of 12.45 NA NA 11.66 11.77 1.36 NA NA 25.47 25.58 090
tendon(s).
23412 ......... A Repair of 13.31 NA NA 12.21 13.36 1.45 NA NA 26.97 28.12 090

[robop...@us.govnews.org]

Archive-Name: gov/us/fed/nara/fed-register/1999/jul/22/64FR39607/part8

Posting-number: Volume 64, Issue 140, Page 39607, Part 1

tendon(s).
23415 ......... A Release of 9.97 NA NA 9.24 7.43 1.09 NA NA 20.30 18.49 090
shoulder ligament.
23420 ......... A Repair of shoulder 13.30 NA NA 12.98 14.43 1.45 NA NA 27.73 29.18 090
23430 ......... A Repair biceps 9.98 NA NA 10.36 9.17 1.09 NA NA 21.43 20.24 090
tendon.
23440 ......... A Removal/transplant 10.48 NA NA 10.71 9.25 1.15 NA NA 22.34 20.88 090
tendon.
23450 ......... A Repair shoulder 13.40 NA NA 11.76 12.80 1.47 NA NA 26.63 27.67 090
capsule.
23455 ......... A Repair shoulder 14.37 NA NA 12.45 14.67 1.57 NA NA 28.39 30.61 090
capsule.
23460 ......... A Repair shoulder 15.37 NA NA 13.22 14.25 1.66 NA NA 30.25 31.28 090
capsule.
23462 ......... A Repair shoulder 15.30 NA NA 12.83 14.63 1.61 NA NA 29.74 31.54 090
capsule.
23465 ......... A Repair shoulder 15.85 NA NA 13.32 14.34 1.74 NA NA 30.91 31.93 090
capsule.
23466 ......... A Repair shoulder 14.22 NA NA 12.16 14.57 1.56 NA NA 27.94 30.35 090
capsule.
23470 ......... A Reconstruct 17.15 NA NA 14.08 16.14 1.87 NA NA 33.10 35.16 090
shoulder joint.
23472 ......... A Reconstruct 16.92 NA NA 13.88 17.04 1.85 NA NA 32.65 35.81 090
shoulder joint.
23480 ......... A Revision of 11.18 NA NA 10.23 8.69 1.25 NA NA 22.66 21.12 090
collarbone.
23485 ......... A Revision of collar 13.43 NA NA 12.78 12.55 1.45 NA NA 27.66 27.43 090
bone.
23490 ......... A Reinforce clavicle 11.86 NA NA 10.69 10.76 1.33 NA NA 23.88 23.95 090
23491 ......... A Reinforce shoulder 14.21 NA NA 11.89 12.84 1.59 NA NA 27.69 28.64 090
bones.
23500 ......... A Treat clavicle 2.08 3.14 2.47 2.15 1.97 0.22 5.44 4.77 4.45 4.27 090
fracture.
23505 ......... A Treat clavicle 3.69 4.86 3.83 3.46 3.13 0.40 8.95 7.92 7.55 7.22 090
fracture.
23515 ......... A Repair clavicle 7.41 NA NA 7.48 7.50 0.81 NA NA 15.70 15.72 090
fracture.
23520 ......... A Treat clavicle 2.16 3.24 2.37 2.20 1.85 0.22 5.62 4.75 4.58 4.23 090
dislocation.
23525 ......... A Treat clavicle 3.60 4.92 3.54 3.13 2.64 0.39 8.91 7.53 7.12 6.63 090
dislocation.
23530 ......... A Repair clavicle 7.31 NA NA 6.94 7.04 0.80 NA NA 15.05 15.15 090
dislocation.
23532 ......... A Repair clavicle 8.01 NA NA 7.12 7.49 0.90 NA NA 16.03 16.40 090
dislocation.

[[Page 39652]]

23540 ......... A Treat clavicle 2.23 3.59 2.64 2.13 1.91 0.22 6.04 5.09 4.58 4.36 090
dislocation.
23545 ......... A Treat clavicle 3.25 4.12 3.14 3.04 2.60 0.33 7.70 6.72 6.62 6.18 090
dislocation.
23550 ......... A Repair clavicle 7.24 NA NA 7.37 8.01 0.77 NA NA 15.38 16.02 090
dislocation.
23552 ......... A Repair clavicle 8.45 NA NA 7.97 7.94 0.91 NA NA 17.33 17.30 090
dislocation.
23570 ......... A Treat 2.23 3.15 2.50 2.27 2.06 0.24 5.62 4.97 4.74 4.53 090
shoulderblade
fracture.
23575 ......... A Treat 4.06 5.07 4.03 3.69 3.34 0.44 9.57 8.53 8.19 7.84 090
shoulderblade
fracture.
23585 ......... A Repair scapula 8.96 NA NA 8.27 8.32 0.98 NA NA 18.21 18.26 090
fracture.
23600 ......... A Treat humerus 2.93 4.93 4.04 3.30 3.23 0.32 8.18 7.29 6.55 6.48 090
fracture.
23605 ......... A Treat humerus 4.87 7.31 6.24 5.82 5.50 0.54 12.72 11.65 11.23 10.91 090
fracture.
23615 ......... A Repair humerus 9.35 NA NA 9.15 10.16 1.03 NA NA 19.53 20.54 090
fracture.
23616 ......... A Repair humerus 21.27 NA NA 14.99 19.61 2.33 NA NA 38.59 43.21 090
fracture.
23620 ......... A Treat humerus 2.40 4.64 3.89 3.03 2.24 0.26 7.30 6.55 5.69 4.90 090
fracture.
23625 ......... A Treat humerus 3.93 6.45 5.30 4.94 4.55 0.44 10.82 9.67 9.31 8.92 090
fracture.
23630 ......... A Repair humerus 7.35 NA NA 7.29 8.04 0.80 NA NA 15.44 16.19 090
fracture.
23650 ......... A Treat shoulder 3.39 4.63 3.46 3.04 2.66 0.34 8.36 7.19 6.77 6.39 090
dislocation.
23655 ......... A Treat shoulder 4.57 NA NA 3.85 3.52 0.48 NA NA 8.90 8.57 090
dislocation.
23660 ......... A Repair shoulder 7.49 NA NA 8.16 8.55 0.73 NA NA 16.38 16.77 090
dislocation.
23665 ......... A Treat dislocation/ 4.47 6.64 5.14 5.18 4.41 0.49 11.60 10.10 10.14 9.37 090
fracture.
23670 ......... A Repair dislocation/ 7.90 NA NA 7.64 8.54 0.85 NA NA 16.39 17.29 090
fracture.
23675 ......... A Treat dislocation/ 6.05 7.35 5.81 6.01 5.14 0.67 14.07 12.53 12.73 11.86 090
fracture.
23680 ......... A Repair dislocation/ 10.06 NA NA 8.73 10.37 1.10 NA NA 19.89 21.53 090
fracture.
23700 ......... A Fixation of 2.52 NA NA 3.00 2.64 0.28 NA NA 5.80 5.44 010
shoulder.
23800 ......... A Fusion of shoulder 14.16 NA NA 13.02 14.97 1.52 NA NA 28.70 30.65 090
joint.
23802 ......... A Fusion of shoulder 16.60 NA NA 13.77 14.52 1.80 NA NA 32.17 32.92 090
joint.
23900 ......... A Amputation of arm 19.72 NA NA 14.42 14.03 1.97 NA NA 36.11 35.72 090
& girdle.
23920 ......... A Amputation at 14.61 NA NA 12.40 13.72 1.56 NA NA 28.57 29.89 090
shoulder joint.
23921 ......... A Amputation follow- 5.49 6.69 5.66 5.97 5.30 0.53 12.71 11.68 11.99 11.32 090
up surgery.
23929 ......... C Shoulder surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
23930 ......... A Drainage of arm 2.94 4.81 3.28 3.36 2.56 0.30 8.05 6.52 6.60 5.80 010
lesion.
23931 ......... A Drainage of arm 1.79 4.59 2.70 3.00 1.71 0.18 6.56 4.67 4.97 3.68 010
bursa.
23935 ......... A Drain arm/elbow 6.09 NA NA 10.29 7.69 0.66 NA NA 17.04 14.44 090
bone lesion.
24000 ......... A Exploratory elbow 5.82 NA NA 6.49 6.72 0.62 NA NA 12.93 13.16 090
surgery.
24006 ......... A Release elbow 9.31 NA NA 7.51 7.63 1.02 NA NA 17.84 17.96 090
joint.
24065 ......... A Biopsy arm/elbow 2.08 3.98 2.42 2.77 1.60 0.12 6.18 4.62 4.97 3.80 010
soft tissue.
24066 ......... A Biopsy arm/elbow 5.21 6.64 4.79 5.87 4.41 0.58 12.43 10.58 11.66 10.20 090
soft tissue.
24075 ......... A Remove arm/elbow 3.92 6.24 4.20 5.08 3.62 0.40 10.56 8.52 9.40 7.94 090
lesion.
24076 ......... A Remove arm/elbow 6.30 NA NA 6.14 5.07 0.67 NA NA 13.11 12.04 090
lesion.
24077 ......... A Remove tumor of 11.76 NA NA 11.31 10.97 1.23 NA NA 24.30 23.96 090
arm/elbow.
24100 ......... A Biopsy elbow joint 4.93 NA NA 4.86 4.73 0.49 NA NA 10.28 10.15 090
lining.
24101 ......... A Explore/treat 6.13 NA NA 6.07 6.69 0.68 NA NA 12.88 13.50 090
elbow joint.
24102 ......... A Remove elbow joint 8.03 NA NA 6.78 8.18 0.88 NA NA 15.69 17.09 090
lining.
24105 ......... A Removal of elbow 3.61 NA NA 4.32 4.21 0.40 NA NA 8.33 8.22 090
bursa.
24110 ......... A Remove humerus 7.39 NA NA 8.22 8.29 0.83 NA NA 16.44 16.51 090
lesion.
24115 ......... A Remove/graft bone 9.63 NA NA 8.11 8.22 0.91 NA NA 18.65 18.76 090
lesion.
24116 ......... A Remove/graft bone 11.81 NA NA 10.63 10.59 1.29 NA NA 23.73 23.69 090
lesion.
24120 ......... A Remove elbow 6.65 NA NA 5.96 6.25 0.73 NA NA 13.34 13.63 090
lesion.
24125 ......... A Remove/graft bone 7.89 NA NA 6.26 6.27 0.82 NA NA 14.97 14.98 090
lesion.
24126 ......... A Remove/graft bone 8.31 NA NA 6.43 7.23 0.93 NA NA 15.67 16.47 090
lesion.
24130 ......... A Removal of head of 6.25 NA NA 6.19 6.74 0.69 NA NA 13.13 13.68 090
radius.
24134 ......... A Removal of arm 9.73 NA NA 13.25 11.34 1.00 NA NA 23.98 22.07 090
bone lesion.
24136 ......... A Remove radius bone 7.99 NA NA 5.72 7.63 0.86 NA NA 14.57 16.48 090
lesion.
24138 ......... A Remove elbow bone 8.05 NA NA 6.92 6.93 0.90 NA NA 15.87 15.88 090
lesion.
24140 ......... A Partial removal of 9.18 NA NA 14.21 11.87 1.01 NA NA 24.40 22.06 090
arm bone.
24145 ......... A Partial removal of 7.58 NA NA 9.66 8.29 0.83 NA NA 18.07 16.70 090
radius.
24147 ......... A Partial removal of 7.54 NA NA 9.31 8.24 0.86 NA NA 17.71 16.64 090
elbow.
24149 ......... A Radical resection 14.20 NA NA 9.94 11.83 1.54 NA NA 25.68 27.57 090
of elbow.
24150 ......... A Extensive humerus 13.27 NA NA 13.24 14.26 1.41 NA NA 27.92 28.94 090
surgery.
24151 ......... A Extensive humerus 15.58 NA NA 13.95 14.48 1.61 NA NA 31.14 31.67 090
surgery.
24152 ......... A Extensive radius 10.06 NA NA 8.11 7.75 1.03 NA NA 19.20 18.84 090
surgery.
24153 ......... A Extensive radius 11.54 NA NA 6.34 8.84 0.71 NA NA 18.59 21.09 090
surgery.
24155 ......... A Removal of elbow 11.73 NA NA 8.50 10.09 1.22 NA NA 21.45 23.04 090
joint.
24160 ......... A Remove elbow joint 7.83 NA NA 6.83 6.04 0.84 NA NA 15.50 14.71 090
implant.
24164 ......... A Remove radius head 6.23 NA NA 5.88 5.94 0.69 NA NA 12.80 12.86 090
implant.
24200 ......... A Removal of arm 1.76 4.24 2.43 2.79 1.55 0.15 6.15 4.34 4.70 3.46 010
foreign body.
24201 ......... A Removal of arm 4.56 7.17 5.25 5.81 4.57 0.50 12.23 10.31 10.87 9.63 090
foreign body.
24220 ......... A Injection for 1.31 11.11 5.83 0.38 0.47 0.07 12.49 7.21 1.76 1.85 000
elbow x-ray.
24301 ......... A Muscle/tendon 10.20 NA NA 8.47 8.52 1.12 NA NA 19.79 19.84 090
transfer.
24305 ......... A Arm tendon 7.45 NA NA 6.88 5.11 0.79 NA NA 15.12 13.35 090
lengthening.
24310 ......... A Revision of arm 5.98 NA NA 6.85 5.03 0.67 NA NA 13.50 11.68 090
tendon.
24320 ......... A Repair of arm 10.56 NA NA 9.83 9.91 1.06 NA NA 21.45 21.53 090
tendon.
24330 ......... A Revision of arm 9.60 NA NA 7.68 8.59 1.09 NA NA 18.37 19.28 090
muscles.
24331 ......... A Revision of arm 10.65 NA NA 8.18 9.31 1.20 NA NA 20.03 21.16 090
muscles.
24340 ......... A Repair of biceps 7.89 NA NA 7.04 7.32 0.86 NA NA 15.79 16.07 090
tendon.
24341 ......... A Repair tendon/ 7.90 NA NA 6.82 7.21 0.87 NA NA 15.59 15.98 090
muscle arm.
24342 ......... A Repair of ruptured 10.62 NA NA 8.46 9.86 1.17 NA NA 20.25 21.65 090
tendon.
24350 ......... A Repair of tennis 5.25 NA NA 5.41 5.00 0.59 NA NA 11.25 10.84 090
elbow.
24351 ......... A Repair of tennis 5.91 NA NA 5.81 5.39 0.66 NA NA 12.38 11.96 090
elbow.
24352 ......... A Repair of tennis 6.43 NA NA 6.35 6.27 0.70 NA NA 13.48 13.40 090
elbow.
24354 ......... A Repair of tennis 6.48 NA NA 6.03 6.06 0.72 NA NA 13.23 13.26 090
elbow.
24356 ......... A Revision of tennis 6.68 NA NA 6.21 7.06 0.74 NA NA 13.63 14.48 090
elbow.
24360 ......... A Reconstruct elbow 12.34 NA NA 8.94 11.84 1.34 NA NA 22.62 25.52 090
joint.
24361 ......... A Reconstruct elbow 14.08 NA NA 10.46 12.36 1.54 NA NA 26.08 27.98 090
joint.
24362 ......... A Reconstruct elbow 14.99 NA NA 8.92 8.03 1.42 NA NA 25.33 24.44 090
joint.
24363 ......... A Replace elbow 18.49 NA NA 12.77 17.42 2.04 NA NA 33.30 37.95 090
joint.

[[Page 39653]]

24365 ......... A Reconstruct head 8.39 NA NA 7.01 7.59 0.93 NA NA 16.33 16.91 090
of radius.
24366 ......... A Reconstruct head 9.13 NA NA 7.39 9.15 0.99 NA NA 17.51 19.27 090
of radius.
24400 ......... A Revision of 11.06 NA NA 11.43 10.29 1.20 NA NA 23.69 22.55 090
humerus.
24410 ......... A Revision of 14.82 NA NA 11.58 13.41 1.45 NA NA 27.85 29.68 090
humerus.
24420 ......... A Revision of 13.44 NA NA 14.05 13.70 1.46 NA NA 28.95 28.60 090
humerus.
24430 ......... A Repair of humerus. 12.81 NA NA 11.70 13.50 1.40 NA NA 25.91 27.71 090
24435 ......... A Repair humerus 13.17 NA NA 12.61 14.17 1.44 NA NA 27.22 28.78 090
with graft.
24470 ......... A Revision of elbow 8.74 NA NA 5.81 7.21 0.98 NA NA 15.53 16.93 090
joint.
24495 ......... A Decompression of 8.12 NA NA 9.99 8.12 0.95 NA NA 19.06 17.19 090
forearm.
24498 ......... A Reinforce humerus. 11.92 NA NA 11.19 11.22 1.31 NA NA 24.42 24.45 090
24500 ......... A Treat humerus 3.21 6.65 4.71 3.01 2.89 0.34 10.20 8.26 6.56 6.44 090
fracture.
24505 ......... A Treat humerus 5.17 9.89 7.39 6.05 5.47 0.57 15.63 13.13 11.79 11.21 090
fracture.
24515 ......... A Repair humerus 11.65 NA NA 11.21 10.84 1.24 NA NA 24.10 23.73 090
fracture.
24516 ......... A Repair humerus 11.65 NA NA 10.58 10.53 1.28 NA NA 23.51 23.46 090
fracture.
24530 ......... A Treat humerus 3.50 7.59 5.28 4.24 3.60 0.38 11.47 9.16 8.12 7.48 090
fracture.
24535 ......... A Treat humerus 6.87 9.99 7.63 6.06 5.66 0.76 17.62 15.26 13.69 13.29 090
fracture.
24538 ......... A Treat humerus 9.43 NA NA 9.36 9.01 1.03 NA NA 19.82 19.47 090
fracture.
24545 ......... A Repair humerus 10.46 NA NA 9.16 9.99 1.14 NA NA 20.76 21.59 090
fracture.
24546 ......... A Repair humerus 15.69 NA NA 12.40 11.61 1.72 NA NA 29.81 29.02 090
fracture.
24560 ......... A Treat humerus 2.80 6.34 4.34 2.76 2.55 0.29 9.43 7.43 5.85 5.64 090
fracture.
24565 ......... A Treat humerus 5.56 9.17 6.46 5.30 4.52 0.61 15.34 12.63 11.47 10.69 090
fracture.
24566 ......... A Treat humerus 7.79 NA NA 8.28 7.43 0.84 NA NA 16.91 16.06 090
fracture.
24575 ......... A Repair humerus 10.66 NA NA 7.87 8.16 1.17 NA NA 19.70 19.99 090
fracture.
24576 ......... A Treat humerus 2.86 6.24 4.29 2.87 2.61 0.31 9.41 7.46 6.04 5.78 090
fracture.
24577 ......... A Treat humerus 5.79 9.37 6.86 5.56 4.95 0.63 15.79 13.28 11.98 11.37 090
fracture.
24579 ......... A Repair humerus 11.60 NA NA 10.22 9.65 1.28 NA NA 23.10 22.53 090
fracture.
24582 ......... A Treat humerus 8.55 NA NA 9.58 8.38 0.94 NA NA 19.07 17.87 090
fracture.
24586 ......... A Repair elbow 15.21 NA NA 10.16 13.07 1.66 NA NA 27.03 29.94 090
fracture.
24587 ......... A Repair elbow 15.16 NA NA 10.10 12.50 1.55 NA NA 26.81 29.21 090
fracture.
24600 ......... A Treat elbow 4.23 8.90 5.51 4.51 3.32 0.44 13.57 10.18 9.18 7.99 090
dislocation.
24605 ......... A Treat elbow 5.42 NA NA 4.37 3.43 0.59 NA NA 10.38 9.44 090
dislocation.
24615 ......... A Repair elbow 9.42 NA NA 7.12 8.60 1.04 NA NA 17.58 19.06 090
dislocation.
24620 ......... A Treat elbow 6.98 NA NA 5.98 5.04 0.74 NA NA 13.70 12.76 090
fracture.
24635 ......... A Repair elbow 13.19 NA NA 19.64 15.82 1.45 NA NA 34.28 30.46 090
fracture.
24640 ......... A Treat elbow 1.20 4.97 3.04 1.64 1.37 0.12 6.29 4.36 2.96 2.69 010
dislocation.
24650 ......... A Treat radius 2.16 6.15 4.30 2.53 1.88 0.23 8.54 6.69 4.92 4.27 090
fracture.
24655 ......... A Treat radius 4.40 8.58 5.93 4.78 4.03 0.48 13.46 10.81 9.66 8.91 090
fracture.
24665 ......... A Repair radius 8.14 NA NA 8.49 8.12 0.89 NA NA 17.52 17.15 090
fracture.
24666 ......... A Repair radius 9.49 NA NA 9.41 10.28 1.05 NA NA 19.95 20.82 090
fracture.
24670 ......... A Treatment of ulna 2.54 6.08 4.10 2.69 2.41 0.27 8.89 6.91 5.50 5.22 090
fracture.
24675 ......... A Treatment of ulna 4.72 8.73 6.27 4.90 4.36 0.52 13.97 11.51 10.14 9.60 090
fracture.
24685 ......... A Repair ulna 8.80 NA NA 8.76 8.94 0.96 NA NA 18.52 18.70 090
fracture.
24800 ......... A Fusion of elbow 11.20 NA NA 8.48 9.99 1.21 NA NA 20.89 22.40 090
joint.
24802 ......... A Fusion/graft of 13.69 NA NA 9.60 11.41 1.42 NA NA 24.71 26.52 090
elbow joint.
24900 ......... A Amputation of 9.60 NA NA 9.39 8.86 1.05 NA NA 20.04 19.51 090
upper arm.
24920 ......... A Amputation of 9.54 NA NA 10.07 8.72 1.02 NA NA 20.63 19.28 090
upper arm.
24925 ......... A Amputation follow- 7.07 NA NA 7.59 7.20 0.76 NA NA 15.42 15.03 090
up surgery.
24930 ......... A Amputation follow- 10.25 NA NA 12.19 10.53 1.03 NA NA 23.47 21.81 090
up surgery.
24931 ......... A Amputate upper arm 12.72 NA NA 10.00 11.06 1.36 NA NA 24.08 25.14 090
& implant.
24935 ......... A Revision of 15.56 NA NA 12.35 13.61 1.67 NA NA 29.58 30.84 090
amputation.
24940 ......... C Revision of upper 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
arm.
24999 ......... C Upper arm/elbow 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
25000 ......... A Incision of tendon 3.38 NA NA 6.14 5.09 0.37 NA NA 9.89 8.84 090
sheath.
25020 ......... A Decompression of 5.92 NA NA 9.54 7.13 0.70 NA NA 16.16 13.75 090
forearm.
25023 ......... A Decompression of 12.96 NA NA 15.25 10.58 1.42 NA NA 29.63 24.96 090
forearm.
25028 ......... A Drainage of 5.25 NA NA 8.72 5.48 0.56 NA NA 14.53 11.29 090
forearm lesion.
25031 ......... A Drainage of 4.14 NA NA 8.04 4.38 0.39 NA NA 12.57 8.91 090
forearm bursa.
25035 ......... A Treat forearm bone 7.36 NA NA 13.96 10.40 0.79 NA NA 22.11 18.55 090
lesion.
25040 ......... A Explore/treat 7.18 NA NA 8.11 7.15 0.79 NA NA 16.08 15.12 090
wrist joint.
25065 ......... A Biopsy forearm 1.99 2.08 1.45 2.08 1.25 0.10 4.17 3.54 4.17 3.34 010
soft tissues.
25066 ......... A Biopsy forearm 4.13 NA NA 7.11 4.39 0.44 NA NA 11.68 8.96 090
soft tissues.
25075 ......... A Removal of forearm 3.74 NA NA 6.34 4.36 0.38 NA NA 10.46 8.48 090
lesion.
25076 ......... A Removal of forearm 4.92 NA NA 10.19 7.14 0.53 NA NA 15.64 12.59 090
lesion.
25077 ......... A Remove tumor, 9.76 NA NA 13.15 11.18 1.02 NA NA 23.93 21.96 090
forearm/wrist.
25085 ......... A Incision of wrist 5.50 NA NA 9.83 7.42 0.61 NA NA 15.94 13.53 090
capsule.
25100 ......... A Biopsy of wrist 3.90 NA NA 6.18 5.42 0.44 NA NA 10.52 9.76 090
joint.
25101 ......... A Explore/treat 4.69 NA NA 6.64 6.12 0.52 NA NA 11.85 11.33 090
wrist joint.
25105 ......... A Remove wrist joint 5.85 NA NA 10.90 8.95 0.63 NA NA 17.38 15.43 090
lining.
25107 ......... A Remove wrist joint 6.43 NA NA 9.37 7.55 0.72 NA NA 16.52 14.70 090
cartilage.
25110 ......... A Remove wrist 3.92 NA NA 6.94 4.99 0.42 NA NA 11.28 9.33 090
tendon lesion.
25111 ......... A Remove wrist 3.39 NA NA 5.58 4.54 0.37 NA NA 9.34 8.30 090
tendon lesion.
25112 ......... A Reremove wrist 4.53 NA NA 6.24 5.14 0.49 NA NA 11.26 10.16 090
tendon lesion.
25115 ......... A Remove wrist/ 8.82 NA NA 13.93 10.84 0.98 NA NA 23.73 20.64 090
forearm lesion.
25116 ......... A Remove wrist/ 7.11 NA NA 12.77 10.63 0.79 NA NA 20.67 18.53 090
forearm lesion.
25118 ......... A Excise wrist 4.37 NA NA 6.66 5.94 0.49 NA NA 11.52 10.80 090
tendon sheath.
25119 ......... A Partial removal of 6.04 NA NA 10.00 8.61 0.67 NA NA 16.71 15.32 090
ulna.
25120 ......... A Removal of forearm 6.10 NA NA 11.94 9.52 0.66 NA NA 18.70 16.28 090
lesion.
25125 ......... A Remove/graft 7.48 NA NA 14.16 10.79 0.83 NA NA 22.47 19.10 090
forearm lesion.
25126 ......... A Remove/graft 7.55 NA NA 16.49 11.94 0.83 NA NA 24.87 20.32 090
forearm lesion.
25130 ......... A Removal of wrist 5.26 NA NA 7.05 5.81 0.58 NA NA 12.89 11.65 090
lesion.
25135 ......... A Remove & graft 6.89 NA NA 7.92 6.93 0.78 NA NA 15.59 14.60 090
wrist lesion.
25136 ......... A Remove & graft 5.97 NA NA 6.72 5.93 0.67 NA NA 13.36 12.57 090
wrist lesion.
25145 ......... A Remove forearm 6.37 NA NA 14.43 10.45 0.69 NA NA 21.49 17.51 090
bone lesion.
25150 ......... A Partial removal of 7.09 NA NA 10.08 8.66 0.76 NA NA 17.93 16.51 090
ulna.

[[Page 39654]]

25151 ......... A Partial removal of 7.39 NA NA 13.30 9.77 0.82 NA NA 21.51 17.98 090
radius.
25170 ......... A Extensive forearm 11.09 NA NA 14.56 12.59 1.24 NA NA 26.89 24.92 090
surgery.
25210 ......... A Removal of wrist 5.95 NA NA 7.40 6.35 0.66 NA NA 14.01 12.96 090
bone.
25215 ......... A Removal of wrist 7.89 NA NA 10.90 10.16 0.87 NA NA 19.66 18.92 090
bones.
25230 ......... A Partial removal of 5.23 NA NA 7.02 6.53 0.57 NA NA 12.82 12.33 090
radius.
25240 ......... A Partial removal of 5.17 NA NA 9.17 7.46 0.57 NA NA 14.91 13.20 090
ulna.
25246 ......... A Injection for 1.45 10.17 5.36 0.40 0.47 0.06 11.68 6.87 1.91 1.98 000
wrist x-ray.
25248 ......... A Remove forearm 5.14 NA NA 8.78 5.58 0.54 NA NA 14.46 11.26 090
foreign body.
25250 ......... A Removal of wrist 6.60 NA NA 8.58 7.35 0.73 NA NA 15.91 14.68 090
prosthesis.
25251 ......... A Removal of wrist 9.57 NA NA 12.84 10.90 1.06 NA NA 23.47 21.53 090
prosthesis.
25260 ......... A Repair forearm 7.80 NA NA 13.56 9.28 0.86 NA NA 22.22 17.94 090
tendon/muscle.
25263 ......... A Repair forearm 7.82 NA NA 13.65 9.96 0.87 NA NA 22.34 18.65 090
tendon/muscle.
25265 ......... A Repair forearm 9.88 NA NA 17.41 13.01 1.07 NA NA 28.36 23.96 090
tendon/muscle.
25270 ......... A Repair forearm 6.00 NA NA 13.37 8.51 0.66 NA NA 20.03 15.17 090
tendon/muscle.
25272 ......... A Repair forearm 7.04 NA NA 12.93 8.33 0.79 NA NA 20.76 16.16 090
tendon/muscle.
25274 ......... A Repair forearm 8.75 NA NA 13.71 10.45 0.98 NA NA 23.44 20.18 090
tendon/muscle.
25280 ......... A Revise wrist/ 7.22 NA NA 12.85 8.72 0.79 NA NA 20.86 16.73 090
forearm tendon.
25290 ......... A Incise wrist/ 5.29 NA NA 14.41 8.55 0.59 NA NA 20.29 14.43 090
forearm tendon.
25295 ......... A Release wrist/ 6.55 NA NA 12.29 7.80 0.72 NA NA 19.56 15.07 090
forearm tendon.
25300 ......... A Fusion of tendons 8.80 NA NA 10.93 9.46 0.92 NA NA 20.65 19.18 090
at wrist.
25301 ......... A Fusion of tendons 8.40 NA NA 8.70 8.03 0.89 NA NA 17.99 17.32 090
at wrist.
25310 ......... A Transplant forearm 8.14 NA NA 14.25 11.00 0.90 NA NA 23.29 20.04 090
tendon.
25312 ......... A Transplant forearm 9.57 NA NA 15.49 11.89 1.05 NA NA 26.11 22.51 090
tendon.
25315 ......... A Revise palsy hand 10.20 NA NA 15.06 11.91 1.18 NA NA 26.44 23.29 090
tendon(s).
25316 ......... A Revise palsy hand 12.33 NA NA 21.69 16.59 1.33 NA NA 35.35 30.25 090
tendon(s).
25320 ......... A Repair/revise 10.77 NA NA 10.70 10.02 1.19 NA NA 22.66 21.98 090
wrist joint.
25332 ......... A Revise wrist joint 11.41 NA NA 10.89 10.86 1.25 NA NA 23.55 23.52 090
25335 ......... A Realignment of 12.88 NA NA 13.00 12.69 1.45 NA NA 27.33 27.02 090
hand.
25337 ......... A Reconstruct ulna/ 10.17 NA NA 11.94 10.64 1.13 NA NA 23.24 21.94 090
radioulnar.
25350 ......... A Revision of radius 8.78 NA NA 14.20 11.23 0.97 NA NA 23.95 20.98 090
25355 ......... A Revision of radius 10.17 NA NA 12.46 11.18 1.12 NA NA 23.75 22.47 090
25360 ......... A Revision of ulna.. 8.43 NA NA 13.82 10.39 0.96 NA NA 23.21 19.78 090
25365 ......... A Revise radius & 12.40 NA NA 14.84 13.02 1.21 NA NA 28.45 26.63 090
ulna.
25370 ......... A Revise radius or 13.36 NA NA 11.53 12.15 1.30 NA NA 26.19 26.81 090
ulna.
25375 ......... A Revise radius & 13.04 NA NA 11.41 12.97 1.27 NA NA 25.72 27.28 090
ulna.
25390 ......... A Shorten radius/ 10.40 NA NA 14.29 11.93 1.13 NA NA 25.82 23.46 090
ulna.
25391 ......... A Lengthen radius/ 13.65 NA NA 15.28 13.75 1.48 NA NA 30.41 28.88 090
ulna.
25392 ......... A Shorten radius & 13.95 NA NA 14.46 13.98 1.57 NA NA 29.98 29.50 090
ulna.
25393 ......... A Lengthen radius & 15.87 NA NA 13.84 14.63 1.72 NA NA 31.43 32.22 090
ulna.
25400 ......... A Repair radius or 10.92 NA NA 15.77 13.74 1.20 NA NA 27.89 25.86 090
ulna.
25405 ......... A Repair/graft 14.38 NA NA 17.59 15.54 1.57 NA NA 33.54 31.49 090
radius or ulna.
25415 ......... A Repair radius & 13.35 NA NA 15.62 14.01 1.47 NA NA 30.44 28.83 090
ulna.
25420 ......... A Repair/graft 16.33 NA NA 18.57 17.26 1.81 NA NA 36.71 35.40 090
radius & ulna.
25425 ......... A Repair/graft 13.21 NA NA 30.34 21.69 1.38 NA NA 44.93 36.28 090
radius or ulna.
25426 ......... A Repair/graft 15.82 NA NA 19.05 15.89 1.42 NA NA 36.29 33.13 090
radius & ulna.
25440 ......... A Repair/graft wrist 10.44 NA NA 10.19 10.01 1.16 NA NA 21.79 21.61 090
bone.
25441 ......... A Reconstruct wrist 12.90 NA NA 11.09 11.71 1.45 NA NA 25.44 26.06 090
joint.
25442 ......... A Reconstruct wrist 10.85 NA NA 9.90 8.78 1.20 NA NA 21.95 20.83 090
joint.
25443 ......... A Reconstruct wrist 10.39 NA NA 11.59 10.89 1.17 NA NA 23.15 22.45 090
joint.
25444 ......... A Reconstruct wrist 11.15 NA NA 12.03 11.52 1.25 NA NA 24.43 23.92 090
joint.
25445 ......... A Reconstruct wrist 9.69 NA NA 11.61 11.43 1.07 NA NA 22.37 22.19 090
joint.
25446 ......... A Wrist replacement. 16.55 NA NA 13.89 16.83 1.80 NA NA 32.24 35.18 090
25447 ......... A Repair wrist 10.37 NA NA 10.47 10.47 1.14 NA NA 21.98 21.98 090
joint(s).
25449 ......... A Remove wrist joint 14.49 NA NA 14.69 11.60 1.60 NA NA 30.78 27.69 090
implant.
25450 ......... A Revision of wrist 7.87 NA NA 6.79 7.36 0.70 NA NA 15.36 15.93 090
joint.
25455 ......... A Revision of wrist 9.49 NA NA 10.27 9.86 0.77 NA NA 20.53 20.12 090
joint.
25490 ......... A Reinforce radius.. 9.54 NA NA 13.90 11.67 1.05 NA NA 24.49 22.26 090
25491 ......... A Reinforce ulna.... 9.96 NA NA 13.68 11.78 1.12 NA NA 24.76 22.86 090
25492 ......... A Reinforce radius 12.33 NA NA 15.67 13.91 1.39 NA NA 29.39 27.63 090
and ulna.
25500 ......... A Treat fracture of 2.45 5.77 4.15 2.58 1.93 0.24 8.46 6.84 5.27 4.62 090
radius.
25505 ......... A Treat fracture of 5.21 8.94 6.41 5.10 4.49 0.56 14.71 12.18 10.87 10.26 090
radius.
25515 ......... A Repair fracture of 9.18 NA NA 12.22 10.25 0.91 NA NA 22.31 20.34 090
radius.
25520 ......... A Repair fracture of 6.26 9.10 7.67 5.58 5.91 0.68 16.04 14.61 12.52 12.85 090
radius.
25525 ......... A Repair fracture of 12.24 NA NA 10.54 11.32 1.37 NA NA 24.15 24.93 090
radius.
25526 ......... A Repair fracture of 12.98 NA NA 15.77 14.32 1.44 NA NA 30.19 28.74 090
radius.
25530 ......... A Treat fracture of 2.09 5.79 4.22 2.51 1.88 0.22 8.10 6.53 4.82 4.19 090
ulna.
25535 ......... A Treat fracture of 5.14 8.48 6.18 5.09 4.48 0.55 14.17 11.87 10.78 10.17 090
ulna.
25545 ......... A Repair fracture of 8.90 NA NA 8.77 8.50 0.98 NA NA 18.65 18.38 090
ulna.
25560 ......... A Treat fracture 2.44 5.79 4.13 2.59 2.53 0.25 8.48 6.82 5.28 5.22 090
radius & ulna.
25565 ......... A Treat fracture 5.63 9.12 7.09 5.29 5.18 0.61 15.36 13.33 11.53 11.42 090
radius & ulna.
25574 ......... A Treat fracture 7.01 NA NA 7.61 7.99 0.77 NA NA 15.39 15.77 090
radius & ulna.
25575 ......... A Repair fracture 10.45 NA NA 9.50 10.56 1.15 NA NA 21.10 22.16 090
radius/ulna.
25600 ......... A Treat fracture 2.63 6.13 4.61 2.73 2.14 0.28 9.04 7.52 5.64 5.05 090
radius/ulna.
25605 ......... A Treat fracture 5.81 9.42 6.86 5.50 4.90 0.64 15.87 13.31 11.95 11.35 090
radius/ulna.
25611 ......... A Repair fracture 7.77 NA NA 8.52 7.52 0.86 NA NA 17.15 16.15 090
radius/ulna.
25620 ......... A Repair fracture 8.55 NA NA 8.60 8.17 0.94 NA NA 18.09 17.66 090
radius/ulna.
25622 ......... A Treat wrist bone 2.61 6.12 4.30 2.73 1.99 0.28 9.01 7.19 5.62 4.88 090
fracture.

[robop...@us.govnews.org]

Archive-Name: gov/us/fed/nara/fed-register/1999/jul/22/64FR39607/part9

Posting-number: Volume 64, Issue 140, Page 39607, Part 1

25624 ......... A Treat wrist bone 4.53 8.56 6.27 4.76 3.38 0.50 13.59 11.30 9.79 8.41 090
fracture.
25628 ......... A Repair wrist bone 8.43 NA NA 8.60 8.17 0.93 NA NA 17.96 17.53 090
fracture.
25630 ......... A Treat wrist bone 2.88 6.22 4.30 2.83 2.01 0.31 9.41 7.49 6.02 5.20 090
fracture.
25635 ......... A Treat wrist bone 4.39 8.53 6.09 5.01 3.42 0.47 13.39 10.95 9.87 8.28 090
fracture.
25645 ......... A Repair wrist bone 7.25 NA NA 8.04 7.65 0.81 NA NA 16.10 15.71 090
fracture.
25650 ......... A Repair wrist bone 3.05 6.20 4.55 2.88 2.17 0.32 9.57 7.92 6.25 5.54 090
fracture.
25660 ......... A Treat wrist 4.76 NA NA 4.74 3.36 0.50 NA NA 10.00 8.62 090
dislocation.

[[Page 39655]]

25670 ......... A Repair wrist 7.92 NA NA 8.09 7.89 0.88 NA NA 16.89 16.69 090
dislocation.
25675 ......... A Treat wrist 4.67 8.30 5.39 4.75 3.61 0.50 13.47 10.56 9.92 8.78 090
dislocation.
25676 ......... A Repair wrist 8.04 NA NA 8.46 8.20 0.88 NA NA 17.38 17.12 090
dislocation.
25680 ......... A Treat wrist 5.99 NA NA 9.75 6.20 0.56 NA NA 16.30 12.75 090
fracture.
25685 ......... A Repair wrist 9.78 NA NA 8.75 9.15 1.06 NA NA 19.59 19.99 090
fracture.
25690 ......... A Treat wrist 5.50 NA NA 6.17 5.74 0.59 NA NA 12.26 11.83 090
dislocation.
25695 ......... A Repair wrist 8.34 NA NA 8.14 7.89 0.91 NA NA 17.39 17.14 090
dislocation.
25800 ......... A Fusion of wrist 9.76 NA NA 10.01 10.84 1.08 NA NA 20.85 21.68 090
joint.
25805 ......... A Fusion/graft of 11.28 NA NA 10.89 12.18 1.25 NA NA 23.42 24.71 090
wrist joint.
25810 ......... A Fusion/graft of 10.57 NA NA 10.46 11.54 1.15 NA NA 22.18 23.26 090
wrist joint.
25820 ......... A Fusion of hand 7.45 NA NA 9.09 9.00 0.80 NA NA 17.34 17.25 090
bones.
25825 ......... A Fusion hand bones 9.27 NA NA 10.31 10.69 1.01 NA NA 20.59 20.97 090
with graft.
25830 ......... A Fusion radioulnar 10.06 NA NA 14.92 12.13 1.09 NA NA 26.07 23.28 090
jnt/ulna.
25900 ......... A Amputation of 9.01 NA NA 12.21 9.95 1.00 NA NA 22.22 19.96 090
forearm.
25905 ......... A Amputation of 9.12 NA NA 13.49 10.61 1.02 NA NA 23.63 20.75 090
forearm.
25907 ......... A Amputation follow- 7.80 NA NA 11.98 9.11 0.87 NA NA 20.65 17.78 090
up surgery.
25909 ......... A Amputation follow- 8.96 NA NA 12.68 9.35 1.03 NA NA 22.67 19.34 090
up surgery.
25915 ......... A Amputation of 17.08 NA NA 16.76 16.97 1.95 NA NA 35.79 36.00 090
forearm.
25920 ......... A Amputate hand at 8.68 NA NA 8.59 8.10 0.98 NA NA 18.25 17.76 090
wrist.
25922 ......... A Amputate hand at 7.42 NA NA 7.71 6.87 0.83 NA NA 15.96 15.12 090
wrist.
25924 ......... A Amputation follow- 8.46 NA NA 7.52 7.83 0.65 NA NA 16.63 16.94 090
up surgery.
25927 ......... A Amputation of hand 8.80 NA NA 11.66 9.25 0.98 NA NA 21.44 19.03 090
25929 ......... A Amputation follow- 7.59 NA NA 6.28 5.71 0.81 NA NA 14.68 14.11 090
up surgery.
25931 ......... A Amputation follow- 7.81 NA NA 16.31 10.62 0.84 NA NA 24.96 19.27 090
up surgery.
25999 ......... C Forearm or wrist 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
26010 ......... A Drainage of finger 1.54 4.31 2.42 3.36 1.81 0.14 5.99 4.10 5.04 3.49 010
abscess.
26011 ......... A Drainage of finger 2.19 5.96 3.82 5.21 3.44 0.23 8.38 6.24 7.63 5.86 010
abscess.
26020 ......... A Drain hand tendon 4.67 NA NA 10.65 7.35 0.51 NA NA 15.83 12.53 090
sheath.
26025 ......... A Drainage of palm 4.82 NA NA 10.46 7.68 0.53 NA NA 15.81 13.03 090
bursa.
26030 ......... A Drainage of palm 5.93 NA NA 11.20 8.71 0.66 NA NA 17.79 15.30 090
bursa(s).
26034 ......... A Treat hand bone 6.23 NA NA 12.41 8.50 0.69 NA NA 19.33 15.42 090
lesion.
26035 ......... A Decompress fingers/ 9.51 NA NA 14.48 10.05 1.03 NA NA 25.02 20.59 090
hand.
26037 ......... A Decompress fingers/ 7.25 NA NA 13.55 10.23 0.80 NA NA 21.60 18.28 090
hand.
26040 ......... A Release palm 3.33 NA NA 9.62 6.36 0.36 NA NA 13.31 10.05 090
contracture.
26045 ......... A Release palm 5.56 NA NA 10.80 8.02 0.61 NA NA 16.97 14.19 090
contracture.
26055 ......... A Incise finger 2.69 6.29 4.93 6.11 4.84 0.30 9.28 7.92 9.10 7.83 090
tendon sheath.
26060 ......... A Incision of finger 2.81 NA NA 6.66 3.95 0.31 NA NA 9.78 7.07 090
tendon.
26070 ......... A Explore/treat hand 3.69 NA NA 9.25 5.38 0.33 NA NA 13.27 9.40 090
joint.
26075 ......... A Explore/treat 3.79 NA NA 9.96 7.03 0.37 NA NA 14.12 11.19 090
finger joint.
26080 ......... A Explore/treat 4.24 NA NA 10.45 6.93 0.45 NA NA 15.14 11.62 090
finger joint.
26100 ......... A Biopsy hand joint 3.67 NA NA 6.53 4.89 0.39 NA NA 10.59 8.95 090
lining.
26105 ......... A Biopsy finger 3.71 NA NA 10.25 7.39 0.40 NA NA 14.36 11.50 090
joint lining.
26110 ......... A Biopsy finger 3.53 NA NA 9.23 6.21 0.39 NA NA 13.15 10.13 090
joint lining.
26115 ......... A Removal of hand 3.86 6.20 4.19 6.20 4.19 0.42 10.48 8.47 10.48 8.47 090
lesion.
26116 ......... A Removal of hand 5.53 NA NA 11.07 7.55 0.61 NA NA 17.21 13.69 090
lesion.
26117 ......... A Remove tumor, hand/ 8.55 NA NA 12.22 8.86 0.94 NA NA 21.71 18.35 090
finger.
26121 ......... A Release palm 7.54 NA NA 12.43 10.72 0.84 NA NA 20.81 19.10 090
contracture.
26123 ......... A Release palm 9.29 NA NA 13.52 11.70 1.03 NA NA 23.84 22.02 090
contracture.
26125 ......... A Release palm 4.61 NA NA 2.50 2.67 0.51 NA NA 7.62 7.79 ZZZ
contracture.
26130 ......... A Remove wrist joint 5.42 NA NA 12.29 8.87 0.60 NA NA 18.31 14.89 090
lining.
26135 ......... A Revise finger 6.96 NA NA 13.42 9.35 0.77 NA NA 21.15 17.08 090
joint, each.
26140 ......... A Revise finger 6.17 NA NA 12.71 8.75 0.69 NA NA 19.57 15.61 090
joint, each.
26145 ......... A Tendon excision, 6.32 NA NA 12.79 8.95 0.71 NA NA 19.82 15.98 090
palm/finger.
26160 ......... A Remove tendon 3.15 6.09 4.31 6.09 4.31 0.34 9.58 7.80 9.58 7.80 090
sheath lesion.
26170 ......... A Removal of palm 4.77 NA NA 7.22 5.15 0.57 NA NA 12.56 10.49 090
tendon, each.
26180 ......... A Removal of finger 5.18 NA NA 7.34 5.85 0.59 NA NA 13.11 11.62 090
tendon.
26185 ......... A Remove finger bone 5.25 NA NA 7.12 5.86 0.58 NA NA 12.95 11.69 090
26200 ......... A Remove hand bone 5.51 NA NA 10.98 7.92 0.59 NA NA 17.08 14.02 090
lesion.
26205 ......... A Remove/graft bone 7.70 NA NA 12.44 9.70 0.87 NA NA 21.01 18.27 090
lesion.
26210 ......... A Removal of finger 5.15 NA NA 10.99 7.61 0.57 NA NA 16.71 13.33 090
lesion.
26215 ......... A Remove/graft 7.10 NA NA 11.77 8.90 0.70 NA NA 19.57 16.70 090
finger lesion.
26230 ......... A Partial removal of 6.33 NA NA 10.51 7.57 0.70 NA NA 17.54 14.60 090
hand bone.
26235 ......... A Partial removal, 6.19 NA NA 10.33 7.43 0.69 NA NA 17.21 14.31 090
finger bone.
26236 ......... A Partial removal, 5.32 NA NA 10.30 7.25 0.59 NA NA 16.21 13.16 090
finger bone.
26250 ......... A Extensive hand 7.55 NA NA 14.25 10.38 0.78 NA NA 22.58 18.71 090
surgery.
26255 ......... A Extensive hand 12.43 NA NA 15.02 12.36 1.28 NA NA 28.73 26.07 090
surgery.
26260 ......... A Extensive finger 7.03 NA NA 13.39 9.81 0.77 NA NA 21.19 17.61 090
surgery.
26261 ......... A Extensive finger 9.09 NA NA 7.90 8.13 0.71 NA NA 17.70 17.93 090
surgery.
26262 ......... A Partial removal of 5.67 NA NA 11.27 8.21 0.63 NA NA 17.57 14.51 090
finger.
26320 ......... A Removal of implant 3.98 NA NA 10.32 7.08 0.44 NA NA 14.74 11.50 090
from hand.
26350 ......... A Repair finger/hand 5.99 NA NA 15.00 10.62 0.66 NA NA 21.65 17.27 090
tendon.
26352 ......... A Repair/graft hand 7.68 NA NA 15.21 11.19 0.85 NA NA 23.74 19.72 090
tendon.
26356 ......... A Repair finger/hand 8.07 NA NA 16.42 12.12 0.90 NA NA 25.39 21.09 090
tendon.
26357 ......... A Repair finger/hand 8.58 NA NA 17.03 12.09 0.94 NA NA 26.55 21.61 090
tendon.
26358 ......... A Repair/graft hand 9.14 NA NA 16.55 12.29 1.03 NA NA 26.72 22.46 090
tendon.
26370 ......... A Repair finger/hand 7.11 NA NA 16.19 11.74 0.78 NA NA 24.08 19.63 090
tendon.
26372 ......... A Repair/graft hand 8.76 NA NA 17.37 12.15 0.96 NA NA 27.09 21.87 090
tendon.
26373 ......... A Repair finger/hand 8.16 NA NA 19.05 13.24 0.90 NA NA 28.11 22.30 090
tendon.
26390 ......... A Revise hand/finger 9.19 NA NA 13.63 11.13 1.01 NA NA 23.83 21.33 090
tendon.
26392 ......... A Repair/graft hand 10.26 NA NA 17.46 13.40 1.14 NA NA 28.86 24.80 090
tendon.
26410 ......... A Repair hand tendon 4.63 NA NA 12.37 7.97 0.51 NA NA 17.51 13.11 090
26412 ......... A Repair/graft hand 6.31 NA NA 13.46 9.99 0.70 NA NA 20.47 17.00 090
tendon.
26415 ......... A Excision, hand/ 8.34 NA NA 12.09 9.71 0.79 NA NA 21.22 18.84 090
finger tendon.
26416 ......... A Graft hand or 9.37 NA NA 14.38 11.88 1.03 NA NA 24.78 22.28 090
finger tendon.

[[Page 39656]]

26418 ......... A Repair finger 4.25 NA NA 12.14 8.02 0.47 NA NA 16.86 12.74 090
tendon.
26420 ......... A Repair/graft 6.77 NA NA 13.48 9.82 0.73 NA NA 20.98 17.32 090
finger tendon.
26426 ......... A Repair finger/hand 6.15 NA NA 12.98 9.92 0.69 NA NA 19.82 16.76 090
tendon.
26428 ......... A Repair/graft 7.21 NA NA 13.93 9.95 0.80 NA NA 21.94 17.96 090
finger tendon.
26432 ......... A Repair finger 4.02 NA NA 10.17 5.94 0.44 NA NA 14.63 10.40 090
tendon.
26433 ......... A Repair finger 4.56 NA NA 10.71 7.50 0.51 NA NA 15.78 12.57 090
tendon.
26434 ......... A Repair/graft 6.09 NA NA 15.07 10.22 0.63 NA NA 21.79 16.94 090
finger tendon.
26437 ......... A Realignment of 5.82 NA NA 11.05 7.73 0.65 NA NA 17.52 14.20 090
tendons.
26440 ......... A Release palm/ 5.02 NA NA 13.94 8.91 0.56 NA NA 19.52 14.49 090
finger tendon.
26442 ......... A Release palm & 8.16 NA NA 15.49 9.58 0.91 NA NA 24.56 18.65 090
finger tendon.
26445 ......... A Release hand/ 4.31 NA NA 13.78 8.66 0.48 NA NA 18.57 13.45 090
finger tendon.
26449 ......... A Release forearm/ 7.00 NA NA 15.86 10.95 0.78 NA NA 23.64 18.73 090
hand tendon.
26450 ......... A Incision of palm 3.67 NA NA 6.89 4.68 0.41 NA NA 10.97 8.76 090
tendon.
26455 ......... A Incision of finger 3.64 NA NA 6.66 4.36 0.41 NA NA 10.71 8.41 090
tendon.
26460 ......... A Incise hand/finger 3.46 NA NA 6.49 4.18 0.38 NA NA 10.33 8.02 090
tendon.
26471 ......... A Fusion of finger 5.73 NA NA 10.80 7.65 0.64 NA NA 17.17 14.02 090
tendons.
26474 ......... A Fusion of finger 5.32 NA NA 11.17 8.09 0.59 NA NA 17.08 14.00 090
tendons.
26476 ......... A Tendon lengthening 5.18 NA NA 12.23 7.69 0.54 NA NA 17.95 13.41 090
26477 ......... A Tendon shortening. 5.15 NA NA 10.43 7.38 0.58 NA NA 16.16 13.11 090
26478 ......... A Lengthening of 5.80 NA NA 11.35 8.01 0.65 NA NA 17.80 14.46 090
hand tendon.
26479 ......... A Shortening of hand 5.74 NA NA 11.29 8.52 0.65 NA NA 17.68 14.91 090
tendon.
26480 ......... A Transplant hand 6.69 NA NA 15.24 11.17 0.74 NA NA 22.67 18.60 090
tendon.
26483 ......... A Transplant/graft 8.29 NA NA 16.17 12.70 0.88 NA NA 25.34 21.87 090
hand tendon.
26485 ......... A Transplant palm 7.70 NA NA 17.09 12.07 0.85 NA NA 25.64 20.62 090
tendon.
26489 ......... A Transplant/graft 9.55 NA NA 18.07 10.88 0.90 NA NA 28.52 21.33 090
palm tendon.
26490 ......... A Revise thumb 8.41 NA NA 12.54 10.51 0.94 NA NA 21.89 19.86 090
tendon.
26492 ......... A Tendon transfer 9.62 NA NA 14.75 12.13 0.96 NA NA 25.33 22.71 090
with graft.
26494 ......... A Hand tendon/muscle 8.47 NA NA 12.92 10.41 0.96 NA NA 22.35 19.84 090
transfer.
26496 ......... A Revise thumb 9.59 NA NA 12.62 11.05 1.07 NA NA 23.28 21.71 090
tendon.
26497 ......... A Finger tendon 9.57 NA NA 15.76 12.23 1.02 NA NA 26.35 22.82 090
transfer.
26498 ......... A Finger tendon 14.00 NA NA 18.12 15.45 1.55 NA NA 33.67 31.00 090
transfer.
26499 ......... A Revision of finger 8.98 NA NA 13.62 11.02 0.86 NA NA 23.46 20.86 090
26500 ......... A Hand tendon 5.96 NA NA 11.71 7.75 0.66 NA NA 18.33 14.37 090
reconstruction.
26502 ......... A Hand tendon 7.14 NA NA 12.83 9.28 0.75 NA NA 20.72 17.17 090
reconstruction.
26504 ......... A Hand tendon 7.47 NA NA 16.06 11.68 0.79 NA NA 24.32 19.94 090
reconstruction.
26508 ......... A Release thumb 6.01 NA NA 11.17 7.84 0.67 NA NA 17.85 14.52 090
contracture.
26510 ......... A Thumb tendon 5.43 NA NA 11.64 8.07 0.59 NA NA 17.66 14.09 090
transfer.
26516 ......... A Fusion of knuckle 7.15 NA NA 11.78 8.15 0.80 NA NA 19.73 16.10 090
joint.
26517 ......... A Fusion of knuckle 8.83 NA NA 16.06 11.87 0.97 NA NA 25.86 21.67 090
joints.
26518 ......... A Fusion of knuckle 9.02 NA NA 12.72 9.90 0.99 NA NA 22.73 19.91 090
joints.
26520 ......... A Release knuckle 5.30 NA NA 13.90 9.38 0.59 NA NA 19.79 15.27 090
contracture.
26525 ......... A Release finger 5.33 NA NA 14.05 9.00 0.59 NA NA 19.97 14.92 090
contracture.
26530 ......... A Revise knuckle 6.69 NA NA 15.62 10.61 0.72 NA NA 23.03 18.02 090
joint.
26531 ......... A Revise knuckle 7.91 NA NA 16.76 11.99 0.87 NA NA 25.54 20.77 090
with implant.
26535 ......... A Revise finger 5.24 NA NA 8.25 6.75 0.42 NA NA 13.91 12.41 090
joint.
26536 ......... A Revise/implant 6.37 NA NA 14.14 10.88 0.69 NA NA 21.20 17.94 090
finger joint.
26540 ......... A Repair hand joint. 6.43 NA NA 11.60 9.41 0.71 NA NA 18.74 16.55 090
26541 ......... A Repair hand joint 8.62 NA NA 13.63 11.67 0.95 NA NA 23.20 21.24 090
with graft.
26542 ......... A Repair hand joint 6.78 NA NA 11.64 8.90 0.73 NA NA 19.15 16.41 090
with graft.
26545 ......... A Reconstruct finger 6.92 NA NA 11.96 8.84 0.78 NA NA 19.66 16.54 090
joint.
26546 ......... A Repair non-union 8.92 NA NA 13.68 11.24 0.99 NA NA 23.59 21.15 090
hand.
26548 ......... A Reconstruct finger 8.03 NA NA 12.76 9.52 0.89 NA NA 21.68 18.44 090
joint.
26550 ......... A Construct thumb 21.24 NA NA 24.47 22.99 2.40 NA NA 48.11 46.63 090
replacement.
26551 ......... A Great toe-hand 46.58 NA NA 34.77 40.31 5.32 NA NA 86.67 92.21 090
transfer.
26553 ......... A Single toe-hand 46.27 NA NA 26.26 35.90 5.28 NA NA 77.81 87.45 090
transfer.
26554 ......... A Double toe-hand 54.95 NA NA 35.67 45.00 6.17 NA NA 96.79 106.12 090
transfer.
26555 ......... A Positional change 16.63 NA NA 17.80 17.26 1.84 NA NA 36.27 35.73 090
of finger.
26556 ......... A Toe joint transfer 47.26 NA NA 26.64 36.48 5.40 NA NA 79.30 89.14 090
26560 ......... A Repair of web 5.38 NA NA 11.78 8.42 0.56 NA NA 17.72 14.36 090
finger.
26561 ......... A Repair of web 10.92 NA NA 16.08 12.87 1.20 NA NA 28.20 24.99 090
finger.
26562 ......... A Repair of web 9.68 NA NA 13.40 12.48 1.10 NA NA 24.18 23.26 090
finger.
26565 ......... A Correct metacarpal 6.74 NA NA 12.55 9.44 0.74 NA NA 20.03 16.92 090
flaw.
26567 ......... A Correct finger 6.82 NA NA 11.75 8.20 0.75 NA NA 19.32 15.77 090
deformity.
26568 ......... A Lengthen 9.08 NA NA 13.89 11.53 0.97 NA NA 23.94 21.58 090
metacarpal/finger.
26580 ......... A Repair hand 18.18 NA NA 14.27 16.30 1.51 NA NA 33.96 35.99 090
deformity.
26585 ......... A Repair finger 14.05 NA NA 12.41 13.23 0.89 NA NA 27.35 28.17 090
deformity.
26587 ......... C Reconstruct extra 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
finger.
26590 ......... A Repair finger 17.96 NA NA 12.01 15.03 1.88 NA NA 31.85 34.87 090
deformity.
26591 ......... A Repair muscles of 3.25 NA NA 10.58 6.54 0.36 NA NA 14.19 10.15 090
hand.
26593 ......... A Release muscles of 5.31 NA NA 10.55 7.51 0.59 NA NA 16.45 13.41 090
hand.
26596 ......... A Excision 8.95 NA NA 8.76 8.85 0.93 NA NA 18.64 18.73 090
constricting
tissue.
26597 ......... A Release of scar 9.82 NA NA 13.65 11.18 1.10 NA NA 24.57 22.10 090
contracture.
26600 ......... A Treat metacarpal 1.96 5.75 3.71 2.45 1.65 0.21 7.92 5.88 4.62 3.82 090
fracture.
26605 ......... A Treat metacarpal 2.85 7.31 4.90 3.75 2.50 0.31 10.47 8.06 6.91 5.66 090
fracture.
26607 ......... A Treat metacarpal 5.36 NA NA 7.46 5.66 0.59 NA NA 13.41 11.61 090
fracture.
26608 ......... A Treat metacarpal 5.36 NA NA 7.17 5.51 0.59 NA NA 13.12 11.46 090
fracture.
26615 ......... A Repair metacarpal 5.33 NA NA 6.56 5.93 0.59 NA NA 12.48 11.85 090
fracture.
26641 ......... A Treat thumb 3.94 7.62 4.41 4.37 2.79 0.39 11.95 8.74 8.70 7.12 090
dislocation.
26645 ......... A Treat thumb 4.41 8.34 5.37 4.64 3.52 0.44 13.19 10.22 9.49 8.37 090
fracture.
26650 ......... A Repair thumb 5.72 NA NA 7.23 5.79 0.62 NA NA 13.57 12.13 090
fracture.
26665 ......... A Repair thumb 7.60 NA NA 8.03 7.48 0.83 NA NA 16.46 15.91 090
fracture.
26670 ......... A Treat hand 3.69 7.67 4.36 4.61 2.83 0.37 11.73 8.42 8.67 6.89 090
dislocation.
26675 ......... A Treat hand 4.64 7.17 5.94 3.73 4.22 0.49 12.30 11.07 8.86 9.35 090
dislocation.
26676 ......... A Pin hand 5.52 NA NA 7.30 6.29 0.61 NA NA 13.43 12.42 090
dislocation.

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