82 FR 33950 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
Federal Register Volume 82, Issue 139 (July 21, 2017)
Page Range
33950-34203
FR Document
2017-14639
This major proposed rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies.
Federal Register, Volume 82 Issue 139 (Friday, July 21, 2017)
[Federal Register Volume 82, Number 139 (Friday, July 21, 2017)]
[Proposed Rules]
[Pages 33950-34203]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2017-14639]
[[Page 33949]]
Vol. 82
Friday,
No. 139
July 21, 2017
Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 405, 410, 414, et al.
Medicare Program; Revisions to Payment Policies Under the Physician
Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared
Savings Program Requirements; and Medicare Diabetes Prevention Program;
Proposed Rule
Federal Register / Vol. 82 , No. 139 / Friday, July 21, 2017 /
Proposed Rules
[[Page 33950]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 410, 414, 424, and 425
[CMS-1676-P]
RIN 0938-AT02
Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule and Other Revisions to Part B for CY 2018;
Medicare Shared Savings Program Requirements; and Medicare Diabetes
Prevention Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This major proposed rule addresses changes to the Medicare
physician fee schedule (PFS) and other Medicare Part B payment
policies.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on September 11,
2017. (See the SUPPLEMENTARY INFORMATION section of this final rule
with comment period for a list of provisions open for comment.)
ADDRESSES: In commenting, please refer to file code CMS-1676-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to www.regulations.gov. Follow the instructions for
``submitting a comment.''
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1676-P, P.O. Box 8016,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1676-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members. Comments mailed to the addresses
indicated as appropriate for hand or courier delivery may be delayed
and received after the comment period.
FOR FURTHER INFORMATION CONTACT:
Jamie Hermansen, (410) 786-2064, for issues related to the
valuation of anesthesia services and any physician payment issues not
identified below.
Lindsey Baldwin, (410) 786-1694, and Emily Yoder, (410) 786-1804,
for issues related to telehealth services and primary care.
Roberta Epps, (410) 786-4503, for issues related to PAMA section
218(a) policy and transition from traditional X-ray imaging to digital
radiography.
Isadora Gil, (410) 786-4532, for issues related to the valuation of
cardiovascular services, bone marrow services, surgical respiratory
services, dermatological procedures, and payment rates for nonexcepted
items and services furnished by nonexcepted off-campus provider-based
departments of a hospital.
Donta Henson, (410) 786-1947, for issues related to ophthalmology
services.
Tourette Jackson, (410) 786-4735, for issues related to the
valuation of musculoskeletal services, allergy and clinical immunology
services, endocrinology services, genital surgical services, nervous
system services, INR monitoring services, injections and infusions, and
chemotherapy services.
Ann Marshall, (410) 786-3059, for issues related to primary care,
chronic care management (CCM), and evaluation and management (E/M)
services.
Geri Mondowney, (410) 786-4584, for issues related to malpractice
RVUs.
Patrick Sartini, (410) 786-9252, for issues related to the
valuation of imaging services and malpractice RVUs.
Michael Soracoe, (410) 786-6312, for issues related to the practice
expense methodology, impacts, conversion factor, and valuation of
pathology and surgical procedures.
Pamela West, (410) 786-2302, for issues related to therapy
services.
Corinne Axelrod, (410) 786-5620, for issues related to rural health
clinics or federally qualified health centers.
Felicia Eggleston, (410) 786-9287, for issues related to DME
infusion drugs.
Rasheeda Johnson, (410) 786-3434, for issues related to initial
data collection and reporting periods for the clinical laboratory fee
schedule.
Edmund Kasaitis, (410) 786-0477, for issues related to biosimilars.
JoAnna Baldwin, (410) 786-7205, or Sarah Fulton, (410) 786-2749,
for issues related to appropriate use criteria for advanced diagnostic
imaging services.
Alesia Hovatter, (410) 786-6861, for issues related to PQRS.
Alexandra Mugge, (410) 786-4457, or Elizabeth Holland, (410) 786-
1309, for issues related to the EHR incentive program.
Rabia Khan or Terri Postma, (410) 786-8084 or [email protected], for
issues related to the Medicare Shared Savings Program.
Kimberly Spalding Bush, (410) 786-3232, or Fiona Larbi, (410) 786-
7224, for issues related to Value-based Payment Modifier and Physician
Feedback Program.
Wilbert Agbenyikey, (410) 786-4399, for issues related to MACRA
patient relationship categories and codes.
Carlye Burd, (410) 786-1972, or Albert Wesley, (410) 786-4204, for
issues related to diabetes prevention program.
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Executive Summary
II. Provisions of the Proposed Rule for PFS
A. Background
B. Determination of Practice Expense Relative Value Units (PE
RVUs)
C. Determination of Malpractice Relative Value Units (MRVUs)
D. Medicare Telehealth Services
E. Potentially Misvalued Services Under the PFS
F. Implementation of Reduced Payment for Film-Based Imaging
Services
G. Proposed Payment Rates Under the Medicare PFS for Nonexcepted
Items and Services Furnished by Nonexcepted Off-Campus Provider-
Based Departments of a Hospital
[[Page 33951]]
H. Proposed Valuation of Specific Codes
I. Evaluation & Management (E/M) Guidelines and Care Management
Services
III. Other Provisions of the Proposed Rule
A. New Care Coordination Services and Payment for Rural Health
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
B. Payment for DME Infusion Drugs
C. Solicitation of Public Comments on Initial Data Collection
and Reporting Periods for Clinical Laboratory Fee Schedule
D. Solicitation of Public Comments on Biosimilars
E. Appropriate Use Criteria for Advanced Diagnostic Imaging
Services
F. Physician Quality Reporting System Criteria for Satisfactory
Reporting for Individual EPs and Group Practices for the 2018 PQRS
Payment Adjustment
G. Medicare EHR Incentive Program
H. Medicare Shared Savings Program
I. Value-Based Payment Modifier and Physician Feedback Program
J. MACRA Patient Relationship Categories and Codes
K. Medicare Diabetes Prevention Program
IV. Collection of Information Requirements
V. Response to Comments
VI. Regulatory Impact Analysis
Regulations Text
Acronyms
In addition, because of the many organizations and terms to which
we refer by acronym in this final rule, we are listing these acronyms
and their corresponding terms in alphabetical order below:
A1c Hemoglobin A1c
AAA Abdominal aortic aneurysms
ACO Accountable care organization
AMA American Medical Association
ASC Ambulatory surgical center
ATA American Telehealth Association
ATRA American Taxpayer Relief Act (Pub. L. 112-240)
AWV Annual wellness visit
BBA Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program]
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
BLS Bureau of Labor Statistics
CAD Coronary artery disease
CAH Critical access hospital
CBSA Core-Based Statistical Area
CCM Chronic care management
CEHRT Certified EHR technology
CF Conversion factor
CG-CAHPS Clinician and Group Consumer Assessment of Healthcare
Providers and Systems
CLFS Clinical Laboratory Fee Schedule
CoA Certificate of Accreditation
CoC Certificate of Compliance
CoR Certificate of Registration
CNM Certified nurse-midwife
CP Clinical psychologist
CPC Comprehensive Primary Care
CPEP Clinical Practice Expert Panel
CPT [Physicians] Current Procedural Terminology (CPT codes,
descriptions and other data only are copyright 2015 American Medical
Association. All rights reserved.)
CQM Clinical quality measure
CSW Clinical social worker
CT Computed tomography
CW Certificate of Waiver
CY Calendar year
DFAR Defense Federal Acquisition Regulations
DHS Designated health services
DM Diabetes mellitus
DSMT Diabetes self-management training
eCQM Electronic clinical quality measures
ED Emergency Department
EHR Electronic health record
E/M Evaluation and management
EMT Emergency Medical Technician
EP Eligible professional
eRx Electronic prescribing
ESRD End-stage renal disease
FAR Federal Acquisition Regulations
FDA Food and Drug Administration
FFS Fee-for-service
FQHC Federally qualified health center
FR Federal Register
FSHCAA Federally Supported Health Centers Assistance Act
GAF Geographic adjustment factor
GAO Government Accountability Office
GPCI Geographic practice cost index
GPO Group purchasing organization
GPRO Group practice reporting option
GTR Genetic Testing Registry
HCPCS Healthcare Common Procedure Coding System
HHS [Department of] Health and Human Services
HOPD Hospital outpatient department
HPSA Health professional shortage area
IDTF Independent diagnostic testing facility
IPPE Initial preventive physical exam
IPPS Inpatient Prospective Payment System
IQR Inpatient Quality Reporting
ISO Insurance service office
IT Information technology
IWPUT Intensity of work per unit of time
LCD Local coverage determination
MA Medicare Advantage
MAC Medicare Administrative Contractor
MACRA Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10)
MAP Measure Applications Partnership
MAPCP Multi-payer Advanced Primary Care Practice
MAV Measure application validity [process]
MCP Monthly capitation payment
MedPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MFP Multi-Factor Productivity
MIPPA Medicare Improvements for Patients and Providers Act (Pub. L.
110-275)
MMA Medicare Prescription Drug, Improvement and Modernization Act of
2003 (Pub. L. 108-173, enacted on December 8, 2003)
MP Malpractice
MPPR Multiple procedure payment reduction
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
MSA Metropolitan Statistical Areas
MSPB Medicare Spending per Beneficiary
MU Meaningful use
NCD National coverage determination
NCQDIS National Coalition of Quality Diagnostic Imaging Services
NP Nurse practitioner
NPI National Provider Identifier
NPP Nonphysician practitioner
NQS National Quality Strategy
OACT CMS's Office of the Actuary
OBRA '89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239)
OBRA '90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508)
OES Occupational Employment Statistics
OMB Office of Management and Budget
OPPS Outpatient prospective payment system
OT Occupational therapy
PA Physician assistant
PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)
PAMPA Patient Access and Medicare Protection Act (Pub. L. 114-115)
PC Professional component
PCIP Primary Care Incentive Payment
PE Practice expense
PE/HR Practice expense per hour
PEAC Practice Expense Advisory Committee
PECOS Provider Enrollment, Chain, and Ownership System
PFS Physician Fee Schedule
PLI Professional Liability Insurance
PMA Premarket approval
PPM Provider-Performed Microscopy
PQRS Physician Quality Reporting System
PPIS Physician Practice Expense Information Survey
PPS Prospective Payment System
PT Physical therapy
PT Proficiency Testing
PT/INR Prothrombin Time/International Normalized Ratio
PY Performance year
QA Quality Assessment
QC Quality Control
QCDR Qualified clinical data registry
QRUR Quality and Resources Use Report
RBRVS Resource-based relative value scale
RFA Regulatory Flexibility Act
RHC Rural health clinic
RIA Regulatory impact analysis
RUC American Medical Association/Specialty Society Relative Value
Scale Update Committee
RUCA Rural Urban Commuting Area
RVU Relative value unit
SBA Small Business Administration
SGR Sustainable growth rate
SIM State Innovation Model
SLP Speech-language pathology
SMS Socioeconomic Monitoring System
SNF Skilled nursing facility
TAP Technical Advisory Panel
TC Technical component
TIN Tax identification number
TCM Transitional Care Management
UAF Update adjustment factor
UPIN Unique Physician Identification Number
USPSTF United States Preventive Services Task Force
VBP Value-based purchasing
VM Value-Based Payment Modifier
[[Page 33952]]
Addenda Available Only Through the Internet on the CMS Web site
The PFS Addenda along with other supporting documents and tables
referenced in this proposed rule are available on the CMS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Click on the
link on the left side of the screen titled, ``PFS Federal Regulations
Notices'' for a chronological list of PFS Federal Register and other
related documents. For the CY 2018 PFS Proposed Rule, refer to item
CMS-1676-P. Readers with questions related to accessing any of the
Addenda or other supporting documents referenced in this proposed rule
and posted on the CMS Web site identified above should contact Jamie
Hermansen at (410) 786-2064.
CPT (Current Procedural Terminology) Copyright Notice
Throughout this proposed rule, we use CPT codes and descriptions to
refer to a variety of services. We note that CPT codes and descriptions
are copyright 2016 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association
(AMA). Applicable Federal Acquisition Regulations (FAR) and Defense
Federal Acquisition Regulations (DFAR) apply.
I. Executive Summary
A. Purpose
This major proposed rule proposes to revise payment polices under
the Medicare PFS and make other policy changes related to Medicare Part
B payment, applicable to services furnished in CY 2018. In addition,
this proposed rule includes proposals related to payment policy changes
that are addressed in section III. of this proposed rule.
1. Summary of the Major Provisions
The statute requires us to establish payments under the PFS based
on national uniform relative value units (RVUs) that account for the
relative resources used in furnishing a service. The statute requires
that RVUs be established for three categories of resources: Work,
practice expense (PE); and malpractice (MP) expense; and, that we
establish by regulation each year's payment amounts for all physicians'
services paid under the PFS, incorporating geographic adjustments to
reflect the variations in the costs of furnishing services in different
geographic areas. In this major proposed rule, we are proposing to
establish RVUs for CY 2018 for the PFS, and other Medicare Part B
payment policies, to ensure that our payment systems are updated to
reflect changes in medical practice and the relative value of services,
as well as changes in the statute. In addition, this proposed rule
includes discussions and proposals regarding:
Potentially Misvalued Codes.
Telehealth Services.
Establishing Values for New, Revised, and Misvalued Codes.
Establishing Payment Rates under the PFS for Nonexcepted
Items and Services Furnished by Nonexcepted Off-Campus Provider-Based
Departments of a Hospital.
Evaluation & Management (E/M) Guidelines and Care
Management Services.
Care Coordination Services and Payment for Rural Health
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Payment for DME Infusion Drugs.
Solicitation of Public Comments on Initial Data Collection
and Reporting Periods for Clinical Laboratory Fee Schedule.
Solicitation of Public Comments on Payment for Biosimilar
Biological Products under Section 1847A of the Act.
Appropriate Use Criteria for Advanced Diagnostic Imaging
Services.
PQRS Criteria for Satisfactory Reporting for Individual
EPs and Group Practices for the 2018 PQRS Payment Adjustment.
Medicare EHR Incentive Program.
Medicare Shared Savings Program.
Value-Based Payment Modifier and the Physician Feedback
Program.
MACRA Patient Relationship Categories and Codes.
Medicare Diabetes Prevention Program.
2. Summary of Costs and Benefits
We have determined that this major proposed rule is economically
significant. For a detailed discussion of the economic impacts, see
section VI. of this proposed rule.
II. Provisions of the Proposed Rule for PFS
A. Background
Since January 1, 1992, Medicare has paid for physicians' services
under section 1848 of the Act, ``Payment for Physicians' Services.''
The PFS relies on national relative values that are established for
work, PE, and MP, which are adjusted for geographic cost variations.
These values are multiplied by a conversion factor (CF) to convert the
RVUs into payment rates. The concepts and methodology underlying the
PFS were enacted as part of the Omnibus Budget Reconciliation Act of
1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA '89), and
the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted
on November 5, 1990) (OBRA '90). The final rule published on November
25, 1991 (56 FR 59502) set forth the first fee schedule used for
payment for physicians' services.
We note that throughout this major proposed rule, unless otherwise
noted, the term ``practitioner'' is used to describe both physicians
and nonphysician practitioners (NPPs) who are permitted to bill
Medicare under the PFS for services furnished to Medicare
beneficiaries.
1. Development of the Relative Values
a. Work RVUs
The work RVUs established for the initial fee schedule, which was
implemented on January 1, 1992, were developed with extensive input
from the physician community. A research team at the Harvard School of
Public Health developed the original work RVUs for most codes under a
cooperative agreement with the Department of Health and Human Services
(HHS). In constructing the code-specific vignettes used in determining
the original physician work RVUs, Harvard worked with panels of
experts, both inside and outside the federal government, and obtained
input from numerous physician specialty groups.
As specified in section 1848(c)(1)(A) of the Act, the work
component of physicians' services means the portion of the resources
used in furnishing the service that reflects physician time and
intensity. We establish work RVUs for new, revised and potentially
misvalued codes based on our review of information that generally
includes, but is not limited to, recommendations received from the
American Medical Association/Specialty Society Relative Value Scale
Update Committee (RUC), the Health Care Professionals Advisory
Committee (HCPAC), the Medicare Payment Advisory Commission (MedPAC),
and other public commenters; medical literature and comparative
databases; as well as a comparison of the work for other codes within
the Medicare PFS, and consultation with other physicians and health
care professionals within CMS and the federal government. We also
assess the methodology and data used to develop the recommendations
[[Page 33953]]
submitted to us by the RUC and other public commenters, and the
rationale for their recommendations. In the CY 2011 PFS final rule with
comment period (75 FR 73328 through 73329), we discussed a variety of
methodologies and approaches used to develop work RVUs, including
survey data, building blocks, crosswalk to key reference or similar
codes, and magnitude estimation. More information on these issues is
available in that rule.
b. Practice Expense RVUs
Initially, only the work RVUs were resource-based, and the PE and
MP RVUs were based on average allowable charges. Section 121 of the
Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on
October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and
required us to develop resource-based PE RVUs for each physicians'
service beginning in 1998. We were required to consider general
categories of expenses (such as office rent and wages of personnel, but
excluding malpractice expenses) comprising PEs. The PE RVUs continue to
represent the portion of these resources involved in furnishing PFS
services.
Originally, the resource-based method was to be used beginning in
1998, but section 4505(a) of the Balanced Budget Act of 1997 (Pub. L.
105-33, enacted on August 5, 1997) (BBA) delayed implementation of the
resource-based PE RVU system until January 1, 1999. In addition,
section 4505(b) of the BBA provided for a 4-year transition period from
the charge-based PE RVUs to the resource-based PE RVUs.
We established the resource-based PE RVUs for each physicians'
service in a final rule, published on November 2, 1998 (63 FR 58814),
effective for services furnished in CY 1999. Based on the requirement
to transition to a resource-based system for PE over a 4-year period,
payment rates were not fully based upon resource-based PE RVUs until CY
2002. This resource-based system was based on two significant sources
of actual PE data: The Clinical Practice Expert Panel (CPEP) data; and
the AMA's Socioeconomic Monitoring System (SMS) data. These data
sources are described in greater detail in the CY 2012 final rule with
comment period (76 FR 73033).
Separate PE RVUs are established for services furnished in facility
settings, such as a hospital outpatient department (HOPD) or an
ambulatory surgical center (ASC), and in nonfacility settings, such as
a physician's office. The nonfacility RVUs reflect all of the direct
and indirect PEs involved in furnishing a service described by a
particular HCPCS code. The difference, if any, in these PE RVUs
generally results in a higher payment in the nonfacility setting
because in the facility settings some costs are borne by the facility.
Medicare's payment to the facility (such as the outpatient prospective
payment system (OPPS) payment to the hospital outpatient department
(HOPD)) would reflect costs typically incurred by the facility. Thus,
payment associated with those facility resources is not made under the
PFS.
Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L.
106-113, enacted on November 29, 1999) (BBRA) directed the Secretary of
Health and Human Services (the Secretary) to establish a process under
which we accept and use, to the maximum extent practicable and
consistent with sound data practices, data collected or developed by
entities and organizations to supplement the data we normally collect
in determining the PE component. On May 3, 2000, we published the
interim final rule (65 FR 25664) that set forth the criteria for the
submission of these supplemental PE survey data. The criteria were
modified in response to comments received, and published in the Federal
Register (65 FR 65376) as part of a November 1, 2000 final rule. The
PFS final rules published in 2001 and 2003, respectively, (66 FR 55246
and 68 FR 63196) extended the period during which we would accept these
supplemental data through March 1, 2005.
In the CY 2007 PFS final rule with comment period (71 FR 69624), we
revised the methodology for calculating direct PE RVUs from the top-
down to the bottom-up methodology beginning in CY 2007. We adopted a 4-
year transition to the new PE RVUs. This transition was completed for
CY 2010. In the CY 2010 PFS final rule with comment period, we updated
the practice expense per hour (PE/HR) data that are used in the
calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010,
we began a 4-year transition to the new PE RVUs using the updated PE/HR
data, which was completed for CY 2013.
c. Malpractice RVUs
Section 4505(f) of the BBA amended section 1848(c) of the Act to
require that we implement resource-based MP RVUs for services furnished
on or after CY 2000. The resource-based MP RVUs were implemented in the
PFS final rule with comment period published November 2, 1999 (64 FR
59380). The MP RVUs are based on commercial and physician-owned
insurers' malpractice insurance premium data from all the states, the
District of Columbia, and Puerto Rico. For more information on MP RVUs,
see section II.C. of this proposed rule.
d. Refinements to the RVUs
Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no
less often than every 5 years. Prior to CY 2013, we conducted periodic
reviews of work RVUs and PE RVUs independently. We completed five-year
reviews of work RVUs that were effective for calendar years 1997, 2002,
2007, and 2012.
Although refinements to the direct PE inputs initially relied
heavily on input from the RUC Practice Expense Advisory Committee
(PEAC), the shifts to the bottom-up PE methodology in CY 2007 and to
the use of the updated PE/HR data in CY 2010 have resulted in
significant refinements to the PE RVUs in recent years.
In the CY 2012 PFS final rule with comment period (76 FR 73057), we
finalized a proposal to consolidate reviews of work and PE RVUs under
section 1848(c)(2)(B) of the Act and reviews of potentially misvalued
codes under section 1848(c)(2)(K) of the Act into one annual process.
In addition to the 5-year reviews, beginning for CY 2009, CMS and
the RUC have identified and reviewed a number of potentially misvalued
codes on an annual basis based on various identification screens. This
annual review of work and PE RVUs for potentially misvalued codes was
supplemented by the amendments to section 1848 of the Act, as enacted
by section 3134 of the Affordable Care Act, that require the agency to
periodically identify, review and adjust values for potentially
misvalued codes.
e. Application of Budget Neutrality to Adjustments of RVUs
As described in section VI.C. of this proposed rule, in accordance
with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs
cause expenditures for the year to change by more than $20 million, we
make adjustments to ensure that expenditures do not increase or
decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
To calculate the payment for each service, the components of the
fee schedule (work, PE, and MP RVUs) are adjusted by geographic
practice cost indices (GPCIs) to reflect the variations in the costs of
furnishing the services.
[[Page 33954]]
The GPCIs reflect the relative costs of work, PE, and MP in an area
compared to the national average costs for each component.
RVUs are converted to dollar amounts through the application of a
conversion factor (CF), which is calculated based on a statutory
formula by CMS's Office of the Actuary (OACT). The formula for
calculating the Medicare PFS payment amount for a given service and fee
schedule area can be expressed as:
Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI
MP)] x CF
3. Separate Fee Schedule Methodology for Anesthesia Services
Section 1848(b)(2)(B) of the Act specifies that the fee schedule
amounts for anesthesia services are to be based on a uniform relative
value guide, with appropriate adjustment of an anesthesia conversion
factor, in a manner to ensure that fee schedule amounts for anesthesia
services are consistent with those for other services of comparable
value. Therefore, there is a separate fee schedule methodology for
anesthesia services. Specifically, we establish a separate conversion
factor for anesthesia services and we utilize the uniform relative
value guide, or base units, as well as time units, to calculate the fee
schedule amounts for anesthesia services. Since anesthesia services are
not valued using RVUs, a separate methodology for locality adjustments
is also necessary. This involves an adjustment to the national
anesthesia CF for each payment locality.
B. Determination of Proposed Practice Expense (PE) Relative Value Units
(RVUs)
1. Overview
Practice expense (PE) is the portion of the resources used in
furnishing a service that reflects the general categories of physician
and practitioner expenses, such as office rent and personnel wages, but
excluding malpractice expenses, as specified in section 1848(c)(1)(B)
of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use
a resource-based system for determining PE RVUs for each physicians'
service. We develop PE RVUs by considering the direct and indirect
practice resources involved in furnishing each service. Direct expense
categories include clinical labor, medical supplies, and medical
equipment. Indirect expenses include administrative labor, office
expense, and all other expenses. The sections that follow provide more
detailed information about the methodology for translating the
resources involved in furnishing each service into service-specific PE
RVUs. We refer readers to the CY 2010 PFS final rule with comment
period (74 FR 61743 through 61748) for a more detailed explanation of
the PE methodology.
2. Practice Expense Methodology
a. Direct Practice Expense
We determine the direct PE for a specific service by adding the
costs of the direct resources (that is, the clinical staff, medical
supplies, and medical equipment) typically involved with furnishing
that service. The costs of the resources are calculated using the
refined direct PE inputs assigned to each CPT code in our PE database,
which are generally based on our review of recommendations received
from the RUC and those provided in response to public comment periods.
For a detailed explanation of the direct PE methodology, including
examples, we refer readers to the 5 Year Review of Work Relative Value
Units under the PFS and Proposed Changes to the Practice Expense
Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final
rule with comment period (71 FR 69629).
b. Indirect Practice Expense per Hour Data
We use survey data on indirect PEs incurred per hour worked in
developing the indirect portion of the PE RVUs. Prior to CY 2010, we
primarily used the practice expense per hour (PE/HR) by specialty that
was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The
AMA administered a new survey in CY 2007 and CY 2008, the Physician
Practice Expense Information Survey (PPIS). The PPIS is a
multispecialty, nationally representative, PE survey of both physicians
and nonphysician practitioners (NPPs) paid under the PFS using a survey
instrument and methods highly consistent with those used for the SMS
and the supplemental surveys. The PPIS gathered information from 3,656
respondents across 51 physician specialty and health care professional
groups. We believe the PPIS is the most comprehensive source of PE
survey information available. We used the PPIS data to update the PE/HR
data for the CY 2010 PFS for almost all of the Medicare-recognized
specialties that participated in the survey.
When we began using the PPIS data in CY 2010, we did not change the
PE RVU methodology itself or the manner in which the PE/HR data are
used in that methodology. We only updated the PE/HR data based on the
new survey. Furthermore, as we explained in the CY 2010 PFS final rule
with comment period (74 FR 61751), because of the magnitude of payment
reductions for some specialties resulting from the use of the PPIS
data, we transitioned its use over a 4-year period from the previous PE
RVUs to the PE RVUs developed using the new PPIS data. As provided in
the CY 2010 PFS final rule with comment period (74 FR 61751), the
transition to the PPIS data was complete for CY 2013. Therefore, PE
RVUs from CY 2013 forward are developed based entirely on the PPIS
data, except as noted in this section.
Section 1848(c)(2)(H)(i) of the Act requires us to use the medical
oncology supplemental survey data submitted in 2003 for oncology drug
administration services. Therefore, the PE/HR for medical oncology,
hematology, and hematology/oncology reflects the continued use of these
supplemental survey data.
Supplemental survey data on independent labs from the College of
American Pathologists were implemented for payments beginning in CY
2005. Supplemental survey data from the National Coalition of Quality
Diagnostic Imaging Services (NCQDIS), representing independent
diagnostic testing facilities (IDTFs), were blended with supplementary
survey data from the American College of Radiology (ACR) and
implemented for payments beginning in CY 2007. Neither IDTFs, nor
independent labs, participated in the PPIS. Therefore, we continue to
use the PE/HR that was developed from their supplemental survey data.
Consistent with our past practice, the previous indirect PE/HR
values from the supplemental surveys for these specialties were updated
to CY 2006 using the Medicare Economic Index (MEI) to put them on a
comparable basis with the PPIS data.
We also do not use the PPIS data for reproductive endocrinology and
spine surgery since these specialties currently are not separately
recognized by Medicare, nor do we have a method to blend the PPIS data
with Medicare-recognized specialty data.
Previously, we established PE/HR values for various specialties
without SMS or supplemental survey data by crosswalking them to other
similar specialties to estimate a proxy PE/HR. For specialties that
were part of the PPIS for which we previously used a crosswalked PE/HR,
we instead used the PPIS-based PE/HR. We use crosswalks for specialties
that did not participate in the PPIS. These crosswalks have been
generally established through notice and
[[Page 33955]]
comment rulemaking and are available in the file called ``CY 2018 PFS
Proposed Rule PE/HR'' on the CMS Web site under downloads for the CY
2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
c. Allocation of PE to Services
To establish PE RVUs for specific services, it is necessary to
establish the direct and indirect PE associated with each service.
(1) Direct Costs
The relative relationship between the direct cost portions of the
PE RVUs for any two services is determined by the relative relationship
between the sum of the direct cost resources (that is, the clinical
staff, medical supplies, and medical equipment) typically involved with
furnishing each of the services. The costs of these resources are
calculated from the refined direct PE inputs in our PE database. For
example, if one service has a direct cost sum of $400 from our PE
database and another service has a direct cost sum of $200, the direct
portion of the PE RVUs of the first service would be twice as much as
the direct portion of the PE RVUs for the second service.
(2) Indirect Costs
We allocate the indirect costs to the code level on the basis of
the direct costs specifically associated with a code and the greater of
either the clinical labor costs or the work RVUs. We also incorporate
the survey data described earlier in the PE/HR discussion (see section
II.B.2.b of this proposed rule). The general approach to developing the
indirect portion of the PE RVUs is as follows:
For a given service, we use the direct portion of the PE
RVUs calculated as previously described and the average percentage that
direct costs represent of total costs (based on survey data) across the
specialties that furnish the service to determine an initial indirect
allocator. That is, the initial indirect allocator is calculated so
that the direct costs equal the average percentage of direct costs of
those specialties furnishing the service. For example, if the direct
portion of the PE RVUs for a given service is 2.00 and direct costs, on
average, represent 25 percent of total costs for the specialties that
furnish the service, the initial indirect allocator would be calculated
so that it equals 75 percent of the total PE RVUs. Thus, in this
example, the initial indirect allocator would equal 6.00, resulting in
a total PE RVU of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75
percent of 8.00).
Next, we add the greater of the work RVUs or clinical
labor portion of the direct portion of the PE RVUs to this initial
indirect allocator. In our example, if this service had a work RVU of
4.00 and the clinical labor portion of the direct PE RVU was 1.50, we
would add 4.00 (since the 4.00 work RVUs are greater than the 1.50
clinical labor portion) to the initial indirect allocator of 6.00 to
get an indirect allocator of 10.00. In the absence of any further use
of the survey data, the relative relationship between the indirect cost
portions of the PE RVUs for any two services would be determined by the
relative relationship between these indirect cost allocators. For
example, if one service had an indirect cost allocator of 10.00 and
another service had an indirect cost allocator of 5.00, the indirect
portion of the PE RVUs of the first service would be twice as great as
the indirect portion of the PE RVUs for the second service.
Next, we incorporated the specialty-specific indirect PE/
HR data into the calculation. In our example, if, based on the survey
data, the average indirect cost of the specialties furnishing the first
service with an allocator of 10.00 was half of the average indirect
cost of the specialties furnishing the second service with an indirect
allocator of 5.00, the indirect portion of the PE RVUs of the first
service would be equal to that of the second service.
(3) Facility and Nonfacility Costs
For procedures that can be furnished in a physician's office, as
well as in a facility setting, where Medicare makes a separate payment
to the facility for its costs in furnishing a service, we establish two
PE RVUs: Facility, and nonfacility. The methodology for calculating PE
RVUs is the same for both the facility and nonfacility RVUs, but is
applied independently to yield two separate PE RVUs. In calculating the
PE RVUs for services furnished in a facility, we do not include
resources that would generally not be provided by physicians when
furnishing the service. For this reason, the facility PE RVUs are
generally lower than the nonfacility PE RVUs.
(4) Services With Technical Components and Professional Components
Diagnostic services are generally comprised of two components: A
professional component (PC) and a technical component (TC). The PC and
TC may be furnished independently or by different providers, or they
may be furnished together as a global service. When services have
separately billable PC and TC components, the payment for the global
service equals the sum of the payment for the TC and PC. To achieve
this, we use a weighted average of the ratio of indirect to direct
costs across all the specialties that furnish the global service, TCs,
and PCs; that is, we apply the same weighted average indirect
percentage factor to allocate indirect expenses to the global service,
PCs, and TCs for a service. (The direct PE RVUs for the TC and PC sum
to the global.)
(5) PE RVU Methodology
For a more detailed description of the PE RVU methodology, we refer
readers to the CY 2010 PFS final rule with comment period (74 FR 61745
through 61746). We also direct interested readers to the file called
``Calculation of PE RVUs under Methodology for Selected Codes'' which
is available on our Web site under downloads for the CY 2018 PFS
proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. This
file contains a table that illustrates the calculation of PE RVUs as
described in this proposed rule for individual codes.
(a) Setup File
First, we create a setup file for the PE methodology. The setup
file contains the direct cost inputs, the utilization for each
procedure code at the specialty and facility/nonfacility place of
service level, and the specialty-specific PE/HR data calculated from
the surveys.
(b) Calculate the Direct Cost PE RVUs
Sum the costs of each direct input.
Step 1: Sum the direct costs of the inputs for each service.
Step 2: Calculate the aggregate pool of direct PE costs for the
current year. We set the aggregate pool of PE costs equal to the
product of the ratio of the current aggregate PE RVUs to current
aggregate work RVUs and the proposed aggregate work RVUs.
Step 3: Calculate the aggregate pool of direct PE costs for use in
ratesetting. This is the product of the aggregate direct costs for all
services from Step 1 and the utilization data for that service.
Step 4: Using the results of Step 2 and Step 3, use the conversion
factor to calculate a direct PE scaling adjustment to ensure that the
aggregate pool of direct PE costs calculated in Step 3 does not vary
from the aggregate pool of direct PE costs for the current year. Apply
the scaling adjustment to the direct costs for each service (as
calculated in Step 1).
[[Page 33956]]
Step 5: Convert the results of Step 4 to a RVU scale for each
service. To do this, divide the results of Step 4 by the conversion
factor (CF). Note that the actual value of the CF used in this
calculation does not influence the final direct cost PE RVUs as long as
the same CF is used in Step 4 and Step 5. Different CFs would result in
different direct PE scaling adjustments, but this has no effect on the
final direct cost PE RVUs since changes in the CFs and changes in the
associated direct scaling adjustments offset one another.
(c) Create the Indirect Cost PE RVUs
Create indirect allocators.
Step 6: Based on the survey data, calculate direct and indirect PE
percentages for each physician specialty.
Step 7: Calculate direct and indirect PE percentages at the service
level by taking a weighted average of the results of Step 6 for the
specialties that furnish the service. Note that for services with TCs
and PCs, the direct and indirect percentages for a given service do not
vary by the PC, TC, and global service.
We generally use an average of the 3 most recent years of available
Medicare claims data to determine the specialty mix assigned to each
code. Prior to implementing that policy, we used the most recent year
of available claims data to determine the specialty mix assigned to
each code.
Under either of these approaches, codes with low Medicare service
volume require special attention since billing or enrollment
irregularities for a given year can result in significant changes in
specialty mix assignment. Prior to adopting the 3-year average of data,
for low-volume services (fewer than 100 Medicare allowed services), we
assigned the values associated with the specialty that most frequently
reported the service in the most recent claims data (dominant
specialty). For some time, stakeholders, including the RUC, have
requested that we use a recommended ``expected'' specialty for all low
volume services instead of the information contained in the claims
data. Currently, in the development of PE RVUs we use ``expected
specialty'' overrides for only several dozen services based on several
code-specific policies we established in prior rulemaking. As we stated
in the CY 2016 final rule with comment period (80 FR 70894), we hoped
that the 3-year average would mitigate the need to use dominant or
expected specialty instead of the specialty identified using claims
data. Because we incorporated CY 2015 claims data for use in the CY
2017 proposed rates, we believe that the finalized PE RVUs associated
with the CY 2017 PFS final rule provided a first opportunity to
determine whether service-level overrides of claims data are necessary.
Although we believe that the use of the 3-year average of claims
data to determine specialty mix has led to an improvement in the
stability of PE and MP RVUs from year to year, after reviewing the RVUs
for low volume services, we continue to see possible distortions and
wide variability from year to year in PE and MP RVUs for low volume
services. Several stakeholders have suggested that CMS implement
service-level overrides based on the expected specialty in order to
determine the specialty mix for these low volume procedures. The RUC
previously supplied us with a list of nearly 2,000 lower volume codes
and their suggested specialty overrides. After reviewing the finalized
PE RVUs for the CY 2017 PFS final rule, we agree that the use of
service-level overrides for low volume services would help mitigate
annual fluctuations and provide greater stability in the valuation of
these services. While the use of the 3-year average of claims data to
determine specialty mix has helped to mitigate some of the year-to-year
variability for low volume services, it has not fully mitigated what
appear to be anomalies for many of these lower volume codes.
We are, therefore, proposing to use the most recent year of claims
data to determine which codes are low volume for the coming year (those
that have fewer than 100 allowed services in the Medicare claims data).
For codes that fall into this category, instead of assigning specialty
mix based on the specialties of the practitioners reporting the
services in the claims data, we are proposing to instead use the
expected specialty that we identify on a list. For CY 2018, we are
proposing to use a list that was developed based on our medical review
of the list most recently recommended by the RUC, in addition to our
own proposed expected specialty for certain other low-volume codes for
which we have historically used expected specialty assignments. We
would display this list as part of the annual set of data files we make
available as part of notice and comment rulemaking. We propose to
consider recommendations from the RUC and other stakeholders on changes
to this list on an annual basis.
We are also proposing to apply these service-level overrides for
both PE and MP, rather than one or the other category. We believe that
this would simplify the implementation of service-level overrides for
PE and MP, and would also address stakeholder concerns about the year-
to-year variability for low volume services. We are soliciting public
comment on the proposal to use service-level overrides to determine the
specialty mix for low volume procedures, as well as on the proposed
list of expected specialty overrides itself, which is largely based on
the recommendations submitted by the RUC last year. The proposed list
of expected specialty assignments for individual low volume services is
available on our Web site under downloads for the CY 2018 PFS proposed
rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Services for
which the specialty is automatically assigned based on previously
finalized policies under our established methodology (for example,
``always therapy'' services) would be unaffected by this proposal.
Step 8: Calculate the service level allocators for the indirect PEs
based on the percentages calculated in Step 7. The indirect PEs are
allocated based on the three components: the direct PE RVUs; the
clinical labor PE RVUs; and the work RVUs.
For most services the indirect allocator is: indirect PE percentage
* (direct PE RVUs/direct percentage) + work RVUs.
There are two situations where this formula is modified:
If the service is a global service (that is, a service
with global, professional, and technical components), then the indirect
PE allocator is: indirect percentage (direct PE RVUs/direct percentage)
+ clinical labor PE RVUs + work RVUs.
If the clinical labor PE RVUs exceed the work RVUs (and
the service is not a global service), then the indirect allocator is:
indirect PE percentage (direct PE RVUs/direct percentage) + clinical
labor PE RVUs.
(Note: For global services, the indirect PE allocator is based on
both the work RVUs and the clinical labor PE RVUs. We do this to
recognize that, for the PC service, indirect PEs would be allocated
using the work RVUs, and for the TC service, indirect PEs would be
allocated using the direct PE RVUs and the clinical labor PE RVUs. This
also allows the global component RVUs to equal the sum of the PC and TC
RVUs.)
For presentation purposes, in the examples in the download file
called ``Calculation of PE RVUs under Methodology for Selected Codes'',
the formulas were divided into two parts for each service.
[[Page 33957]]
The first part does not vary by service and is the
indirect percentage (direct PE RVUs/direct percentage).
The second part is either the work RVU, clinical labor PE
RVU, or both depending on whether the service is a global service and
whether the clinical PE RVUs exceed the work RVUs (as described earlier
in this step).
Apply a scaling adjustment to the indirect allocators.
Step 9: Calculate the current aggregate pool of indirect PE RVUs by
multiplying the result of Step 8 by the average indirect PE percentage
from the survey data.
Step 10: Calculate an aggregate pool of indirect PE RVUs for all
PFS services by adding the product of the indirect PE allocators for a
service from Step 8 and the utilization data for that service.
Step 11: Using the results of Step 9 and Step 10, calculate an
indirect PE adjustment so that the aggregate indirect allocation does
not exceed the available aggregate indirect PE RVUs and apply it to
indirect allocators calculated in Step 8.
Calculate the indirect practice cost index.
Step 12: Using the results of Step 11, calculate aggregate pools of
specialty-specific adjusted indirect PE allocators for all PFS services
for a specialty by adding the product of the adjusted indirect PE
allocator for each service and the utilization data for that service.
Step 13: Using the specialty-specific indirect PE/HR data,
calculate specialty-specific aggregate pools of indirect PE for all PFS
services for that specialty by adding the product of the indirect PE/HR
for the specialty, the work time for the service, and the specialty's
utilization for the service across all services furnished by the
specialty.
Step 14: Using the results of Step 12 and Step 13, calculate the
specialty-specific indirect PE scaling factors.
Step 15: Using the results of Step 14, calculate an indirect
practice cost index at the specialty level by dividing each specialty-
specific indirect scaling factor by the average indirect scaling factor
for the entire PFS.
Step 16: Calculate the indirect practice cost index at the service
level to ensure the capture of all indirect costs. Calculate a weighted
average of the practice cost index values for the specialties that
furnish the service. (Note: For services with TCs and PCs, we calculate
the indirect practice cost index across the global service, PCs, and
TCs. Under this method, the indirect practice cost index for a given
service (for example, echocardiogram) does not vary by the PC, TC, and
global service.)
Step 17: Apply the service level indirect practice cost index
calculated in Step 16 to the service level adjusted indirect allocators
calculated in Step 11 to get the indirect PE RVUs.
(d) Calculate the Final PE RVUs
Step 18: Add the direct PE RVUs from Step 5 to the indirect PE RVUs
from Step 17 and apply the final PE budget neutrality (BN) adjustment.
The final PE BN adjustment is calculated by comparing the sum of steps
5 and 17 to the proposed aggregate work RVUs scaled by the ratio of
current aggregate PE and work RVUs. This adjustment ensures that all PE
RVUs in the PFS account for the fact that certain specialties are
excluded from the calculation of PE RVUs but included in maintaining
overall PFS budget neutrality. (See ``Specialties excluded from
ratesetting calculation'' later in this proposed rule.)
Step 19: Apply the phase-in of significant RVU reductions and its
associated adjustment. Section 1848(c)(7) of the Act specifies that for
services that are not new or revised codes, if the total RVUs for a
service for a year would otherwise be decreased by an estimated 20
percent or more as compared to the total RVUs for the previous year,
the applicable adjustments in work, PE, and MP RVUs shall be phased in
over a 2-year period. In implementing the phase-in, we consider a 19
percent reduction as the maximum 1-year reduction for any service not
described by a new or revised code. This approach limits the year one
reduction for the service to the maximum allowed amount (that is, 19
percent), and then phases in the remainder of the reduction. To comply
with section 1848(c)(7) of the Act, we adjust the PE RVUs to ensure
that the total RVUs for all services that are not new or revised codes
decrease by no more than 19 percent, and then apply a relativity
adjustment to ensure that the total pool of aggregate PE RVUs remains
relative to the pool of work and MP RVUs. For a more detailed
description of the methodology for the phase-in of significant RVU
changes, we refer readers to the CY 2016 PFS final rule with comment
period (80 FR 70927 through 70931).
(e) Setup File Information
Specialties excluded from ratesetting calculation: For the
purposes of calculating the PE RVUs, we exclude certain specialties,
such as certain NPPs paid at a percentage of the PFS and low-volume
specialties, from the calculation. These specialties are included for
the purposes of calculating the BN adjustment. They are displayed in
Table 1.
TABLE 1--Specialties Excluded From Ratesetting Calculation
------------------------------------------------------------------------
Specialty code Specialty description
------------------------------------------------------------------------
49....................... Ambulatory surgical center.
50....................... Nurse practitioner.
51....................... Medical supply company with certified
orthotist.
52....................... Medical supply company with certified
prosthetist.
53....................... Medical supply company with certified
prosthetist[dash]orthotist.
54....................... Medical supply company not included in 51,
52, or 53.
55....................... Individual certified orthotist.
56....................... Individual certified prosthetist.
57....................... Individual certified
prosthetist[dash]orthotist.
58....................... Medical supply company with registered
pharmacist.
59....................... Ambulance service supplier, e.g., private
ambulance companies, funeral homes, etc.
60....................... Public health or welfare agencies.
61....................... Voluntary health or charitable agencies.
73....................... Mass immunization roster biller.
74....................... Radiation therapy centers.
87....................... All other suppliers (e.g., drug and
department stores).
88....................... Unknown supplier/provider specialty.
89....................... Certified clinical nurse specialist.
96....................... Optician.
[[Page 33958]]
97....................... Physician assistant.
A0....................... Hospital.
A1....................... SNF.
A2....................... Intermediate care nursing facility.
A3....................... Nursing facility, other.
A4....................... HHA.
A5....................... Pharmacy.
A6....................... Medical supply company with respiratory
therapist.
A7....................... Department store.
B2....................... Pedorthic personnel.
B3....................... Medical supply company with pedorthic
personnel.
------------------------------------------------------------------------
Crosswalk certain low volume physician specialties:
Crosswalk the utilization of certain specialties with relatively low
PFS utilization to the associated specialties.
Physical therapy utilization: Crosswalk the utilization
associated with all physical therapy services to the specialty of
physical therapy.
Identify professional and technical services not
identified under the usual TC and 26 modifiers: Flag the services that
are PC and TC services but do not use TC and 26 modifiers (for example,
electrocardiograms). This flag associates the PC and TC with the
associated global code for use in creating the indirect PE RVUs. For
example, the professional service, CPT code 93010 (Electrocardiogram,
routine ECG with at least 12 leads; interpretation and report only), is
associated with the global service, CPT code 93000 (Electrocardiogram,
routine ECG with at least 12 leads; with interpretation and report).
Payment modifiers: Payment modifiers are accounted for in
the creation of the file consistent with current payment policy as
implemented in claims processing. For example, services billed with the
assistant at surgery modifier are paid 16 percent of the PFS amount for
that service; therefore, the utilization file is modified to only
account for 16 percent of any service that contains the assistant at
surgery modifier. Similarly, for those services to which volume
adjustments are made to account for the payment modifiers, time
adjustments are applied as well. For time adjustments to surgical
services, the intraoperative portion in the work time file is used;
where it is not present, the intraoperative percentage from the payment
files used by contractors to process Medicare claims is used instead.
Where neither is available, we use the payment adjustment ratio to
adjust the time accordingly. Table 2 details the manner in which the
modifiers are applied.
Table 2--Application of Payment Modifiers to Utilization Files
----------------------------------------------------------------------------------------------------------------
Modifier Description Volume adjustment Time adjustment
----------------------------------------------------------------------------------------------------------------
80,81,82.......................... Assistant at Surgery... 16%........................ Intraoperative
portion.
AS................................ Assistant at Surgery-- 14% (85% * 16%)............ Intraoperative
Physician Assistant. portion.
50 or LT and RT................... Bilateral Surgery...... 150%....................... 150% of work time.
51................................ Multiple Procedure..... 50%........................ Intraoperative
portion.
52................................ Reduced Services....... 50%........................ 50%.
53................................ Discontinued Procedure. 50%........................ 50%.
54................................ Intraoperative Care Preoperative + Preoperative +
only. Intraoperative Percentages Intraoperative
on the payment files used portion.
by Medicare contractors to
process Medicare claims.
55................................ Postoperative Care only Postoperative Percentage on Postoperative portion.
the payment files used by
Medicare contractors to
process Medicare claims.
62................................ Co-surgeons............ 62.5%...................... 50%.
66................................ Team Surgeons.......... 33%........................ 33%.
----------------------------------------------------------------------------------------------------------------
We also make adjustments to volume and time that correspond to
other payment rules, including special multiple procedure endoscopy
rules and multiple procedure payment reductions (MPPRs). We note that
section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments
for multiple imaging procedures and multiple therapy services from the
BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These
MPPRs are not included in the development of the RVUs.
For anesthesia services, we do not apply adjustments to volume
since we use the average allowed charge when simulating RVUs;
therefore, the RVUs as calculated already reflect the payments as
adjusted by modifiers, and no volume adjustments are necessary.
However, a time adjustment of 33 percent is made only for medical
direction of two to four cases since that is the only situation where a
single practitioner is involved with multiple beneficiaries
concurrently, so that counting each service without regard to the
overlap with other services would overstate the amount of time spent by
the practitioner furnishing these services.
Work RVUs: The setup file contains the work RVUs from this
proposed rule.
(6) Equipment Cost per Minute
The equipment cost per minute is calculated as:
(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 +
interest rate)[supcaret] life of equipment)))) + maintenance)
Where:
[[Page 33959]]
minutes per year = maximum minutes per year if usage were continuous
(that is, usage=1); generally 150,000 minutes.
usage = variable, see discussion in this proposed rule.
price = price of the particular piece of equipment.
life of equipment = useful life of the particular piece of
equipment.
maintenance = factor for maintenance; 0.05.
interest rate = variable, see discussion in this proposed rule.
Usage: We currently use an equipment utilization rate assumption of
50 percent for most equipment, with the exception of expensive
diagnostic imaging equipment, for which we use a 90 percent assumption
as required by section 1848(b)(4)(C) of the Act.
Stakeholders have often suggested that particular equipment items
are used less frequently than 50 percent of the time in the typical
setting and that CMS should reduce the equipment utilization rate based
on these recommendations. We appreciate and share stakeholders'
interest in using the most accurate assumption regarding the equipment
utilization rate for particular equipment items. However, we believe
that absent robust, objective, auditable data regarding the use of
particular items, the 50 percent assumption is the most appropriate
within the relative value system. We welcome the submission of data
that illustrates an alternative rate.
Maintenance: This factor for maintenance was finalized in the CY
1998 PFS final rule with comment period (62 FR 33164). We continue to
investigate potential avenues for determining equipment maintenance
costs across a broad range of equipment items.
Interest Rate: In the CY 2013 PFS final rule with comment period
(77 FR 68902), we updated the interest rates used in developing an
equipment cost per minute calculation (see 77 FR 68902 for a thorough
discussion of this issue). The interest rate was based on the Small
Business Administration (SBA) maximum interest rates for different
categories of loan size (equipment cost) and maturity (useful life). We
are not proposing any changes to these interest rates for CY 2018. The
interest rates are listed in Table 3.
Table 3--SBA Maximum Interest Rates
------------------------------------------------------------------------
Interest rate
Price Useful life (%)
------------------------------------------------------------------------
<$25K............................. <7 Years............ 7.50
$25K to $50K...................... <7 Years............ 6.50
>$50K............................. <7 Years............ 5.50
<$25K............................. 7+ Years............ 8.00
$25K to $50K...................... 7+ Years............ 7.00
>$50K............................. 7+ Years............ 6.00
------------------------------------------------------------------------
3. Changes to Direct PE Inputs for Specific Services
This section focuses on specific PE inputs. The direct PE inputs
are included in the CY 2018 direct PE input database, which is
available on the CMS Web site under downloads for the CY 2018 PFS
proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(a) PE Inputs for Digital Imaging Services
In the CY 2017 PFS final rule (81 FR 80179 through 80184), we
finalized our proposal to add a professional PACS workstation (ED053)
used for interpretation of digital images to a series of CPT codes and
to address costs related to the use of film that had previously been
incorporated as direct PE inputs for these services. We finalized the
following criteria for the inclusion of a professional PACS
workstation:
We did not add the professional PACS workstation to any
code that currently lacks a technical PACS workstation (ED050) or lacks
a work RVU. We continue to believe that procedures that do not include
a technical workstation, or do not have physician work, would not
require a professional workstation.
We did not add the professional PACS workstation to add-on
codes. Because the base codes include equipment minutes for the
professional PACS workstation, we continue to believe it would be
duplicative to add additional equipment time for the professional PACS
workstation in the add-on code.
We also did not add the professional PACS workstation to
image guidance codes where the dominant provider is not a radiologist
according to the most recent year of claims data, because we believe a
single technical PACS workstation would be more typical in those cases.
We agreed with commenters that because the clinical
utility of the PACS workstation is not necessarily limited to
diagnostic services, there may be therapeutic codes where it would be
reasonable to assume its use to be typical. Based on information
provided by commenters and our own medical review, we stated that we
believe that the use of the professional PACS workstation is typical
for many of the specific codes that were identified. We added the
workstation to many of the therapeutic codes requested by commenters,
specifically CPT codes listed outside the 70000 series, where we agreed
that use of the professional PACS workstation was typical.
For CPT codes in the 80000 and 90000 series, we expressed
our concerns about whether it is appropriate to include the technical
PACS workstation in many of these services. PACS workstations were
created for imaging purposes, but many of these services that include a
technical PACS workstation do not appear to make use of imaging.
Although we did not remove the technical PACS workstation from these
codes at that time, we did not believe that a professional PACS
workstation should be added to these procedures.
Prior to the publication of this CY 2018 PFS proposed rule, a
stakeholder expressed concern about our decision not to include the
professional PACS workstation in a series of vascular ultrasound codes
that use technical PACS workstations. The stakeholder indicated that
the vascular ultrasound codes in question do make use of a professional
PACS workstation, and that the dominant specialty provider requirement
(that is, that the code's dominant specialty provider being diagnostic
radiology) would exclude codes for which the professional PACS
workstation is typical based on a mistaken assumption. The stakeholder
stated that to furnish vascular ultrasound services following the
transition from film to digital imaging, both a technical and a
professional PACS workstation are required, regardless of whether the
practitioner furnishing the service is a radiologist, cardiologist,
neurologist, or vascular surgeon.
We appreciate the submission of this additional information
regarding the use of the professional PACS workstation in vascular
ultrasound codes. Therefore, we seek comments regarding whether or not
the use of the professional PACS workstation would be typical in the
following list of CPT and HCPCS codes. The codes brought to our
attention by the stakeholder are CPT codes 93880, 93882, 93886, 93888,
93890, 93892, 93893, 93922, 93923, 93924, 93925, 93926, 93930, 93931,
93965, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981, 93990,
and 76706, and HCPCS code G0365. We will consider information submitted
in comments to determine whether the professional
[[Page 33960]]
PACS workstation should be included as a direct PE input for these
codes.
(2) Standardization of Clinical Labor Tasks
As we noted in the CY 2015 PFS final rule with comment period (79
FR 67640-67641), we continue to make improvements to the direct PE
input database to provide the number of clinical labor minutes assigned
for each task for every code in the database instead of only including
the number of clinical labor minutes for the preservice, service, and
postservice periods for each code. In addition to increasing the
transparency of the information used to set PE RVUs, this improvement
would allow us to compare clinical labor times for activities
associated with services across the PFS, which we believe is important
to maintaining the relativity of the direct PE inputs. This information
would facilitate the identification of the usual numbers of minutes for
clinical labor tasks and the identification of exceptions to the usual
values. It would also allow for greater transparency and consistency in
the assignment of equipment minutes based on clinical labor times.
Finally, we believe that the information can be useful in maintaining
standard times for particular clinical labor tasks that can be applied
consistently to many codes as they are valued over several years,
similar in principle to the use of physician preservice time packages.
We believe such standards would provide greater consistency among codes
that share the same clinical labor tasks and could improve relativity
of values among codes. For example, as medical practice and
technologies change over time, changes in the standards could be
updated simultaneously for all codes with the applicable clinical labor
tasks, instead of waiting for individual codes to be reviewed.
In the following paragraphs, we address a series of issues related
to clinical labor tasks, particularly relevant to services currently
being reviewed under the misvalued code initiative.
a. Preservice Clinical Labor for 0-Day and 10-Day Global Services
Several years ago, the RUC's PE Subcommittee reviewed the
preservice clinical labor times for CPT codes with 0-day and 10-day
global periods. The RUC concluded that these codes are assumed to have
no preservice clinical staff time (standard time of 0 minutes) unless
the specialty can provide evidence that the preservice time is
appropriate. In other words, for minor procedures, it is assumed that
there is no clinical staff time typically spent preparing for the
specific procedure prior to the patient's arrival. However, we note
that for CY 2018, 41 of the 53 reviewed codes with 0-day or 10-day
global periods include preservice clinical labor of some kind,
suggesting that it is typical for clinical staff to prepare for the
procedure prior to the patient's arrival. As we review misvalued codes,
we believe that the general adherence to values that we have
established as standards supports relativity within the PFS. Because 77
percent of the reviewed codes for the current calendar year deviate
from the ``standard,'' we are seeking comment on the value and
appropriate application of the standard in our review of RUC
recommendations in future rulemaking. In reviewing the inputs included
in the direct PE inputs database, we found that for the 1,142 total 0-
day global codes, 741 of them had preservice clinical labor of some
kind (65 percent). We also noticed a general correlation between
preservice clinical labor time and the recent review. We are seeking
comment specifically on whether the standard preservice clinical labor
time of 0 minutes should be consistently applied for 0-day and 10-day
global codes in future rulemaking.
b. Obtain Vital Signs Clinical Labor
The direct PE inputs for each CPT code paid under the PFS include
minutes assigned to a series of standard clinical labor tasks assumed
to be typical for the service in question. The minutes assigned to each
of these tasks for each CPT code have been developed over several
decades, and what was previously considered to be a standard value in
the review of the codes has changed over time. Because each year we
perform a detailed review of all of the inputs for only several hundred
of the over 7,000 CPT codes paid under the PFS, valuation for
individual services can be influenced by shifts in review standards
over time rather than purely based on changes in practice.
For example, we traditionally assigned a clinical labor time of 3
minutes for the ``Obtain vital signs'' clinical labor activity, based
on the amount of time typically required to check a patient's vitals.
Over time, that number of minutes has increased as codes are reviewed.
For example, many of the reviewed codes for the current CY 2018
rulemaking cycle have a recommended clinical labor time of 5 minutes
for ``Obtain vital signs,'' based on the understanding that these
services are measuring two additional vital signs: The patient's height
and weight. We do not have any reason to believe that measuring a
patient's height and weight is only typical for services described by
recently reviewed codes. Instead, we believe that the review standards
have changed, perhaps in conjunction with changes in medical practice,
and that the change in the minutes assigned for the ``Obtain vital
signs'' task for newer-reviewed services is detrimental to relativity
among PFS services.
Therefore, to preserve relativity among the PFS codes, we are
proposing to assign 5 minutes of clinical labor time for all codes that
include the ``Obtain vital signs'' task, regardless of the date of last
review. We are proposing to assign this 5 minutes of clinical labor
time for all codes that include at least 1 minute previously assigned
to this task. We are also proposing to update the equipment times of
the codes with this clinical labor task accordingly to match the
changes in clinical labor time. For codes that were not recently
reviewed and for which we lacked a breakdown of how the equipment time
was derived from the clinical labor tasks, we could not determine if
the equipment time included time assigned for the ``Obtain vital
signs'' task. In these cases, we are proposing to adjust the equipment
time of any equipment item that matched the clinical labor time of the
full service period to match the change in the ``Obtain vital signs''
clinical labor time. The proposed list of all codes affected by these
proposed vital signs changes to direct PE inputs is available on the
CMS Web site under downloads for the CY 2018 PFS proposed rule at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
c. Establishment of Clinical Labor Activity Codes
Historically, the RUC has submitted a ``PE worksheet'' that details
the recommended direct PE inputs for our use in developing PE RVUs. The
format of the PE worksheet has varied over time and among the medical
specialties developing the recommendations. These variations have made
it difficult for both the RUC's development and our review of code
values for individual codes. Beginning for the CY 2019 PFS rulemaking
cycle, we understand that the RUC intends to mandate the use of a new
PE worksheet for purposes of their recommendation development process
that standardizes the clinical labor tasks and assigns them a clinical
labor activity code. We believe the RUC's use of the new PE worksheet
in developing and submitting recommendations to us would, in turn, help
us to simplify and standardize the hundreds of different clinical labor
tasks
[[Page 33961]]
currently listed in our direct PE database.
To help facilitate this transition to the new clinical labor
activity codes, we have developed a crosswalk to link the old clinical
labor tasks to the new clinical labor activity codes. Our crosswalk is
for informational purposes only, and would not change either the direct
PE input values or the PE RVUs for codes. Instead, we hope that the
crosswalk would help us to translate the sprawling, existing data set
into a condensed version that would significantly improve the
standardization of clinical labor recommendations and improve the
ability of commenters to identify concerns with our proposed valuation.
For CY 2018 rulemaking, we are displaying two versions of the Labor
Task Detail public use file: One version with the old listing of
clinical labor tasks, and one with the same tasks as described by the
new listing of clinical labor activity codes. These lists are available
on the CMS Web site under downloads for the CY 2018 PFS proposed rule
at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(3) Equipment Recommendations for Scope Systems
During our routine reviews of direct PE input recommendations, we
have regularly found unexplained inconsistencies involving the use of
scopes and the video systems associated with them. Some of the scopes
include video systems bundled into the equipment item, some of them
include scope accessories as part of their price, and some of them are
standalone scopes with no other equipment included. It is not always
clear which equipment items related to scopes fall into which of these
categories. We have also frequently found anomalies in the equipment
recommendations, with equipment items that consist of a scope and video
system bundle recommended, along with a separate scope video system.
Based on our review, the variations do not appear to be consistent with
the different code descriptions.
To promote appropriate relativity among the services and facilitate
the transparency of our review process, during review of recommended
direct PE inputs for the CY 2017 PFS proposed rule, we developed a
structure that separates the scope and the associated video system as
distinct equipment items for each code. Under this approach, we
proposed standalone prices for each scope, and separate prices for the
video systems that are used with scopes. We proposed to define the
scope video system as including: (1) A monitor; (2) a processor; (3) a
form of digital capture; (4) a cart; and (5) a printer. We believe that
these equipment components represent the typical case for a scope video
system. Our model for this system was the ``video system, endoscopy
(processor, digital capture, monitor, printer, cart)'' equipment item
(ES031), which we proposed to re-price as part of this separate pricing
approach. We obtained current pricing invoices for the endoscopy video
system as part of our investigation of these issues involving scopes,
which we proposed to use for this re-pricing. We understand that there
may be other accessories associated with the use of scopes; we proposed
to separately price any scope accessories, and individually evaluate
their inclusion or exclusion as direct PE inputs for particular codes
as usual under our current policy based on whether they are typically
used in furnishing the services described by the particular codes.
We also proposed standardizing refinements to the way scopes have
been defined in the direct PE input database. We believe that there are
four general types of scopes: non-video scopes; flexible scopes; semi-
rigid scopes, and rigid scopes. Flexible scopes, semi-rigid scopes, and
rigid scopes would typically be paired with one of the scope video
systems, while the non-video scopes would not. The flexible scopes can
be further divided into diagnostic (or non-channeled) and therapeutic
(or channeled) scopes. We proposed to identify for each anatomical
application: (1) A rigid scope; (2) a semi-rigid scope; (3) a non-video
flexible scope; (4) a non-channeled flexible video scope; and (5) a
channeled flexible video scope. We proposed to classify the existing
scopes in our direct PE database under this classification system, to
improve the transparency of our review process and improve appropriate
relativity among the services. We planned to propose input prices for
these equipment items through future rulemaking.
We proposed these changes only for the reviewed codes for CY 2017
that made use of scopes, along with updated prices for the equipment
items related to scopes utilized by these services. But, we did not
propose to apply these policies to codes with inputs reviewed prior to
CY 2017. We also solicited comment on this separate pricing structure
for scopes, scope video systems, and scope accessories, which we could
consider proposing to apply to other codes in future rulemaking. In
response to comments, we finalized the addition of a digital capture
device to the endoscopy video system (ES031) in the CY 2017 PFS final
rule. We finalized our proposal to price the system at $33,391, based
on component prices of $9,000 for the processor, $18,346 for the
digital capture device, $2,000 for the monitor, $2,295 for the printer,
and $1,750 for the cart. We also finalized a price of $16,843.87 for
the stroboscopy system scope accessory (ES065). We did not finalize
price increases for a series of other scopes and scope accessories, as
the invoices submitted for these components indicated that they are
different forms of equipment with different product IDs and different
prices. We did not receive any data to indicate that the equipment on
the newly submitted invoices was more typical in its use than the
equipment that we were currently using for pricing.
We did not make further changes to existing scope equipment in CY
2017 in order to allow the RUC's PE Subcommittee the opportunity to
provide feedback. However, we believe there was some miscommunication
on this point, as the RUC's PE Subcommittee workgroup that was created
to address scope systems stated that no further action was required
following the finalization of our proposal. We are making further
proposals to continue clarifying scope equipment inputs, and seek
comments regarding the new set of scope proposals. We welcome feedback
from all stakeholders, including practitioners with direct experience
in the use of scope equipment.
We are seeking comment on several potential categories of scope
system PE inputs. We are considering creating a single scope equipment
code for each of the five categories detailed in this proposed rule:
(1) A rigid scope; (2) a semi-rigid scope; (3) a non-video flexible
scope; (4) a non-channeled flexible video scope; and (5) a channeled
flexible video scope. Under the current classification system, there
are many different scopes in each category depending on the medical
specialty furnishing the service and the part of the body affected. We
believe that the variation between these scopes is not significant
enough to warrant maintaining these distinctions, and we believe that
creating and pricing a single scope equipment code for each category
would help provide additional clarity. We are seeking public comment on
the merits of this potential scope organization, as well as any pricing
information regarding these five new scope categories.
[[Page 33962]]
For CY 2018, we are proposing two minor changes to PE inputs
related to scopes. We are proposing to add an LED light source into the
cost of the scope video system (ES031), which would remove the need for
a separate light source in these procedures. If this proposal were to
be finalized, we would remove the equipment time for the separate light
source from CPT codes that include the scope video system. We are also
proposing an increase to the price of the scope video system of
$1,000.00 to cover the expense of miscellaneous small equipment
associated with the system that falls below the threshold of individual
equipment pricing as scope accessories (such as cables, microphones,
foot pedals, etc.) We seek comments on the inclusion of the LED light
in the scope video system, and the appropriate pricing of the system
with the inclusion of these additional equipment items.
We anticipate adopting detailed changes to scope systems at the
code level through rulemaking for CY 2019, because we believe that
additional feedback from expert stakeholders will improve the details
of the proposed changes. We are not proposing any additional pricing
changes to scope equipment for CY 2018 due to the proposed
reorganization into a single type of scope equipment for each of the
five scope categories. However, we would consider updating prices for
these equipment items through the public request process for price
updates, or based on information submitted as part of RUC
recommendations.
(4) Clarivein Kit for Mechanochemical Vein Ablation
In the CY 2017 PFS final rule, we finalized work RVUs and direct PE
inputs for two new codes related to mechanochemical vein ablation, CPT
codes 36473 and 36474. Following the publication of the final rule,
stakeholders contacted CMS and requested that a Clarivein kit supply
item (SA122) be added to the direct PE inputs for CPT code 36474, the
add-on code for ablation of subsequent veins. They stated that the
Clarivein kit was accidentally omitted from the RUC recommendations,
and that an additional kit is necessary to perform the service
described by the add-on procedure. We are soliciting comment regarding
the use of multiple kits during procedures described by the base and
add-on codes to determine whether or not this supply should be included
as a direct PE input for CPT code 36474 for CY 2018.
(5) Removal of Oxygen From Non-Moderate Sedation Post-Procedure
Monitoring
After finalizing the creation of separately billable codes for
moderate sedation during the CY 2017 PFS final rule, we received
additional recommendations to remove the oxygen gas supply item (SD084)
from a series of CPT codes that were previously valued with moderate
sedation as an inherent part of the procedure. Because oxygen gas is
included in the moderate sedation pack contained within the separately
billed moderate sedation codes, we believe that the continued inclusion
of the oxygen gas in these codes is a duplicative supply. We are
therefore proposing to remove the oxygen gas from the following codes
(see Table 4):
Table 4--CY 2018 Proposed Removal of Oxygen (SD084) From Non-Moderate Sedation Post-Procedure Monitoring
----------------------------------------------------------------------------------------------------------------
Current
HCPCS NF/F (liters) Cost
----------------------------------------------------------------------------------------------------------------
31622......................................... NF.............................. 90 -0.27
31625......................................... NF.............................. 105 -0.32
31626......................................... NF.............................. 135 -0.41
31627......................................... NF.............................. 150 -0.45
31628......................................... NF.............................. 120 -0.36
31629......................................... NF.............................. 105 -0.32
31632......................................... NF.............................. 54 -0.16
31633......................................... NF.............................. 60 -0.18
31645......................................... NF.............................. 175 -0.53
31652......................................... NF.............................. 180 -0.54
31653......................................... NF.............................. 225 -0.68
31654......................................... NF.............................. 90 -0.27
52647......................................... NF.............................. 10 -0.03
52648......................................... NF.............................. 10 -0.03
90870......................................... NF.............................. 198 -0.59
----------------------------------------------------------------------------------------------------------------
(6) Technical Corrections to Direct PE Input Database and Supporting
Files
Subsequent to the publication of the CY 2017 PFS final rule,
stakeholders alerted us to several clerical inconsistencies in the
direct PE database. We are proposing to correct these inconsistencies
as described in this proposed rule and reflected in the CY 2018
proposed direct PE input database displayed on the CMS Web site under
downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
For CY 2018, we are proposing to address the following
inconsistencies:
For CY 2018, we are proposing to make direct PE changes
for CPT code 96416 (Chemotherapy administration, intravenous infusion
technique; initiation of prolonged chemotherapy infusion (more than 8
hours), requiring use of a portable or implantable pump) to improve
payment accuracy, in response to a stakeholder inquiry regarding the
use of the ambulatory IV pump equipment for this service. We are
proposing to add 6 additional minutes of RN/OCN clinical labor (L056A),
4 minutes for the ``Review charts by chemo nurse regarding course of
treatment & obtain chemotherapy-related medical hx'' task, and 2
minutes for the ``Greet patient and provide gowning'' task. We are
proposing to add 1 quantity of the IV infusion set supply (SC018) and
proposing to lower the quantity from 2 to 1 of the 20 ml syringe supply
(SC053). We are proposing to add 1800 minutes for the new ambulatory IV
pump equipment, and we are proposing to increase the equipment time of
the medical recliner chair (EF009) from 83 minutes to 89 minutes to
match the increase in RN/OCN clinical labor. For CY 2018, these
[[Page 33963]]
proposed direct PE changes would be used to calculate the PE RVU for
CPT code 96416. We seek comments on these proposed direct PE
refinements.
We propose to correct an anomaly in the postservice work
time for CPT code 91200 (Liver elastography, mechanically induced shear
wave (e.g., vibration), without imaging, with interpretation and
report) by changing it from 5 minutes to 3 minutes, which also results
in a refinement in the total work time for the code from 18 minutes to
16 minutes.
In the process of making updates to our direct PE
database, we discovered a series of discrepancies between the finalized
direct PE inputs and the values entered into the database from previous
calendar years. To reconcile these discrepancies, we are proposing the
following direct PE refinements:
Table 5--Direct PE Database Data Discrepancies and Proposed Changes
--------------------------------------------------------------------------------------------------------------------------------------------------------
HCPCS Input code Input code description NF/F Old New Cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
11307............................ SF033.............. scalpel with blade, NF 1 2 0.69
surgical (#10-20).
11311............................ SG056.............. gauze, sterile 4in x 4in NF 1 2 0.80
(10 pack uou).
11311............................ SH046.............. lidocaine 1% w-epi inj NF 10 4 -0.38
(Xylocaine w-epi).
11719............................ L037D.............. Greet patient, provide NF 1 3 0.74
gowning, ensure
appropriate medical
records are available.
11719............................ L037D.............. Provide pre-service NF 1 2 0.37
education/obtain
consent.
11719............................ L037D.............. Prepare room, equipment, NF 1 2 0.37
supplies.
11719............................ L037D.............. Clean room/equipment by NF 1 3 0.74
physician staff.
17312............................ SL097.............. OCT Tissue-Tek.......... NF 8 6 -0.12
17313............................ SF004.............. blade, microtome........ NF 1 0 -1.72
17313............................ SF044.............. blade, surgical, super- NF 0 1 4.17
sharp.
17313............................ SG056.............. gauze, sterile 4in x 4in NF 3 0 -2.39
(10 pack uou).
17313............................ SG088.............. tape, foam, elastic, 2in NF 10 8 -0.01
(Microfoam).
17314............................ SG056.............. gauze, sterile 4in x 4in NF 2 0 -1.60
(10 pack uou).
17314............................ SL097.............. OCT Tissue-Tek.......... NF 8 6 -0.12
17315............................ SL078.............. histology freezing spray NF 0 0.2 0.29
(Freeze-It).
19283............................ L043A.............. Service total costs..... NF 55 54 -0.43
19286............................ L051B.............. Service total costs..... NF 30 31 0.51
19286............................ EL015.............. room, ultrasound, NF 19 20 1.40
general.
19286............................ EQ168.............. light, exam............. NF 19 20 0.00
23333............................ L037D.............. Post service total costs F 63 90 9.99
28045............................ SC029.............. needle, 18-27g.......... NF 2 1 -0.09
32405............................ L041B.............. Service total costs..... NF 52 57 2.05
37765............................ L037D.............. Service total costs..... NF 91 94 1.11
37766............................ L037D.............. Service total costs..... NF 121 124 1.11
45171............................ SJ052.............. swab, procto 16in....... F 2 3 0.12
45172............................ L037D.............. Service total costs..... F 6 12 2.22
45172............................ SJ052.............. swab, procto 16in....... F 2 3 0.12
52214............................ SH047.............. lidocaine 1%-2% inj NF 1 50 1.72
(Xylocaine).
72120............................ EL012.............. room, basic radiology... NF 16 17 0.48
72148............................ L047A.............. Service total costs..... NF 47 49 0.84
74230............................ L041B.............. Technologist QC's images NF 0 2 0.82
in PACS, checking for
all images, reformats,
and dose page.
91013............................ EF023.............. table, exam............. NF 0 9 0.03
91013............................ EF015.............. mayo stand.............. NF 0 9 0.01
91013............................ EQ235.............. suction machine (Gomco). NF 0 9 0.02
91013............................ EQ181.............. manometry system NF 0 9 1.15
(computer, transducers,
catheter).
91013............................ EQ339.............. manometry accessory NF 0 9 0.05
cable.
91013............................ ED050.............. PACS Workstation Proxy.. NF 0 9 0.20
91132............................ EQ019.............. EGG monitoring system... NF 22 30 0.83
92227............................ EL006.............. lane, screening (oph)... NF 12 0 -1.07
92227............................ EL005.............. lane, exam (oph)........ NF 0 12 1.15
93017............................ L051A.............. Preservice total costs.. NF 15 5 -5.10
95819............................ SG079.............. tape, surgical paper 1in NF 6 42 0.07
(Micropore).
--------------------------------------------------------------------------------------------------------------------------------------------------------
The proposed PE RVUs displayed in Addendum B on our Web site were
calculated with the inputs displayed in the CY 2018 proposed direct PE
input database.
(7) Updates to Prices for Existing Direct PE Inputs
In the CY 2011 PFS final rule with comment period (75 FR 73205), we
finalized a process to act on public requests to update equipment and
supply price and equipment useful life inputs through annual
rulemaking, beginning with the CY 2012 PFS proposed rule. For CY 2018,
we are proposing the following price updates for existing direct PE
inputs.
We are proposing to update the price of thirteen supplies and one
equipment item in response to the public submission of invoices. For
the details of these proposed price updates, please refer to section
II.H, of this proposed rule, Table 14: Invoices Received for Existing
Direct PE Inputs.
We are not proposing to update the price of the blood warmer
(EQ072), the cell separator system (EQ084), or the photopheresor system
(EQ206) equipment items. The only pricing information that we received
for these three equipment items was an invoice that included a hand-
written price over redacted information. We were unable to verify the
accuracy of this invoice. We are also not proposing to update the price
of the DNA image analyzer (ACIS) (EP001) equipment item, due to the
[[Page 33964]]
inclusion of many components on the submitted invoice that are not part
of the price of the DNA image analyzer. We were unable to determine
which of these components were included in the cost of the DNA image
analyzer, and which of these components were unrelated types of
equipment. To price these equipment items accurately, we believe that
we need additional information. We continue to use the current price
for these equipment items pending the submission of additional pricing
information. We welcome the submission of updated pricing information
regarding these equipment items through valid invoices from commenters
and other stakeholders.
We are also proposing to change the name of the ED050 equipment
from the ``PACS Workstation Proxy'' to the ``Technologist PACS
workstation.'' In the CY 2017 final rule (81 FR 80180-80182), we
finalized a policy to add a professional PACS workstation (ED053) to
the list of approved equipment items, and we believe that renaming
ED050 to the technologist PACS workstation would help to alleviate
potential confusion between the two PACS workstations.
We routinely accept public submission of invoices as part of our
process for developing payment rates for new, revised, and potentially
misvalued codes. Often these invoices are submitted in conjunction with
the RUC-recommended values for the codes. For CY 2018, we note that
some stakeholders have submitted invoices for new, revised, or
potentially misvalued codes after the February 10th deadline
established for code valuation recommendations. To be included in a
given year's proposed rule, we generally need to receive invoices by
the same February 10th deadline. However, we would consider invoices
submitted as public comments during the comment period following the
publication of the proposed rule, and would consider any invoices
received after February or outside of the public comment process as
part of our established annual process for requests to update supply
and equipment prices.
4. Adjustment to Allocation of Indirect PE for Some Office-Based
Services
As we explain in section II.B.2.c.(2) of this proposed rule, we
allocate indirect costs for each code on the basis of the direct costs
specifically associated with a code and the greater of either the
clinical labor costs or the work RVUs. Indirect expenses include
administrative labor, office expense, and all other expenses. For PFS
services priced in both the facility and non-facility settings, the
difference in indirect PE RVUs between the settings is driven by
differences in direct PE inputs for those settings since the other
allocator of indirect PE, the work RVU, does not differ between
settings. For most services, the direct PE input costs are higher in
the nonfacility setting than in the facility setting. As a result,
indirect PE RVUs allocated to these services are higher in the
nonfacility setting than in the facility setting. When direct PE inputs
for a service are very low, however, the allocation of indirect PE RVUs
is almost exclusively based on work RVUs, which results in a very small
(or no) site of service differential between the total PE RVUs in the
facility and nonfacility setting.
Some stakeholders have suggested that for codes in which direct PE
inputs for a service are very low, this allocation methodology does not
allow for a site of service differential that accurately reflects the
relative indirect costs involved in furnishing services in nonfacility
settings. Among the services most affected by this anomaly are the
primary therapy and counseling services available to Medicare
beneficiaries for treatment of behavioral health conditions, including
substance use disorders. For example, for the most commonly reported
psychotherapy service (CPT code 90834), the difference between the
nonfacility and facility PE RVUs is only 0.02 RVUs, which seems
unlikely to represent the difference in relative resource costs in
terms of administrative labor, office expense, and all other expenses
incurred by the billing practitioner for 45 minutes of psychotherapy
services when furnished in the office setting versus the facility
setting.
We agree with these stakeholders that the site of service
differential for these services that is produced by our PE methodology
seems unlikely to reflect the relative resource costs for the
practitioners furnishing these services in nonfacility settings. For
example, we believe the 0.02 RVUs, which translates to approximately
$0.72, would be unlikely to reflect the relative administrative labor,
office rent, and other overhead involved in furnishing the 45 minute
psychotherapy service in a nonfacility setting. Consequently, we
believe it would be appropriate to modify the existing methodology for
allocating indirect PE RVUs in order to better reflect the relative
indirect PE resources involved in furnishing these kinds of services in
the nonfacility setting.
In examining the range of services furnished in the nonfacility
setting that are most affected by this circumstance, we identified
HCPCS codes that describe face-to-face services, have work RVUs greater
than zero, and are priced in both the facility and nonfacility setting.
From among these codes, we further selected those with the lowest ratio
between nonfacility PE RVUs and work RVUs. We selected 0.4 as an
appropriate threshold based on several factors, including the range of
nonfacility PE RVU to work RVU ratios among the codes identified. Based
on these criteria, there were fewer than 50 codes that we identified
with a ratio of less than 0.4 nonfacility PE RVUs for each work RVU,
most of which are primarily furnished by behavioral health
professionals, for a potential modification to our indirect PE
allocation methodology.
In considering how to address the anomaly and ensure that an
appropriate number of indirect PE RVUs are allocated to these services
in the nonfacility setting, we looked at the indirect, nonfacility PE
RVU for the most commonly billed physician office visit, CPT code
99213, which is billed by a wide range of physicians and non-physician
practitioners under the PFS. We believe that the indirect PE costs
allocated to services reported with CPT code 99213, including
administrative labor and office rent, would be common for a broad range
of physicians and non-physician practitioners across the PFS. We
recognize that the services we seek to address are primarily furnished
by behavioral health professionals who may be unlikely to incur some of
the costs incurred by other practitioners furnishing a broader range of
medical services. For instance, a practitioner furnishing a broader
range of primary care services likely requires separate office and
examination room space, and storage for disposable medical supplies and
equipment. Some costs, however, such as those for office staff and
records maintenance, would be analogous.
We looked at the relationship between indirect PE and work RVUs for
CPT code 99213 as a marker because that is the most commonly and
broadly reported PFS code that describes face-to-face office-based
services. We compared the relationship between indirect PE and work
RVUs for the set of HCPCS codes that we identified using the criteria
discussed above and found that for the significant majority of codes,
that ratio was at least 0.4 nonfacility PE RVUs for each work RVU. We
believe the 0.4 nonfacility PE RVUs can serve as an appropriate marker
that appropriately reflects the relative resources involved in
furnishing these services.
[[Page 33965]]
For the fewer than 50 outlier codes identified using the criteria
above, we believe it would be appropriate to establish a minimum
nonfacility indirect PE RVU that would be a better reflection the
resources involved in furnishing these services. We propose to set the
nonfacility indirect PE RVUs for these codes using the indirect PE RVU
to work RVU ratio for the most commonly furnished office-based, face-
to-face service (CPT 99213) as a marker. Specifically, for each of
these outlier codes, we propose to compare the ratio between indirect
PE RVUs and work RVUs that result from the preliminary application of
the standard methodology to the ratio for the marker code, CPT code
99213. Our proposed change in the methodology would then increase the
allocation of indirect PE RVUs to the outlier codes to at least one
quarter of the difference between the two ratios. We believe this
approach reflects a reasonable minimum allocation of indirect PE RVUs,
but we do not currently have empirical data that would be useful in
establishing a more precise number.
In developing the proposed PE RVUs for CY 2018, we propose to
implement only one quarter of this proposed minimum value for
nonfacility indirect PE for the outlier codes. We recognize that this
change in the PE methodology could have a significant impact on the
allocation of indirect PE RVUs across all PFS services. In making
significant changes to the PE methodology in previous years, we have
implemented such changes using 4 year transitions, based largely on
concerns that some specialties experience significant payment
reductions with changes in PE relativity, and a transition period
allows for a more gradual adjustment for affected practitioners. Under
the approach we are proposing, we estimate that approximately $40
million, or approximately 0.04 percent of total PFS allowed charges,
would shift within the PE methodology for each year of the proposed 4-
year transition, including for CY 2018. We also note that we are
proposing to exclude the codes directly subject to this proposed change
from the misvalued code target calculation because the proposed change
is a methodological change to address an anomaly produced by our
indirect PE allocation process as opposed to a change to address
misvalued codes. The PE RVUs displayed in Addendum B on our Web site
were calculated with the one quarter of the indirect PE adjustment
factor implemented.
C. Determination of Malpractice Relative Value Units (RVUs)
1. Overview
Section 1848(c) of the Act requires that each service paid under
the PFS be composed of three components: work, PE, and malpractice (MP)
expense. As required by section 1848(c)(2)(C)(iii) of the Act,
beginning in CY 2000, MP RVUs are resource based. Section
1848(c)(2)(B)(i) of the Act also requires that we review, and if
necessary adjust, RVUs no less often than every 5 years. In the CY 2015
PFS final rule with comment period, we implemented the third review and
update of MP RVUs. For a comprehensive discussion of the third review
and update of MP RVUs see the CY 2015 proposed rule (79 FR 40349
through 40355) and final rule with comment period (79 FR 67591 through
67596).
To determine MP RVUs for individual PFS services, our MP
methodology is composed of three factors: (1) Specialty-level risk
factors derived from data on specialty-specific MP premiums incurred by
practitioners, (2) service level risk factors derived from Medicare
claims data of the weighted average risk factors of the specialties
that furnish each service, and (3) an intensity/complexity of service
adjustment to the service level risk factor based on either the higher
of the work RVU or clinical labor RVU. Prior to CY 2016, MP RVUs were
only updated once every 5 years, except in the case of new and revised
codes.
As explained in the CY 2011 PFS final rule with comment period (75
FR 73208), MP RVUs for new and revised codes effective before the next
5-year review of MP RVUs were determined either by a direct crosswalk
from a similar source code or by a modified crosswalk to account for
differences in work RVUs between the new/revised code and the source
code. For the modified crosswalk approach, we adjusted (or scaled) the
MP RVU for the new/revised code to reflect the difference in work RVU
between the source code and the new/revised work RVU (or, if greater,
the difference in the clinical labor portion of the fully implemented
PE RVU) for the new code. For example, if the proposed work RVU for a
revised code were 10 percent higher than the work RVU for its source
code, the MP RVU for the revised code would be increased by 10 percent
over the source code MP RVU. Under this approach, the same risk factor
was applied for the new/revised code and source code, but the work RVU
for the new/revised code was used to adjust the MP RVUs for risk.
In the CY 2016 PFS final rule with comment period (80 FR 70906
through 70910), we finalized a policy to begin conducting annual MP RVU
updates to reflect changes in the mix of practitioners providing
services (using Medicare claims data), and to adjust MP RVUs for risk,
intensity and complexity (using the work RVU or clinical labor RVU). We
also finalized a policy to modify the specialty mix assignment
methodology (for both MP and PE RVU calculations) to use an average of
the 3 most recent years of data instead of a single year of data. Under
this approach, for new and revised codes, we generally assign a
specialty risk factor to individual codes based on the same utilization
assumptions we make regarding specialty mix we use for calculating PE
RVUs and for PFS budget neutrality. We continue to use the work RVU or
clinical labor RVU to adjust the MP RVU for each code for intensity and
complexity. In finalizing this policy, we stated that the specialty-
specific risk factors would continue to be updated through notice and
comment rulemaking every 5 years using updated premium data, but would
remain unchanged between the 5-year reviews.
In CY 2017, we finalized the eighth GPCI update, which reflected
updated MP premium data. We did not propose to use the updated MP
premium data to propose updates for CY 2017 to the specialty risk
factors used in the calculation of MP RVUs because it was inconsistent
with the policy we previously finalized in the CY 2016 PFS final rule
with comment period, whereby we indicated that the specialty-specific
risk factors would continue to be updated through notice and comment
rulemaking every 5 years using updated premium data, but would remain
unchanged between the 5-year reviews. However, we solicited comment on
whether we should consider doing so, perhaps as early as for CY 2018,
prior to the fourth review and update of MP RVUs that must occur no
later than CY 2020. After consideration of the comments received, we
stated that we would consider the possibility of using the updated MP
data to update the specialty risk factors used in the calculation of
the MP RVUs prior to the next 5-year update in future rulemaking (81 FR
80191 through 80192). Since MP premium data are used to update both the
MP GPCIs and the MP RVUs, going forward we believe it would be logical
to align the update of MP premium data used to determine the MP RVUs
with the update of the MP GPCI. Section 1848(e)(1)(C) of the Act
requires us to review and, if necessary, adjust the
[[Page 33966]]
GPCIs at least every 3 years. The next review of the GPCIs must occur
by CY 2020.
We propose to use the most recent data for the proposed MP RVUs for
CY 2018 and to align the update of MP premium data and MP GPCIs to once
every 3 years. We are seeking comment on these proposals, and we are
also seeking comment on methodologies and sources that we might use to
improve the next update of MP premium data.
2. Methodology for the Proposed Revision of Resource Based Malpractice
RVUs
a. General Discussion
The proposed MP RVUs were calculated based on updated malpractice
premium data obtained from state insurance rate filings by a CMS
contractor. The methodology used in calculating the proposed CY 2018
review and update of resource based MP RVUs largely parallels the
process used in the CY 2015 update. The calculation requires using
information on specialty-specific malpractice premiums linked to
specific services based upon the relative risk factors of the various
specialties that furnish a particular service. Because malpractice
premiums vary by state and specialty, the malpractice premium
information must be weighted geographically and by specialty.
Accordingly, the proposed MP RVUs are based upon four data sources: CY
2014 and CY 2015 malpractice premium data; CY 2016 and 2017 Medicare
payment and utilization data; CY 2017 geographic practice cost indices
(GPCIs), and CY 2018 proposed work and clinical labor RVUs.
Similar to the previous update, we calculated the proposed MP RVUs
using specialty-specific malpractice premium data because they
represent the actual expense incurred by practitioners to obtain
malpractice insurance. We obtained malpractice premium data exclusively
from the most recently available data published in the 2014 and 2015
Market Share Reports accessed from the National Association of
Insurance Commissioners (NAIC) Web site. We used information obtained
from malpractice insurance rate filings with effective dates in 2014
and 2015. These were the most current data available during our data
collection process. We collected malpractice insurance premium data
from all 50 States, and the District of Columbia, and Puerto Rico. Rate
filings were not available in American Samoa, Guam or the Virgin
Islands. Premiums were for $1 million/$3 million, mature, claims-made
policies (policies covering claims made, rather than those covering
services furnished, during the policy term). A $1 million/$3 million
liability limit policy means that the most that would be paid on any
claim is $1 million and the most that the policy would pay for claims
over the timeframe of the policy is $3 million. We made adjustments to
the premium data to reflect mandatory surcharges for patient
compensation funds (funds to pay for any claim beyond the statutory
amount, thereby limiting an individual physician's liability in cases
of a large suit) in states where participation in such funds is
mandatory.
We included premium information for all physician and NPP
specialties, and all risk classifications available in the collected
rate filings. Although we collected premium data from all states, the
District of Columbia, and Puerto Rico, not all specialties had distinct
premium data in the rate filings from all states. Additionally, for
some specialties, MP premiums were not available from the rate filings
in any state. Therefore, for specialties for which there were not
premium data for at least 35 states, and specialties for which there
were not distinct premium data in the rate filings, we crosswalked the
specialty to a similar specialty, either conceptually or by available
premium data, for which we did have sufficient and reliable data. These
specialties and the specialty data that we propose to use are shown in
Table 6.
For example, for radiation oncology, data were only available from
23 states, and therefore this specialty does not meet our 35-state
threshold, which determines whether or not a specialty is deemed to
have premium data sufficient to construct a unique risk factor.
However, based on the 23 states' worth of rate filings for radiation
oncology, the resource costs for the premiums suggests a similar,
though slightly lesser average than that of the premiums for diagnostic
radiology. We developed the proposed MP RVUs for radiation oncology by
crosswalking the risk factor for diagnostic radiology as a similar
specialty with similar premium data. We are seeking comment as to the
appropriateness of this and the other crosswalks used in developing MP
RVUs.
For the proposed CY 2018 MP RVU update, sufficient and reliable
premium data were available for 43 specialty types, representing over
76 percent of allowed Medicare PFS services, which we used to develop
specialty specific malpractice risk factors. (See Table 8 for a list of
these specialties.)
Table 6--Proposed Crosswalk of Specialties to Similar Specialties
----------------------------------------------------------------------------------------------------------------
Crosswalk
Specialty code Medicare specialty name specialty code Crosswalk specialty
----------------------------------------------------------------------------------------------------------------
12............................ Osteopathic Manipulative 03 Allergy/Immunology.
Medicine.
15............................ Speech Language Pathology...... 03 Allergy/Immunology.
17............................ Hospice and Palliative Care.... 03 Allergy/Immunology.
19............................ Oral Surgery (Dentist only).... 24 Plastic and Reconstructive
Surgery.
23............................ Sports Medicine................ 01 General Practice.
27............................ Geriatric Psychiatry........... 26 Psychiatry.
32............................ Anesthesiology Assistant....... 05 Anesthesiology.
35............................ Chiropractic................... 03 Allergy/Immunology.
36............................ Nuclear Medicine............... 30 Diagnostic Radiology.
40............................ Hand Surgery................... 20 Orthopedic Surgery.
41............................ Optometry...................... 03 Allergy/Immunology.
42............................ Certified Nurse Midwife........ 16 Obstetrics & Gynecology.
43............................ Certified Registered Nurse 05 Anesthesiology.
Anesthetist (CRNA).
48............................ Podiatry....................... 07 Dermatology.
62............................ Psychologist................... 03 Allergy/Immunology.
64............................ Audiologist.................... 03 Allergy/Immunology.
65............................ Physical Therapist in Private 03 Allergy/Immunology.
Practice.
67............................ Occupational Therapist in 03 Allergy/Immunology.
Private Practice.
68............................ Psychologist, Clinical......... 03 Allergy/Immunology.
[[Page 33967]]
76............................ Peripheral Vascular Disease.... 77 Vascular Surgery.
79............................ Addiction Medicine............. 03 Allergy/Immunology.
80............................ Licensed Clinical Social Worker 03 Allergy/Immunology.
81............................ Critical Care (Intensivists)... 29 Pulmonary Disease.
85............................ Maxillofacial Surgery.......... 24 Plastic and Reconstructive
Surgery.
86............................ Neuropsychiatry................ 26 Psychiatry.
89............................ Certified Clinical Nurse 01 General Practice.
Specialist.
92............................ Radiation Oncology............. 30 Diagnostic Radiology.
94............................ Interventional Radiology....... 30 Diagnostic Radiology.
97............................ Physician Assistant............ 03 Allergy/Immunology.
98............................ Gynecological Oncology......... 02 General Surgery.
C0............................ Sleep Medicine................. 01 General Practice.
----------------------------------------------------------------------------------------------------------------
b. Steps for Calculating Malpractice RVUs
Calculation of the proposed MP RVUs conceptually follows the
specialty-weighted approach used in the CY 2015 final rule with comment
period (79 FR 67591). The specialty-weighted approach bases the MP RVUs
for a given service upon a weighted average of the risk factors of all
specialties furnishing the service. This approach ensures that all
specialties furnishing a given service are accounted for in the
calculation of the MP RVUs. The steps for calculating the proposed MP
RVUs are described below.
Step (1): Compute a preliminary national average premium for each
specialty.
Insurance rating area malpractice premiums for each specialty are
mapped to the county level. The specialty premium for each county is
then multiplied by its share of the total U.S. population (from the
U.S. Census Bureau's 2014 American Community (ACS) estimates). This is
in contrast to the method used for creating national average premiums
for each specialty in the 2015 update; in that update, specialty
premiums were weighted by the total RVU per county, rather than by the
county share of the total U.S. population. We refer readers to the PFS
2016 Final Rule with comment period (80 FR 70909) for a discussion of
why we have adopted a weighting method based on share of total U.S.
population. This calculation is then divided by the average MP GPCI
across all counties for each specialty to yield a normalized national
average premium for each specialty. The specialty premiums are
normalized for geographic variation so that the locality cost
differences (as reflected by the GPCIs) would not be counted twice.
Without the geographic variation adjustment, the cost differences among
fee schedule areas would be reflected once under the methodology used
to calculate the MP RVUs and again when computing the service specific
payment amount for a given fee schedule area.
Step (2): Determine which premium class(es) to use within each
specialty.
Some specialties had premium rates that differed for surgery,
surgery with obstetrics, and non-surgery. These premium classes are
designed to reflect differences in risk of professional liability and
the cost of malpractice claims if they occur. To account for the
presence of different classes in the malpractice premium data and the
task of mapping these premiums to procedures, we calculated distinct
risk factors for surgical, surgical with obstetrics, and nonsurgical
procedures. However, the availability of data by surgery and non-
surgery varied across specialties. Consistent with the CY 2015 MP RVU
update, because no single approach accurately addressed the variability
in premium class among specialties, we employed several methods for
calculating average premiums by specialty. These methods are discussed
below.
(a) Substantial Data for Each Class: For 10 out of 86 specialties,
we determined that there were sufficient data for surgery and non-
surgery premiums, as well as sufficient differences in rates between
classes. These specialties are listed in Table 7. Therefore, we
calculated a national average surgical premium and non-surgical
premium. We note that, unlike in the CY 2015 MP RVU update, for CY
2018, there were no specialties that fell under the ``unspecified
dominates'' specialty/surgery class scenario, therefore we have omitted
that surgical class category.
(b) Major Surgery Dominates: For 9 surgical specialties, rate
filings that included non-surgical premiums were relatively rare. For
most of these surgical specialties, the rate filings did not include an
``unspecified'' premium. When it did, the unspecified premium was lower
than the major surgery rate. For these surgical specialties, we
calculated only a surgical premium and used the premium for major
surgery for all procedures furnished by this specialty.
(c) Blend All Available: For the remaining specialties, there was
wide variation across the rate filings in terms of whether or not
premium classes were reported and which categories were reported.
Because there was no clear strategy for these remaining specialties, we
blended the available rate information into one general premium rate.
For these specialties, we developed a weighted average ``blended''
premium at the national level, according to the percentage of work RVUs
correlated with the premium classes within each specialty. For example,
the surgical premiums for a given specialty were weighted by that
specialty's work RVUs for surgical services; the nonsurgical premiums
were weighted by the work RVUs for non-surgical services and the
unspecified premiums were weighted by all work RVUs for the specialty
type.
The three methods for calculating premiums by specialty type are
summarized in Table 7. (See Table 8: ``Proposed Risk Factors by
Specialty Type'' for the specialty names associated with the specialty
codes listed in Table 7.)
Table 7--Proposed Premium Calculation Approach by Specialty Type
------------------------------------------------------------------------
Method Medicare specialty codes
------------------------------------------------------------------------
(a) Substantial Data for Each Class (10).. 01, 04, 08, 09, 13, 16, 18,
34, 72, 93.
(b) Major Surgery Dominates (9)........... 02, 14, 20, 24, 28, 33, 77,
78, 91.
[[Page 33968]]
(c) Blend all Available (24).............. 03, 05, 06, 07, 10, 11, 22,
25, 26, 29, 30, 37, 38, 39,
44, 46, 50, 66, 71, 82, 83,
84, 90, 99.
------------------------------------------------------------------------
Step (3): Calculate a risk factor for each specialty.
The relative differences in national average premiums between
specialties are expressed in our methodology as a specialty risk
factor. 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 premiums for which we had
sufficient and reliable data, allergy and immunology. For specialties
with sufficient surgical and non-surgical premium data, we calculated
both a surgical and non-surgical risk factor. For specialties with rate
filings that distinguished surgical premiums with obstetrics, we
calculated a separate surgical with obstetrics risk factor. For all
other specialties we calculated a single risk factor and applied the
specialty risk factor to both surgery and non-surgery services.
We note that for determining the risk factor for suppliers of TC-
only services in the CY 2015 update, we updated the premium data for
independent diagnostic testing facilities (IDTFs) that we used in the
CY 2010 update. These data were obtained from a survey conducted by the
Radiology Business Management Association (RBMA) in 2009; we ultimately
used these data to calculate an updated TC specialty risk factor. We
applied the updated TC specialty risk factor to suppliers of TC-only
services. In the CY 2015 final rule with comment period (79 FR 67595),
RBMA voluntarily submitted updated MP premium information collected
from independent diagnostic testing facilities (IDTFs) in 2014, and
requested that we use the data for calculating the CY 2015 MP RVUs for
TC services. We declined to utilize the data and stated that we believe
further study is necessary and we would consider this matter and
propose any changes through future rulemaking. We believe that data for
a broader set of technical component services are needed, and seek
comment on appropriate, comparable data sources for such information.
We also seek comment on whether the data for IDTFs are comparable and
appropriate as a proxy for the broader set of TC services. We endeavor
to, in the next update of specialty risk factors, collect more data
across a broader set of the technical component services, not just for
radiology (as is currently reflected in the RBMA data), but data for
services performed by other non-physician practitioners including
cytotechnologists, and cardiovascular technologists. In the interim,
for CY 2018, we propose to assign a TC risk factor of 1.0, which
corresponds to the lowest physician specialty risk factor.
We assigned the risk factor of 1.0 to the TC services because we do
not have comparable professional liability premium data for the full
range of clinicians that furnish these services. In lieu of
comprehensive, comparable data, we used 1.0 as the default minimum risk
factor, though we seek information on the best available data sources
for use in the next update, as well as empirical information that would
support assignment of an alternative risk factor for these services.
Table 8 shows the proposed risk factors by specialty type.
Table 8--Proposed Risk Factors by Specialty Type
----------------------------------------------------------------------------------------------------------------
Non-surgical Surgical risk
Specialty code Medicare specialty name risk factor factor
----------------------------------------------------------------------------------------------------------------
01......................................... General Practice................... 1.80 3.72
01......................................... General Practice w/OB.............. .............. 4.30
02......................................... General Surgery.................... .............. 6.75
03......................................... Allergy/Immunology................. 1.00 1.00
04......................................... Otolaryngology..................... 1.53 4.08
05......................................... Anesthesiology..................... 2.58 2.58
06......................................... Cardiovascular Disease (Cardiology) 1.90 1.90
07......................................... Dermatology........................ 2.77 2.77
08......................................... Family Practice.................... 1.67 3.74
08......................................... Family Practice w/OB............... .............. 4.31
09......................................... Interventional Pain Management..... 2.08 2.97
10......................................... Gastroenterology................... 2.40 2.40
11......................................... Internal Medicine.................. 2.70 2.70
12......................................... Osteopathic Manipulative Medicine.. 1.00 1.00
13......................................... Neurology.......................... 2.46 13.02
14......................................... Neurosurgery....................... .............. 10.66
15......................................... Speech Language Pathology.......... 1.00 1.00
16......................................... Obstetrics & Gynecology............ 1.59 4.52
16......................................... Obstetrics & Gynecology w/OB....... .............. 8.67
17......................................... Hospice and Palliative Care........ 1.00 1.00
18......................................... Ophthalmology...................... 1.03 2.16
19......................................... Oral Surgery (Dentist only)........ .............. 4.93
20......................................... Orthopedic Surgery................. .............. 6.22
22......................................... Pathology.......................... 1.60 1.60
23......................................... Sports Medicine.................... 1.80 3.72
24......................................... Plastic and Reconstructive Surgery. .............. 4.93
25......................................... Physical Medicine and 1.49 1.49
Rehabilitation.
26......................................... Psychiatry......................... 1.27 1.27
27......................................... Geriatric Psychiatry............... 1.27 1.27
28......................................... Colorectal Surgery (Proctology).... .............. 4.19
29......................................... Pulmonary Disease.................. 1.82 1.82
30......................................... Diagnostic Radiology............... 2.82 2.82
32......................................... Anesthesiology Assistant........... 2.58 2.58
33......................................... Thoracic Surgery................... .............. 6.06
34......................................... Urology............................ 1.66 2.97
[[Page 33969]]
35......................................... Chiropractic....................... 1.00 1.00
36......................................... Nuclear Medicine................... 2.82 2.82
37......................................... Pediatric Medicine................. 1.82 1.82
38......................................... Geriatric Medicine................. 1.52 1.52
39......................................... Nephrology......................... 1.56 1.56
40......................................... Hand Surgery....................... .............. 6.22
41......................................... Optometry.......................... 1.00 1.00
42......................................... Certified Nurse Midwife............ 1.59 4.52
42......................................... Certified Nurse Midwife w/OB....... .............. 8.67
43......................................... Certified Registered Nurse 2.58 2.58
Anesthetist (CRNA).
44......................................... Infectious Disease................. 2.03 2.03
46......................................... Endocrinology...................... 1.75 1.75
48......................................... Podiatry........................... 2.77 2.77
50......................................... Nurse Practitioner................. 1.95 1.95
62......................................... Psychologist....................... 1.00 1.00
64......................................... Audiologist........................ 1.00 1.00
65......................................... Physical Therapist in Private 1.00 1.00
Practice.
66......................................... Rheumatology....................... 1.58 1.58
67......................................... Occupational Therapist in Private 1.00 1.00
Practice.
68......................................... Psychologist, Clinical............. 1.00 1.00
71......................................... Registered Dietitian or Nutrition 1.37 1.37
Professional.
72......................................... Pain Management.................... 2.65 3.65
76......................................... Peripheral Vascular Disease........ .............. 6.67
77......................................... Vascular Surgery................... .............. 6.67
78......................................... Cardiac Surgery.................... .............. 6.87
79......................................... Addiction Medicine................. 1.00 1.00
80......................................... Licensed Clinical Social Worker.... 1.00 1.00
81......................................... Critical Care (Intensivists)....... 1.82 1.82
82......................................... Hematology......................... 1.77 1.77
83......................................... Hematology-Oncology................ 1.85 1.85
84......................................... Preventive Medicine................ 1.15 1.15
85......................................... Maxillofacial Surgery.............. .............. 4.93
86......................................... Neuropsychiatry.................... 1.27 1.27
89......................................... Certified Clinical Nurse Specialist 1.80 3.72
90......................................... Medical Oncology................... 1.82 1.82
91......................................... Surgical Oncology.................. .............. 4.32
92......................................... Radiation Oncology................. 2.82 2.82
93......................................... Emergency Medicine................. 2.29 5.03
94......................................... Interventional Radiology........... 2.82 2.82
97......................................... Physician Assistant................ 1.95 1.95
98......................................... Gynecological Oncology............. .............. 6.75
99......................................... Undefined Physician type........... 1.95 1.95
C0......................................... Sleep Medicine..................... 1.80 3.72
----------------------------------------------------------------------------------------------------------------
Step (4): Calculate malpractice RVUs for each HCPCS code.
Resource-based MP RVUs were calculated for each HCPCS code that has
work or PE RVUs. The first step was to identify the percentage of
services furnished by each specialty for each respective HCPCS code.
This percentage was then multiplied by each respective specialty's risk
factor as calculated in Step 3. The products for all specialties for
the HCPCS code were then added together, yielding a specialty-weighted
service specific risk factor reflecting the weighted malpractice costs
across all specialties furnishing that procedure. The service specific
risk factor was multiplied by the greater of the work RVU or PE
clinical labor index for that service to reflect differences in the
complexity and risk-of-service between services.
Low volume service codes: As we discussed in section II.B. of this
proposed rule, we are proposing to use a list of expected specialties
instead of the claims-based specialty mix for low volume services in
order to address stakeholder concerns about the year to year
variability in PE and MP RVUs for low volume services. We are
soliciting comments on the proposal to use these service-level
overrides to determine the specialty for low volume procedures, as well
as on the list of overrides itself. The proposed list of codes and
expected specialties is available on our Web site under downloads for
the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. In previous MP RVU updates, as discussed in the CY 2015
final rule with comment period (79 FR 40354), we assigned specialty for
low volume services based on dominant specialty. As discussed in the CY
2012 final rule with comment period (76 FR 73187 through 73189), we
applied an additional list of service-level overrides for purposes of
calculating MP RVUs for a number of cardiothoracic surgery codes.
Therefore, we note that there are certain codes for which we have
previously applied expected specialty overrides for purposes of
calculating MP RVUs based on assumptions regarding low Medicare volume.
Because we are consolidating policies for low volume service expected
specialty overrides into a single list for PE and MP, and because we do
not believe that there is a reason to assume different specialties for
purposes of calculating PE RVUs than for MP RVUs for any particular
code, we
[[Page 33970]]
are also proposing to assign the specialty mix solely based on the
claims data for any code that does not meet the low volume threshold of
99 allowed services or fewer in the previous year, for the purposes of
calculating MP RVUs.
Given that we now annually recalibrate MP RVUs based on claims
data, and in light of our proposed introduction of the service-level
specialty override for low volume services, we believe that there would
no longer be a need to apply service-level MP crosswalks in order to
assign a specialty-mix risk factor. Contingent on finalizing this
proposal, we are also proposing to eliminate general use of an MP-
specific specialty-mix crosswalk for new and revised codes. However, we
would continue to consider, in conjunction with annual recommendations,
specific recommendations from the public and the RUC regarding
specialty mix assignments for new and revised codes, particularly in
cases where coding changes are expected to result in differential
reporting of services by specialty, or where the new or revised code is
expected to be low-volume. Absent such information, we would derive the
specialty mix assumption for the first year for a new or revised code
from the specialty mix used for purposes of ratesetting. In subsequent
years when claims data are available, we would assign the specialty
based on claims data unless the service does not exceed the low volume
threshold (99 or fewer allowed services). If the service is low volume,
we would assign the expected specialty, establishing a new expected
specialty through rulemaking as needed, which is consistent with our
approach for developing PE RVUs.
Step (5): Rescale for budget neutrality.
The statute requires that changes to fee schedule RVUs must be
budget neutral. Thus, the last step is to adjust for relativity by
rescaling the proposed MP RVUs so that the total proposed resource
based MP RVUs are equal to the total current resource based MP RVUs
scaled by the ratio of current aggregate MP and work RVUs. This scaling
is necessary in order to maintain the work RVUs for individual services
from year to year while also maintaining the overall relationship among
work, PE, and MP RVUs.
The proposed resource based MP RVUs are shown in Addendum B, which
is available on the CMS Web site under the downloads section of the CY
2018 PFS proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
Because a different share of the resources involved in furnishing
PFS services is reflected in each of the three fee schedule components,
implementation of the resource based MP RVU update will have much
smaller payment effects than implementing updates of resource based
work RVUs and resource based PE RVUs. On average, work represents about
50.9 percent of payment for a service under the fee schedule, PE about
44.8 percent, and MP about 4.3 percent. Therefore, a 25 percent change
in PE RVUs or work RVUs for a service would result in a change in
payment of about 11 to 13 percent. In contrast, a corresponding 25
percent change in MP values for a service would yield a change in
payment of only about one percent. Estimates of the effects on payment
by specialty type can be found in section VI. of this proposed rule.
Additional information on our proposed methodology for updating the
MP RVUs may be found in our contractor's report, ``Interim Report on
Malpractice RVUs for the CY 2018 PFS Proposed Rule,'' which is
available on the CMS Web site under the downloads section of the CY
2018 PFS proposed rule located at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
We are seeking comments on these proposals for calculating the MP
RVUs for CY 2018.
C. Medicare Telehealth Services
1. Billing and Payment for Telehealth Services
Several conditions must be met for Medicare to make payments for
telehealth services under the PFS. The service must be on the list of
Medicare telehealth services and meet all of the following additional
requirements:
The service must be furnished via an interactive
telecommunications system.
The service must be furnished by a physician or other
authorized practitioner.
The service must be furnished to an eligible telehealth
individual.
The individual receiving the service must be located in a
telehealth originating site.
When all of these conditions are met, Medicare pays a facility fee
to the originating site and makes a separate payment to the distant
site practitioner furnishing the service.
Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth
services to include professional consultations, office visits, office
psychiatry services, and any additional service specified by the
Secretary, when furnished via a telecommunications system. We first
implemented this statutory provision, which was effective October 1,
2001, in the CY 2002 PFS final rule with comment period (66 FR 55246).
We established a process for annual updates to the list of Medicare
telehealth services as required by section 1834(m)(4)(F)(ii) of the Act
in the CY 2003 PFS final rule with comment period (67 FR 79988).
As specified at Sec. 410.78(b), we generally require that a
telehealth service be furnished via an interactive telecommunications
system. Under Sec. 410.78(a)(3), an interactive telecommunications
system is defined as multimedia communications equipment that includes,
at a minimum, audio and video equipment permitting two-way, real-time
interactive communication between the patient and distant site
physician or practitioner.
Telephones, facsimile machines, and stand-alone electronic mail
systems do not meet the definition of an interactive telecommunications
system. An interactive telecommunications system is generally required
as a condition of payment; however, section 1834(m)(1) of the Act
allows the use of asynchronous ``store-and-forward'' technology when
the originating site is part of a federal telemedicine demonstration
program in Alaska or Hawaii. As specified in Sec. 410.78(a)(1),
asynchronous store-and-forward is the transmission of medical
information from an originating site for review by the distant site
physician or practitioner at a later time.
Medicare telehealth services may be furnished to an eligible
telehealth individual notwithstanding the fact that the practitioner
furnishing the telehealth service is not at the same location as the
beneficiary. An eligible telehealth individual is an individual
enrolled under Part B who receives a telehealth service furnished at a
telehealth originating site.
Practitioners furnishing Medicare telehealth services are reminded
that these services are subject to the same non-discrimination laws as
other services, including the effective communication requirements for
persons with disabilities of section 504 of the Rehabilitation Act and
language access for persons with limited English proficiency, as
required under Title VI of the Civil Rights Act of 1964. For more
information, see http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication.
Practitioners furnishing Medicare telehealth services submit claims
for
[[Page 33971]]
telehealth services to the Medicare Administrative Contractors (MACs)
that process claims for the service area where their distant site is
located. Section 1834(m)(2)(A) of the Act requires that a practitioner
who furnishes a telehealth service to an eligible telehealth individual
be paid an amount equal to the amount that the practitioner would have
been paid if the service had been furnished without the use of a
telecommunications system.
Originating sites, which can be one of several types of sites
specified in the statute where an eligible telehealth individual is
located at the time the service is being furnished via a
telecommunications system, are paid a facility fee under the PFS for
each Medicare telehealth service. The statute specifies both the types
of entities that can serve as originating sites and the geographic
qualifications for originating sites. For geographic qualifications,
our regulation at Sec. 410.78(b)(4) limits originating sites to those
located in rural health professional shortage areas (HPSAs) or in a
county that is not included in a metropolitan statistical area (MSA).
Historically, we have defined rural HPSAs to be those located
outside of MSAs. Effective January 1, 2014, we modified the regulations
regarding originating sites to define rural HPSAs as those located in
rural census tracts as determined by the Federal Office of Rural Health
Policy of the Health Resources and Services Administration (HRSA) (78
FR 74811). Defining ``rural'' to include geographic areas located in
rural census tracts within MSAs allows for broader inclusion of sites
within HPSAs as telehealth originating sites. Adopting the more precise
definition of ``rural'' for this purpose expands access to health care
services for Medicare beneficiaries located in rural areas. HRSA has
developed a Web site tool to provide assistance to potential
originating sites to determine their geographic status. To access this
tool, see our Web site at https://www.cms.gov/MedicareMedicare-General-Information/Telehealth/index.html.
An entity participating in a federal telemedicine demonstration
project that has been approved by, or received funding from, the
Secretary as of December 31, 2000 is eligible to be an originating site
regardless of its geographic location.
Effective January 1, 2014, we also changed our policy so that
geographic status for an originating site would be established and
maintained on an annual basis, consistent with other telehealth payment
policies (78 FR 74400). Geographic status for Medicare telehealth
originating sites for each calendar year is now based upon the status
of the area as of December 31 of the prior calendar year.
For a detailed history of telehealth payment policy, see 78 FR
74399.
2. Adding Services to the List of Medicare Telehealth Services
As noted previously, in the CY 2003 PFS final rule with comment
period (67 FR 79988), we established a process for adding services to
or deleting services from the list of Medicare telehealth services.
This process provides the public with an ongoing opportunity to submit
requests for adding services. Under this process, we assign any
qualifying request to make additions to the list of telehealth services
to one of two categories. Revisions to criteria that we use to review
requests in the second category were finalized in the CY 2012 PFS final
rule with comment period (76 FR 73102). The two categories are:
Category 1: Services that are similar to professional
consultations, office visits, and office psychiatry services that are
currently on the list of telehealth services. In reviewing these
requests, we look for similarities between the requested and existing
telehealth services for the roles of, and interactions among, the
beneficiary, the physician (or other practitioner) at the distant site
and, if necessary, the telepresenter, a practitioner who is present
with the beneficiary in the originating site. We also look for
similarities in the telecommunications system used to deliver the
service; for example, the use of interactive audio and video equipment.
Category 2: Services that are not similar to the current
list of telehealth services. Our review of these requests includes an
assessment of whether the service is accurately described by the
corresponding code when furnished via telehealth and whether the use of
a telecommunications system to furnish the service produces
demonstrated clinical benefit to the patient. Submitted evidence should
include both a description of relevant clinical studies that
demonstrate the service furnished by telehealth to a Medicare
beneficiary improves the diagnosis or treatment of an illness or injury
or improves the functioning of a malformed body part, including dates
and findings, and a list and copies of published peer reviewed articles
relevant to the service when furnished via telehealth. Our evidentiary
standard of clinical benefit does not include minor or incidental
benefits.
Some examples of clinical benefit include the following:
Ability to diagnose a medical condition in a patient
population without access to clinically appropriate in-person
diagnostic services.
Treatment option for a patient population without access
to clinically appropriate in-person treatment options.
Reduced rate of complications.
Decreased rate of subsequent diagnostic or therapeutic
interventions (for example, due to reduced rate of recurrence of the
disease process).
Decreased number of future hospitalizations or physician
visits.
More rapid beneficial resolution of the disease process
treatment.
Decreased pain, bleeding, or other quantifiable symptom.
Reduced recovery time.
The list of telehealth services, including the proposed additions
described below, is included in the Downloads section to this proposed
rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Requests to add services to the list of Medicare telehealth
services must be submitted and received no later than December 31 of
each calendar year to be considered for the next rulemaking cycle. For
example, qualifying requests submitted before the end of CY 2017 will
be considered for the CY 2019 proposed rule. Each request to add a
service to the list of Medicare telehealth services must include any
supporting documentation the requester wishes us to consider as we
review the request. Because we use the annual PFS rulemaking process as
a vehicle for making changes to the list of Medicare telehealth
services, requesters should be advised that any information submitted
is subject to public disclosure for this purpose. For more information
on submitting a request for an addition to the list of Medicare
telehealth services, including where to mail these requests, see our
Web site at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.
3. Submitted Requests To Add Services to the List of Telehealth
Services for CY 2018
Under our existing policy, we add services to the telehealth list
on a category 1 basis when we determine that they are similar to
services on the existing telehealth list for the roles of, and
interactions among, the beneficiary, physician (or other practitioner)
at the distant site and, if necessary, the telepresenter. As we stated
in the CY
[[Page 33972]]
2012 final rule with comment period (76 FR 73098), we believe that the
category 1 criteria not only streamline our review process for publicly
requested services that fall into this category, but also expedite our
ability to identify codes for the telehealth list that resemble those
services already on this list.
We received several requests in CY 2016 to add various services as
Medicare telehealth services effective for CY 2018. The following
presents a discussion of these requests, and our proposals for
additions to the CY 2018 telehealth list. Of the requests received, we
found that three services were sufficiently similar to services
currently on the telehealth list to qualify on a category 1 basis.
Therefore, we are proposing to add the following services to the
telehealth list on a category 1 basis for CY 2018:
HCPCS code G0296 (Counseling visit to discuss need for
lung cancer screening using low dose ct scan (ldct) (service is for
eligibility determination and shared decision making))
We found that the service described by HCPCS code G0296 is
sufficiently similar to office visits currently on the telehealth list.
We believe that all the components of this service, which include
assessment of the patient's risk for lung cancer, shared decision
making, and counseling on the risks and benefits of LDCT, can be
furnished via interactive telecommunications technology.
CPT codes 90839 and 90840 (Psychotherapy for crisis; first
60 minutes) and (Psychotherapy for crisis; each additional 30 minutes
(List separately in addition to code for primary service))
We are proposing to add CPT codes 90839 and 90840 on a Category 1
basis. We found that these services are sufficiently similar to the
psychotherapy services currently on the telehealth list, even though
these codes describe patients requiring more urgent care and
psychotherapeutic interventions to minimize the potential for
psychological trauma. However, we did identify one specific element of
the services as described in the CPT prefatory language that we
concluded may or may not be able to be furnished via telehealth,
depending on the circumstances of the particular service. The CPT
prefatory language specifies that the treatment described by these
codes requires, ``mobilization of resources to defuse the crisis and
restore safety.'' In many cases, we believe that a distant site
practitioner would have access (via telecommunication technology,
presumably) to the resources at the originating site that would allow
for the kind of mobilization required to restore safety. However, we
also believe that it would be possible that a distant site practitioner
would not have access to such resources. Therefore we are proposing to
add the codes to the telehealth list with the explicit condition of
payment that the distant site practitioner be able to mobilize
resources at the originating site to defuse the crisis and restore
safety, when applicable, when the codes are furnished via telehealth.
``Mobilization of resources'' is a description used in the CPT
prefatory language. We believe the critical element of ``mobilizing
resources'' is the ability to communicate with and inform staff at the
originating site to the extent necessary to restore safety. We solicit
comment on whether our assumption that the remote practitioner is able
to mobilize resources at the originating site to defuse the crisis and
restore safety is valid.
Although we did not receive specific requests, we are also
proposing to add four additional services to the telehealth list based
on our review of services. All four of these codes are add-on codes
that describe additional elements of services currently on the
telehealth list and would only be considered telehealth services when
billed as an add-on to codes already on the telehealth list. The four
codes are:
CPT code 90785 (Interactive complexity (List separately in
addition to the code for primary procedure))
CPT codes 96160 and 96161 (Administration of patient-
focused health risk assessment instrument (e.g., health hazard
appraisal) with scoring and documentation, per standardized instrument)
and (Administration of caregiver-focused health risk assessment
instrument (e.g., depression inventory) for the benefit of the patient,
with scoring and documentation, per standardized instrument))
HCPCS code G0506 (Comprehensive assessment of and care
planning for patients requiring chronic care management services (list
separately in addition to primary monthly care management service))
In the case of CPT codes 96160 and 96161, and HCPCS code G0506, we
recognize that these services may not necessarily be ordinarily
furnished in-person with a physician or billing practitioner.
Ordinarily, services that are typically not considered to be face-to-
face services do not need to be on the list of Medicare telehealth
services; however, these services would only be considered Medicare
telehealth services when billed with a base code that is also on the
telehealth list and would not be considered Medicare telehealth
services when billed with codes not on the Medicare telehealth list. We
believe that by adding these services to the telehealth list it will be
administratively easier for practitioners who report these services in
association with a visit code that is furnished via telehealth as both
the base code and the add-on code would be reported with the telehealth
place of service.
We also received requests to add services to the telehealth list
that do not meet our criteria for Medicare telehealth services. We are
not proposing to add the following procedures for physical,
occupational, and speech therapy, initial hospital care, and online E/M
by physician/qualified healthcare professional to the telehealth list,
or changing the requirements for ESRD procedure codes furnished via
telehealth, for the reasons noted in the paragraphs that follow.
a. Physical and Occupational Therapy and Speech-Language Pathology
Services: CPT Codes--
CPT code 97001: Now deleted and reported as CPT code 97161
(Physical therapy evaluation: low complexity, requiring these
components: A history with no personal factors and/or comorbidities
that impact the plan of care; An examination of body system(s) using
standardized tests and measures addressing 1-2 elements from any of the
following: Body structures and functions, activity limitations, and/or
participation restrictions; A clinical presentation with stable and/or
uncomplicated characteristics; and Clinical decision making of low
complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome.)
CPT code 97002: Now deleted and reported as CPT code 97162
(Physical therapy evaluation: moderate complexity, requiring these
components: A history of present problem with 1-2 personal factors and/
or comorbidities that impact the plan of care; An examination of body
systems using standardized tests and measures in addressing a total of
3 or more elements from any of the following: Body structures and
functions, activity limitations, and/or participation restrictions; An
evolving clinical presentation with changing characteristics; and
Clinical decision making of moderate complexity using standardized
patient assessment instrument and/or measurable assessment of
functional outcome)
CPT code 97003: Now deleted and reported as CPT code 97165
(Occupational therapy evaluation, low
[[Page 33973]]
complexity, requiring these components: An occupational profile and
medical and therapy history, which includes a brief history including
review of medical and/or therapy records relating to the presenting
problem; An assessment(s) that identifies 1-3 performance deficits
(i.e., relating to physical, cognitive, or psychosocial skills) that
result in activity limitations and/or participation restrictions; and
Clinical decision making of low complexity, which includes an analysis
of the occupational profile, analysis of data from problem-focused
assessment(s), and consideration of a limited number of treatment
options. Patient presents with no comorbidities that affect
occupational performance. Modification of tasks or assistance (e.g.,
physical or verbal) with assessment(s) is not necessary to enable
completion of evaluation component)
CPT code 97004: Now deleted and reported as CPT code 97166
(Occupational therapy evaluation, moderate complexity, requiring these
components: An occupational profile and medical and therapy history,
which includes an expanded review of medical and/or therapy records and
additional review of physical, cognitive, or psychosocial history
related to current functional performance; An assessment(s) that
identifies 3-5 performance deficits (i.e., relating to physical,
cognitive, or psychosocial skills) that result in activity limitations
and/or participation restrictions; and Clinical decision making of
moderate analytic complexity, which includes an analysis of the
occupational profile, analysis of data from detailed assessment(s), and
consideration of several treatment options. Patient may present with
comorbidities that affect occupational performance. Minimal to moderate
modification of tasks or assistance (e.g., physical or verbal) with
assessment(s) is necessary to enable patient to complete evaluation
component))
CPT code 97110 (Therapeutic procedure, 1 or more areas,
each 15 minutes; therapeutic exercises to develop strength and
endurance, range of motion and flexibility)
CPT code 97112 (Therapeutic procedure, 1 or more areas,
each 15 minutes; neuromuscular reeducation of movement, balance,
coordination, kinesthetic sense, posture, and/or proprioception for
sitting and/or standing activities)
CPT code 97116 (Therapeutic procedure, 1 or more areas,
each 15 minutes; gait training (includes stair climbing))
CPT code 97535 (Self-care/home management training (e.g.,
activities of daily living (ADL) and compensatory training, meal
preparation, safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one contact, each
15 minutes)
CPT code 97750 (Physical performance test or measurement
(e.g., musculoskeletal, functional capacity), with written report, each
15 minutes)
CPT code 97755 (Assistive technology assessment (e.g., to
restore, augment or compensate for existing function, optimize
functional tasks and/or maximize environmental accessibility), direct
one-on-one contact, with written report, each 15 minutes).
CPT code 97760 (Orthotic(s) management and training
(including assessment and fitting when not otherwise reported), upper
extremity(s), lower extremity(s) and/or trunk, each 15 minutes).
CPT code 97761 (Prosthetic training, upper and/or lower
extremity(s), each 15 minutes).
CPT code 97762 (Checkout for orthotic/prosthetic use,
established patient, each 15 minutes).
In section 1834(m)(4)(E) of the Act, the statute specifies the
types of practitioners who may furnish and bill for Medicare telehealth
services as those practioners under section 1842(b)(18)(C) of the Act.
Physical therapists, occupational therapists and speech-language
pathologists are not among the practitioners identified in section
1842(b)(18)(C) of the Act. We stated in the CY 2017 PFS final rule (81
FR 80198) that because these services are predominantly furnished by
physical therapists, occupational therapists and speech-language
pathologists, we did not believe it would be appropriate to add them to
the list of telehealth services at this time. In an ensuing submission
for 2018, the original requester suggested that we might propose these
services to be added to the list so that they can be furnished via
telehealth when furnished by eligible distant site practitioners. We
considered that possibility; however, since the majority of the codes
are furnished by therapy professionals over 90 percent of the time, we
believe that adding therapy services to the telehealth list that
explicitly describe the services of the kinds of professionals not
included on the statutory list of distant site practitioners could
result in confusion about who is authorized to furnish and bill for
these services when furnished via telehealth. We also note that several
of these services, such as CPT code 97761, require directly physically
manipulating the beneficiary, which is not possible to do through
telecommunications technology. Therefore, we are not proposing to add
these codes to the list of Medicare telehealth services.
b. Initial Hospital Care Services: CPT Codes--
CPT code 99221 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A detailed or comprehensive history; A detailed or
comprehensive examination; and Medical decision making that is
straightforward or of low complexity. Counseling and/or coordination of
care with other physicians, other qualified health care professionals,
or agencies are provided consistent with the nature of the problem(s)
and the patient's and/or family's needs. Usually, the problem(s)
requiring admission are of low severity.)
CPT code 99222 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A comprehensive history; A comprehensive examination; and
Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
problem(s) requiring admission are of moderate severity.)
CPT code 99223 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A comprehensive history; A comprehensive examination; and
Medical decision making of high complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
problem(s) requiring admission are of high severity.)
We previously considered a request to add these codes to the
telehealth list. As we stated in the CY 2011 PFS final rule with
comment period (75 FR 73315), while initial inpatient consultation
services are currently on the list of approved telehealth services,
there are no services on the current list of telehealth services that
resemble initial hospital care for an acutely ill patient by the
admitting practitioner who has ongoing responsibility for the patient's
[[Page 33974]]
treatment during the hospital course. Therefore, consistent with prior
rulemaking, we are not proposing initial hospital care services be
added to the Medicare telehealth services list on a category 1 basis.
The initial hospital care codes describe the first visit of the
hospitalized patient by the admitting practitioner who may or may not
have seen the patient in the decision-making phase regarding
hospitalization. Based on the description of the services for these
codes, we believe it is critical that the initial hospital visit by the
admitting practitioner be conducted in person to ensure that the
practitioner with ongoing treatment responsibility comprehensively
assesses the patient's condition upon admission to the hospital through
a thorough in-person examination. Additionally, the requester submitted
no additional research or evidence that the use of a telecommunications
system to furnish the service produces demonstrated clinical benefit to
the patient; therefore, we also are not proposing to add initial
hospital care services to the Medicare telehealth services list on a
category 2 basis.
We note that Medicare beneficiaries who are being treated in the
hospital setting can receive reasonable and necessary E/M services
using other HCPCS codes that are currently on the Medicare telehealth
list including those for subsequent hospital care, initial and followup
telehealth inpatient and emergency department consultations, as well as
initial and followup critical care telehealth consultations.
Therefore, we do not propose to add the initial hospital care
services to the list of Medicare telehealth services for CY 2018.
c. Online E/M by physician/QHP: CPT Code--
CPT code 99444 (Online evaluation and management service
provided by a physician or other qualified health care professional who
may report evaluation and management services provided to an
established patient or guardian, not originating from a related E/M
service provided within the previous 7 days, using the Internet or
similar electronic communications network)
As we indicated in the CY 2016 final rule with comment period (80
FR 71061), CPT code 99444 is assigned a status indicator of ``N'' (Non-
covered service). Under section 1834(m)(2)(A) of the Act, Medicare pays
the physician or practitioner furnishing a telehealth service an amount
equal to the amount that would have been paid if the service was
furnished without the use of a telecommunications system. Because CPT
code 99444 is currently non-covered, there would be no Medicare payment
if this service were furnished without the use of a telecommunications
system. Because this code is a non-covered service for which no
Medicare payment may be made under the PFS, we do not propose to add
online E/M services to the list of Medicare telehealth services for CY
2018.
d. Monthly Capitation Payment (MCP) for ESRD-Related Services for Home
Dialysis, by Age: CPT Codes--
CPT codes 90963 (End-stage renal disease (ESRD) related
services for home dialysis per full month, for patients younger than 2
years of age to include monitoring for the adequacy of nutrition,
assessment of growth and development, and counseling of parents); 90964
(End-stage renal disease (ESRD) related services for home dialysis per
full month, for patients 2- 11 years of age to include monitoring for
the adequacy of nutrition, assessment of growth and development, and
counseling of parents); 90965 (End-stage renal disease (ESRD) related
services for home dialysis per full month, for patients 12-19 years of
age to include monitoring for the adequacy of nutrition, assessment of
growth and development, and counseling of parents); and 90966 (End-
stage renal disease (ESRD) related services for home dialysis per full
month, for patients 20 years of age and older)
90967 (End-stage renal disease (ESRD) related services for
dialysis less than a full month of service, per day; for patients
younger than 2 years of age); 90968 (End-stage renal disease (ESRD)
related services for dialysis less than a full month of service, per
day; for patients 2-11 years of age); and 90969 (End-stage renal
disease (ESRD) related services for dialysis less than a full month of
service, per day; for patients 12-19 years of age); and 90970 (End-
stage renal disease (ESRD) related services for dialysis less than a
full month of service, per day; for patients 20 years of age and
older).
In the CY 2004 PFS final rule (68 FR 63216), we established G-codes
for ESRD monthly capitation payments (MCPs), which were replaced by CPT
codes in CY 2009 (73 FR 69898). The services described by CPT codes
90963 through 90966 were added to the Medicare telehealth list in CY
2005 (69 FR 66276) and CPT codes 90967 through 90970 were added to the
Medicare telehealth list in the CY 2017 PFS final rule (81 FR 80194);
however, we specified that the required clinical examination of the
vascular access site must be furnished face-to-face ``hands on''
(without the use of an interactive telecommunications system) by a
physician, clinical nurse specialist (CNS), nurse practitioner (NP), or
physician assistant (PA). The American Telemedicine Association (ATA)
submitted a new request for CY 2018 requesting that we allow telehealth
coverage of ESRD procedure codes without in-person exam of the catheter
access site monthly. Our current policy reflects our understanding that
evaluation of the integrity and functionality of the access site is a
critical element of the services described by the codes and that this
element cannot be performed via telecommunications technology. The
requester did not submit evidence to support the assertation that
effective examination of the access site can be executed via
telecommunications technology. Therefore, for CY 2018, we are not
proposing any changes to the policy requiring that the MCP practitioner
must furnish at least one face-to-face encounter with the home dialysis
patient per month for clinical examination of the catheter access site.
However, we are interested in more information about current clinically
accepted care practices and to what extent telecommunications
technology can be used to examine the access site. We are also
interested in information about the clinical standards of care
regarding the frequency of the evaluation of the access site.
In summary, we are proposing to add the following codes to the list
of Medicare telehealth services beginning in CY 2018 on a category 1
basis:
HCPCS code G0296 (Counseling visit to discuss need for
lung cancer screening using low dose CT scan (ldct) (service is for
eligibility determination and shared decision making)).
HCPCS code G0506 (Comprehensive assessment of and care
planning for patients requiring chronic care management services (list
separately in addition to primary monthly care management service)).
CPT code 90785 (Interactive complexity (List separately in
addision to the code for primary procedure)).
CPT codes 90839 and 90840 (Psychotherapy for crisis; first
60 minutes) and (Psychotherapy for crisis; each additional 30 minutes
(List separately in addition to code for primary procedure)).
CPT codes 96160 and 96161 (Administration of patient-
focused health risk assessment instrument (e.g., health hazard
appraisal) with scoring and documentation, per standardized
[[Page 33975]]
instrument) and (Administration of caregiver-focused health risk
assessment instrument (e.g., depression inventory) for the benefit of
the patient, with scoring and documentation, per standardized
instrument).
4. Elimination of the Required Use of the GT Modifier on Professional
Claims
Medicare has required distant site practitioners to report one of
two longstanding HCPCS modifiers when reporting telehealth services.
Current guidance instructs practitioners to submit claims for
telehealth services using the appropriate CPT or HCPCS code for the
professional service along with the telehealth modifier GT (via
interactive audio and video telecommunications systems). For federal
telemedicine demonstration programs in Alaska or Hawaii, practitioners
are instructed to submit claims using the appropriate CPT or HCPCS code
for the professional service along with the telehealth modifier GQ if
telehealth services are performed ``via an asynchronous
telecommunications system.'' By coding and billing these modifiers with
a service code, practitioners are certifying that both the broad and
code-specific telehealth requirements have been met.
In the CY 2017 PFS final rule (81 FR 80201), we finalized payment
policies regarding Medicare's use of a new Place of Service (POS) Code
describing services furnished via telehealth. The new POS code became
effective January 1, 2017, and we believe its use is redundant with the
requirements to apply the GT modifier for telehealth services. We did
not propose to implement a change to the modifier requirements during
CY 2017 rulemaking because at the time of the CY 2017 PFS proposed
rule, we did not know whether the telehealth POS code would be made
effective for January 1, 2017. However, we noted in the CY 2017 PFS
final rule that, like the modifiers, use of the telehealth POS code
certifies that the service meets the telehealth requirements.
Because a valid POS code is required on professional claims for all
services, and the appropriate reporting of the telehealth POS code
serves to indicate both the provision of the service via telehealth and
certification that the requirements have been met, we believe that it
is unnecessary to also require the distant site practitioner report the
GT modifier on the claim. Therefore, we are proposing to eliminate the
required use of the GT modifier on professional claims. Because
institutional claims do not use a POS code, we propose for distant site
practitioners billing under CAH Method II to continue to use the GT
modifier on institutional claims. For purposes of the federal
telemedicine demonstration programs in Alaska or Hawaii, we propose to
retain the GQ modifier to maintain the distinction between synchronous
and asynchronous telehealth services, as reflected in statute.
5. Comment Solicitation on Medicare Telehealth Services
We have received numerous requests from stakeholders to expand
access to telehealth services. As noted above, Medicare payment for
telehealth services is restricted by statute, which establishes the
services initially eligible for Medicare telehealth and limits the use
of telehealth by defining both eligible originating sites (the location
of the beneficiary) and the distant site practitioners who may furnish
and bill for telehealth services. Originating sites are limited both by
geography and provider setting. We have the authority to add to the
list of eligible services based on our annual process, but cannot
change the limitations relating to geography, patient setting, or type
of furnishing practitioner because these requirements are specified in
statute. For CY 2018, we are seeking information regarding ways that we
might further expand access to telehealth services within the current
statutory authority and pay appropriately for services that take full
advantage of communication technologies.
6. Comment Solicitation on Remote Patient Monitoring
In addition to the broad comment solicitation regarding Medicare
telehealth services, we are also specifically seeking comment on
whether to make separate payment for CPT codes that describe remote
patient monitoring. We note that remote patient monitoring services
would generally not be considered Medicare telehealth services as
defined under section 1834(m) of the Act. Rather, like the
interpretation by a physician of an actual electrocardiogram or
electroencephalogram tracing that has been transmitted electronically,
these services involve the interpretation of medical information
without a direct interaction between the practitioner and beneficiary.
As such, they are paid under the same conditions as in-person
physicians' services with no additional requirements regarding
permissible originating sites or use of the telehealth place of service
code.
We are particularly interested in comments regarding CPT code 99091
(Collection and interpretation of physiologic data (e.g., ECG, blood
pressure, glucose monitoring) digitally stored and/or transmitted by
the patient and/or caregiver to the physician or other qualified health
care professional, qualified by education, training, licensure/
regulation (when applicable) requiring a minimum of 30 minutes of
time). This code is currently assigned a procedure status of B
(bundled). As with many other bundled codes, we currently assign RVUs
for this code based on existing RUC recommendations, even though we
have considered the services described by the code to be bundled with
other services. In addition to comments on the payment status and
valuation for this code (the RUC-recommended value, specifically) we
are seeking information about the circumstances under which this code
might be reported for separate payment, including how to differentiate
the time related to these services from other services, including care
management services. For example, PFS payment for analysis of patient-
generated health data is considered included in chronic care management
(CCM) services (CPT codes 99487, 99489, and 99490) to the extent that
this activity is medically necessary and performed as part of CCM (see
the CY 2015 PFS final rule (79 FR 67727), CY 2016 PFS final rule (81 FR
80244), and the CMS FAQ available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf.). We also seek comment from
beneficiaries and beneficiary advocacy organizations on the value of
such services and what protections might be necessary to assure that
beneficiaries are properly informed that they are receiving a remote
monitoring service, since beneficiaries would be required to pay
standard cost sharing for such services. Finally, regarding CPT code
99091, we are seeking available information regarding potential
utilization assumptions we might make for the service for purposes of
PFS ratesetting, were we to make it payable for CY 2018 or in the
future; since making such asumptions would be necessary to implement
separate payment. We note that since the PFS is a budget neutral
system, any increase in payment made for particular services would
result in decreases in payment for other services, and the degree of
that decrease would depend, in large part, on the utilization
assumptions.
We are also seeking comment on other existing codes that describe
extensive use of communications technology for
[[Page 33976]]
consideration for future rulemaking, including CPT code 99090 (Analysis
of clinical data stored in computers (e.g., ECGs, blood pressures,
hematologic data)). CPT code 99090 is also assigned a procedure status
of B (bundled). However, we do not have RUC recommended values for this
service, and therefore, currently do not assign RVUs.
E. Proposed Potentially Misvalued Services Under the Physician Fee
Schedule
1. Background
Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a
periodic review, not less often than every 5 years, of the RVUs
established under the PFS. Section 1848(c)(2)(K) of the Act requires
the Secretary to periodically identify potentially misvalued services
using certain criteria and to review and make appropriate adjustments
to the relative values for those services. Section 1848(c)(2)(L) to the
Act also requires the Secretary to develop a process to validate the
RVUs of certain potentially misvalued codes under the PFS, using the
same criteria used to identify potentially misvalued codes, and to make
appropriate adjustments.
As discussed in section II.H. of this proposed rule, each year we
develop appropriate adjustments to the RVUs taking into account
recommendations provided by the American Medical Association/Specialty
Society Relative Value Scale Update Committee (RUC), the Medicare
Payment Advisory Commission (MedPAC), and others. For many years, the
RUC has provided us with recommendations on the appropriate relative
values for new, revised, and potentially misvalued PFS services. We
review these recommendations on a code-by-code basis and consider these
recommendations in conjunction with analyses of other data, such as
claims data, to inform the decision-making process as authorized by
law. We may also consider analyses of work time, work RVUs, or direct
PE inputs using other data sources, such as Department of Veteran
Affairs (VA), National Surgical Quality Improvement Program (NSQIP),
the Society for Thoracic Surgeons (STS), and the Physician Quality
Reporting System (PQRS) databases. In addition to considering the most
recently available data, we assess the results of physician surveys and
specialty recommendations submitted to us by the RUC for our review. We
also consider information provided by other stakeholders. We conduct a
review to assess the appropriate RVUs in the context of contemporary
medical practice. We note that section 1848(c)(2)(A)(ii) of the Act
authorizes the use of extrapolation and other techniques to determine
the RVUs for physicians' services for which specific data are not
available and requires us to take into account the results of
consultations with organizations representing physicians who provide
the services. In accordance with section 1848(c) of the Act, we
determine and make appropriate adjustments to the RVUs.
In its March 2006 Report to the Congress (http://www.medpac.gov/documents/reports/Mar06_EntireReport.pdf?sfvrsn=0), MedPAC discussed
the importance of appropriately valuing physicians' services, noting
that misvalued services can distort the market for physicians'
services, as well as for other health care services that physicians
order, such as hospital services. In that same report MedPAC postulated
that physicians' services under the PFS can become misvalued over time.
MedPAC stated, ``When a new service is added to the physician fee
schedule, it may be assigned a relatively high 0l value because of the
time, technical skill, and psychological stress that are often required
to furnish that service. Over time, the work required for certain
services would be expected to decline as physicians become more
familiar with the service and more efficient in furnishing it.'' We
believe services can also become overvalued when PE declines. This can
happen when the costs of equipment and supplies fall, or when equipment
is used more frequently than is estimated in the PE methodology,
reducing its cost per use. Likewise, services can become undervalued
when physician work increases or PE rises.
As MedPAC noted in its March 2009 Report to Congress (http://www.medpac.gov/documents/reports/march-2009-report-to-congress-medicare-payment-policy.pdf?sfvrsn=0), in the intervening years since
MedPAC made the initial recommendations, CMS and the RUC have taken
several steps to improve the review process. Also, section
1848(c)(2)(K)(ii) of the Act augments our efforts by directing the
Secretary to specifically examine, as determined appropriate,
potentially misvalued services in the following categories:
Codes that have experienced the fastest growth.
Codes that have experienced substantial changes in
practice expenses.
Codes that describe new technologies or services within an
appropriate time period (such as 3 years) after the relative values are
initially established for such codes.
Codes which are multiple codes that are frequently billed
in conjunction with furnishing a single service.
Codes with low relative values, particularly those that
are often billed multiple times for a single treatment.
Codes that have not been subject to review since
implementation of the fee schedule.
Codes that account for the majority of spending under the
physician fee schedule.
Codes for services that have experienced a substantial
change in the hospital length of stay or procedure time.
Codes for which there may be a change in the typical site
of service since the code was last valued.
Codes for which there is a significant difference in
payment for the same service between different sites of service.
Codes for which there may be anomalies in relative values
within a family of codes.
Codes for services where there may be efficiencies when a
service is furnished at the same time as other services.
Codes with high intra-service work per unit of time.
Codes with high practice expense relative value units.
Codes with high cost supplies.
Codes as determined appropriate by the Secretary.
Section 1848(c)(2)(K)(iii) of the Act also specifies that the
Secretary may use existing processes to receive recommendations on the
review and appropriate adjustment of potentially misvalued services. In
addition, the Secretary may conduct surveys, other data collection
activities, studies, or other analyses, as the Secretary determines to
be appropriate, to facilitate the review and appropriate adjustment of
potentially misvalued services. This section also authorizes the use of
analytic contractors to identify and analyze potentially misvalued
codes, conduct surveys or collect data, and make recommendations on the
review and appropriate adjustment of potentially misvalued services.
Additionally, this section provides that the Secretary may coordinate
the review and adjustment of any RVU with the periodic review described
in section 1848(c)(2)(B) of the Act. Section 1848(c)(2)(K)(iii)(V) of
the Act specifies that the Secretary may make appropriate coding
revisions
[[Page 33977]]
(including using existing processes for consideration of coding
changes) that may include consolidation of individual services into
bundled codes for payment under the physician fee schedule.
2. Progress in Identifying and Reviewing Potentially Misvalued Codes
To fulfill our statutory mandate, we have identified and reviewed
numerous potentially misvalued codes as specified in section
1848(c)(2)(K)(ii) of the Act, and we plan to continue our work
examining potentially misvalued codes in these areas over the upcoming
years. As part of our current process, we identify potentially
misvalued codes for review, and request recommendations from the RUC
and other public commenters on revised work RVUs and direct PE inputs
for those codes. The RUC, through its own processes, also identifies
potentially misvalued codes for review. Through our public nomination
process for potentially misvalued codes established in the CY 2012 PFS
final rule with comment period, other individuals and stakeholder
groups submit nominations for review of potentially misvalued codes as
well.
Since CY 2009, as a part of the annual potentially misvalued code
review and Five-Year Review process, we have reviewed approximately
1,700 potentially misvalued codes to refine work RVUs and direct PE
inputs. We have assigned appropriate work RVUs and direct PE inputs for
these services as a result of these reviews. A more detailed discussion
of the extensive prior reviews of potentially misvalued codes is
included in the CY 2012 PFS final rule with comment period (76 FR 73052
through 73055). In the CY 2012 PFS final rule with comment period (76
FR 73055 through 73958), we finalized our policy to consolidate the
review of physician work and PE at the same time, and established a
process for the annual public nomination of potentially misvalued
services.
In the CY 2013 PFS final rule with comment period, we built upon
the work we began in CY 2009 to review potentially misvalued codes that
have not been reviewed since the implementation of the PFS (so-called
``Harvard-valued codes''). In CY 2009 (73 FR 38589), we requested
recommendations from the RUC to aid in our review of Harvard-valued
codes that had not yet been reviewed, focusing first on high-volume,
low intensity codes. In the fourth Five-Year Review (76 FR 32410), we
requested recommendations from the RUC to aid in our review of Harvard-
valued codes with annual utilization of greater than 30,000. In the CY
2013 PFS final rule with comment period, we identified specific
Harvard-valued services with annual allowed charges that total at least
$10,000,000 as potentially misvalued. In addition to the Harvard-valued
codes, in the CY 2013 PFS final rule with comment period we finalized
for review a list of potentially misvalued codes that have stand-alone
PE (codes with physician work and no listed work time and codes with no
physician work that have listed work time).
In the CY 2016 PFS final rule with comment period, we finalized for
review a list of potentially misvalued services, which included eight
codes in the neurostimulators analysis-programming family (CPT 95970-
95982). We also finalized as potentially misvalued 103 codes identified
through our screen of high expenditure services across specialties.
In the CY 2017 PFS final rule, we finalized for review a list of
potentially misvalued services, which included eight codes in the end-
stage renal disease home dialysis family (CPT codes 90963-90970). We
also finalized as potentially misvalued 19 codes identified through our
screen for 0-day global services that are typically billed with an
evaluation and management (E/M) service with modifier 25.
3. CY 2018 Identification and Review of Potentially Misvalued Services
In the CY 2012 PFS final rule with comment period (76 FR 73058), we
finalized a process for the public to nominate potentially misvalued
codes. The public and stakeholders may nominate potentially misvalued
codes for review by submitting the code with supporting documentation
by February 10 of each year. Supporting documentation for codes
nominated for the annual review of potentially misvalued codes may
include the following:
Documentation in peer reviewed medical literature or other
reliable data that there have been changes in physician work due to one
or more of the following: technique, knowledge and technology, patient
population, site-of-service, length of hospital stay, and work time.
An anomalous relationship between the code being proposed
for review and other codes.
Evidence that technology has changed physician work.
Analysis of other data on time and effort measures, such
as operating room logs or national and other representative databases.
Evidence that incorrect assumptions were made in the
previous valuation of the service, such as a misleading vignette,
survey, or flawed crosswalk assumptions in a previous evaluation.
Prices for certain high cost supplies or other direct PE
inputs that are used to determine PE RVUs are inaccurate and do not
reflect current information.
Analyses of work time, work RVU, or direct PE inputs using
other data sources (for example: Department of Veteran Affairs (VA)
National Surgical Quality Improvement Program (NSQIP), the Society for
Thoracic Surgeons (STS) National Database, and the Physician Quality
Reporting System (PQRS) databases).
National surveys of work time and intensity from
professional and management societies and organizations, such as
hospital associations.
We evaluate the supporting documentation submitted with the
nominated codes and assess whether the nominated codes appear to be
potentially misvalued codes appropriate for review under the annual
process. In the following year's PFS proposed rule, we publish the list
of nominated codes and indicate whether we are proposing each nominated
code as a potentially misvalued code. The public has the opportunity to
comment on these and all other proposed potentially misvalued codes. In
that year's final rule, we finalize our list of potentially misvalued
codes.
After we issued the CY 2017 PFS final rule, we received a
nomination and supporting documentation for one code to be considered
as potentially misvalued. We evaluated the supporting documentation for
this nominated code to ascertain whether the submitted information
demonstrated that the code should be proposed as potentially misvalued.
CPT code 27279 (Arthrodesis, sacroiliac joint, percutaneous or
minimally invasive (indirect visualization), with image guidance,
includes obtaining bone graft when performed, and placement of
transfixing device) was nominated for review as a potentially misvalued
code because the current work RVU is potentially undervalued and
stakeholders recommend that it should be increased to 14.23. We are
proposing this code as a potentially misvalued code. In the CY 2017 PFS
final rule, we noted that some assertions regarding appropriate values
for the dialysis vascular access codes newly created in CY 2017 (CPT
codes 36901 through 36909) did not include data that would warrant
increases to the work RVUs. However, we urged interested stakeholders
to consider
[[Page 33978]]
submitting robust data regarding costs for these and other services (81
FR 80294). We have continued to receive feedback from stakeholders
regarding the work valuation of these codes. Stakeholders have
expressed concerns regarding the typical patient for these procedures
as reflected in the information included in the RUC recommendations for
CY 2017 and the importance of appropriate payment for ensuring access
to care for Medicare beneficiaries. Therefore, we are seeking
additional comment and continuing to request robust data regarding the
potentially misvalued work RVUs for CPT codes 36901 through 36909 and
considering alternate work valuations for CY 2018, such as the RUC-
recommended work RVUs from CY 2017, or other potential values based on
submission of data through the public comment process. We note that the
RUC recommended work RVUs for these services are displayed in the CY
2017 PFS final rule (81 FR 80290 through 80296). We have received
conflicting information about the direct PE inputs for CPT codes 88184
(Flow cytometry, cell surface, cytoplasmic, or nuclear marker,
technical component only; first marker) and 88185 (Flow cytometry, cell
surface, cytoplasmic, or nuclear marker, technical component only; each
additional marker (List separately in addition to code for first
marker)), and we are proposing these codes as potentially misvalued so
that they can be reviewed again because some stakeholders have
suggested the clinical labor and supplies that were previously
finalized are no longer accurate.
We have received information suggesting that the work RVUs for
emergency department visits may not appropriately reflect the full
resources involved in furnishing these services. Specifically,
stakeholders have expressed concerns that the work RVUs for these
services have been undervalued given the increased acuity of the
patient population and the heterogeneity of the sites, such as
freestanding and off-campus emergency departments, where emergency
department visits are furnished. We are, therefore, seeking comment on
whether CPT codes 99281-99385 (Emergency department visits for the
evaluation and management of a patient) should be reviewed under the
misvalued code initiative.
For over a decade, CMS has collaborated with the RUC to regularly
prioritize codes for review by using the categories specified in the
statute or as determined appropriate. We generally have referred to
these categories as ``misvalued code screens.'' To supplement ongoing
RUC identification of potentially misvalued codes through established
screens, CMS regularly uses PFS rulemaking to identify other screens
for use in identifying potentially misvalued codes. For example, in
recent years, CMS has prioritized the following screens:
Codes with low work RVUs commonly billed in multiple units
per single encounter.
Codes with high volume and low work RVUs.
Codes with site-of-service-anomalies.
E/M codes.
PFS high expenditure services.
Services with standalone PE procedure time.
Services with anomalous time.
Contractor Medical Director identified potentially
misvalued codes.
Codes with higher total Medicare payments in office than
in hospital or ASC.
Publicly nominated potentially misvalued codes.
0-day global services that are typically billed with an
evaluation and management (E/M) service with modifier 25.
Although we are not proposing a new screen for CY 2018, we continue
to believe that it is important to prioritize codes for review under
the misvalued code initiative. As a result, we are seeking public
comment on the best approach for developing screens, as well as what
particular new screens we might consider. We will consider these
comments for future rulemaking.
F. Payment Incentive for the Transition From Traditional X-Ray Imaging
to Digital Radiography and Other Imaging Services
Section 502(a)(1) of Division O, Title V of the Consolidated
Appropriations Act of 2016 (Pub. L. 114-113) amended section 1848(b) of
the Act by establishing a new paragraph (9) of subsection (b). Section
1848(b)(9)(B) of the Act provides for a 7 percent reduction in payments
for the technical component (TC) for imaging services made under the
PFS that are X-rays (including the technical component portion of a
global service) taken using computed radiography technology furnished
during CYs 2018, 2019, 2020, 2021, or 2022, and for a 10 percent
reduction for the technical component of such imaging services
furnished during CY 2023 or a subsequent year. Computed radiography
technology is defined for purposes of this paragraph as cassette-based
imaging that utilizes an imaging plate to create the image involved.
Section 1848(b)(9) of the Act also requires implementation of the
reduction in payments through appropriate mechanisms, which can include
the use of modifiers. In accordance with section 1848(c)(2)(B)(v)(X) of
the Act, the adjustments under section 1848(b)(9)(A) of the Act are
exempt from the budget neutrality requirement.
We stated in the CY 2017 PFS proposed rule that because the
required reductions in PFS payment for the TC of imaging services
(including the TC portion of a global service) that are X-rays taken
using computed radiography technology did not apply for CY 2017, we
would address implementation of section 1848(b)(9)(B) of the Act in
future rulemaking. Therefore, to implement the provisions of section
1848(b)(9)(B) of the Act relating to the payment reduction for the TC
(including the TC portion of a global service) of X-rays taken using
computed radiography technology during CY 2018 or subsequent years, we
are proposing to establish a new modifier to be used on claims for
these services.
We are proposing that beginning January 1, 2018, this modifier
would be required to be used when reporting imaging services for which
payment is made under the PFS that are X-rays (including the X-ray
component of a packaged service) taken using computed radiography
technology. The modifier would be required on claims for the technical
component of the X-ray service, including when the service is billed
globally because the PFS payment adjustment is made to the technical
component regardless of whether it is billed globally, or billed
separately using the TC modifier. The modifier must be used to report
the specific services that are subject to the payment reduction and
accurate use is subject to audit. The use of this proposed modifier to
indicate an X-ray taken using computed radiography would result in a 7
percent reduction for CYs 2018 through 2022 and a 10 percent reduction
for CY 2023 or a subsequent calendar year to the payments for the TC
for such imaging services furnished as specified under section
1848(b)(9)(B) of the Act.
G. Proposed Payment Rates Under the Medicare Physician Fee Schedule for
Nonexcepted Items and Services Furnished by Nonexcepted Off-Campus
Provider-Based Departments of a Hospital
1. Background
Sections 1833(t)(1)(B)(v) and (t)(21) of the Act require that
certain items and services furnished by certain off-campus
[[Page 33979]]
provider-based departments (PBDs) (collectively referenced here as
nonexcepted items and services furnished by nonexcepted off-campus
PBDs) shall not be considered covered OPD services for purposes of
payment under the OPPS, and payment for those nonexcepted items and
services furnished on or after January 1, 2017 shall be made under the
applicable payment system. In the CY 2017 OPPS/ASC final rule with
comment period (81 FR 79713), we finalized the PFS as the ``applicable
payment system'' for most nonexcepted items and services furnished by
off-campus PBDs.
As part of that discussion, we indicated that, in response to
public comments received on the proposed payment policies for
nonexcepted items and services, we would issue an interim final rule
with comment period (the CY 2017 interim final rule, 81 FR 79720
through 79729) to establish payment policies under the PFS for
nonexcepted items and services furnished on or after January 1, 2017.
In the following paragraphs, we propose the payment policies under the
PFS for nonexcepted items and services furnished during CY 2018. The CY
2017 interim final rule can be found on the Internet at https://www.thefederalregister.org/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf. We anticipate
responding to public comments and finalizing the CY 2017 interim final
rule in future PFS rulemaking.
2. Payment Mechanism
Coding and payment policies under the PFS have long recognized the
differences between the portions of services for which direct costs
generally are incurred by practitioners and the portions of services
for which direct costs generally are incurred by facilities. At
present, the coding and RVUs established for particular groups of
services under the PFS generally reflect such direct cost differences.
As described in section II.B of this proposed rule, we establish
separate nonfacility and facility RVUs for many HCPCS codes describing
particular services paid under the PFS. For many other services, we
establish separate RVUs for the professional component and the
technical component of the service described by the same HCPCS code.
For other services, we establish RVUs for the different HCPCS codes
that segregate and describe the discrete professional and technical
aspects of particular services.
Because hospitals with nonexcepted off-campus PBDs that furnish
nonexcepted items and services are likely to furnish a broader range of
services than other provider or supplier types for which there is a
separately valued technical component under the PFS, for CY 2017, we
established a new set of payment rates under the PFS that reflected the
relative resource costs of furnishing the technical component of a
broad range of services to be paid under the PFS specific to the off-
campus PBD of a hospital with packaging (bundling) rules that are
unique to the hospital outpatient setting under the OPPS.
In principle, the coding and billing mechanisms required to make
appropriate payment to hospitals for nonexcepted items and services
furnished by nonexcepted off-campus PBDs are parallel to those used to
make payment for the technical component services for a range of
supplier types paid under the PFS. That is, payments to hospitals are
made for the technical aspect of services, while physicians and other
practitioners report the professional aspect of these same services. In
some cases, the entities reporting the technical aspect of services use
the same coding that is used by the individuals reporting the
professional services. In other cases, different coding applies. We are
proposing to maintain this mechanism for CY 2018.
3. Establishment of Payment Rates
Using the relativity among OPPS payments to establish rates for the
nonexcepted items and services furnished by nonexcepted off-campus PBDs
and billed by hospitals under the PFS was only one aspect of
establishing the necessary relativity of these services under the PFS
more broadly. It was necessary to estimate the relativity of these
services compared to PFS services furnished in other settings. For CY
2017, we used our best estimate of the more general relativity between
the technical component of PFS services furnished in nonexcepted off-
campus PBDs and all other PFS services furnished in other settings
using the limited information available to us at that time. As
described in the CY 2017 interim final rule (81 FR 79722 through
79726), we estimated that for CY 2017, scaling the OPPS payment rates
by 50 percent would strike an appropriate balance that avoided
potentially underestimating the relative resources involved in
furnishing services in nonexcepted off-campus PBDs as compared to the
services furnished in other settings for which payment was made under
the PFS. Specifically, we established site-specific rates under the PFS
for the technical component of the broad range of nonexcepted items and
services furnished by nonexcepted off-campus PBDs to be paid under the
PFS that was based on the OPPS payment amount for the same items and
services, scaled downward by 50 percent. We called this adjustment the
``PFS Relativity Adjuster.'' The PFS Relativity Adjuster refers to the
percentage of the OPPS payment amount paid under the PFS for a
nonexcepted item or service to the non-excepted off-campus PBD under
this policy.
a. Methodology for Establishing CY 2017 PFS Relativity Adjuster
In developing the CY 2017 interim final rule, we began by analyzing
hospital outpatient claims data from January 1 through August 26, 2016,
that contained the ``PO'' modifier signifying that they were billed by
an off-campus department of a hospital paid under the OPPS other than a
remote location, a satellite facility, or a dedicated emergency
department (ED). We noted that the use of the ``PO'' modifier was a new
mandatory reporting requirement for CY 2016. We limited our analysis to
those claims billed on the 13X Type of Bill because those claims were
used for Medicare Part B billing under the OPPS. We then identified the
top (most frequently billed) 25 major codes that were billed by claim
line; that is, items and services that were separately payable or
conditionally packaged. Specifically, we restricted our analysis to
codes with OPPS status indicators ``J1'', ``J2'', ``Q1'', ``Q2'',
``Q3'', ``S'', ``T'', or ``V''. We did not include separately payable
drugs or biologicals in this analysis because those drugs or
biologicals were not paid under the PFS under the CY 2017 interim final
rule. As such, under the CY 2017 interim final rule, the PFS Relativity
Adjuster did not apply to separately payable drugs and biologicals
furnished by a nonexcepted PBD. Similarly, we excluded codes assigned
an OPPS status indicator ``A'' because the services described by those
codes were already paid at a rate under a fee schedule other than the
OPPS and payment for those nonexcepted items and services was not
changed by the rates established under the CY 2017 interim final rule.
Next, for the same major codes (or analogous codes in the rare instance
that different coding applies under the OPPS than the PFS), we compared
the CY 2016 payment rate under the OPPS to a CY 2016 payment rate under
the PFS attributable to the nonprofessional relative resource costs
involved in furnishing the services.
The most frequently billed service with the ``PO'' modifier was
described by HCPCS code G0463 (Hospital outpatient clinic visit for
assessment and management of a patient), which is paid under APC 5012;
the total number
[[Page 33980]]
of CY 2016 claim lines for that service was approximately 6.7 million
as of August 2016. In CY 2016, the OPPS payment rate for APC 5012 was
$102.12. Because there were multiple CPT codes (CPT codes 99201 through
99215) used under the PFS for billing that service, an exact comparison
between the $102.12 OPPS payment rate for APC 5012 and the payment rate
for a single CPT code billed under the PFS was not possible. However,
for purposes of the analysis, we examined the difference between the
nonfacility payment rates and the facility payment rates under the PFS
for CPT codes 99213 and 99214, which were the billing codes for a Level
III and a Level IV office visit. While we did not have data to
precisely determine the equivalent set of PFS visit codes to use for
the comparison, we believed that, based on the distribution of services
billed for the visit codes under the PFS and the distribution of the
visit codes under the OPPS from the last time period the CPT codes were
used under the OPPS in CY 2014, those two codes provided reliable
points of comparison. For CPT code 99213, the difference between the
nonfacility payment rate and the facility payment rate under the PFS in
CY 2016 was $21.86, which was 21 percent of the OPPS payment rate for
APC 5012 of $102.12. For CPT code 99214, the difference between the
nonfacility payment rate and the facility payment rate under the PFS in
CY 2016 was $29.02, which was 28 percent of the OPPS payment rate for
APC 5012. However, we recognized that, due to the more extensive
packaging that occurred under the OPPS for services provided along with
clinic visits relative to the more limited packaging that occurred
under the PFS for office visits, those payment rates were not entirely
comparable.
We then assessed the next 24 major codes most frequently billed on
the 13X claim form by hospitals. We removed HCPCS code 36591
(Collection of blood specimen from a completely implantable venous
access device) because, under current PFS policies, the code is used
only to pay separately under the PFS when no other service was on the
claim. We also removed HCPCS code G0009 (Administration of Pneumococcal
Vaccine) because there was no payment for the code under the PFS. For
the remaining 22 major codes most frequently billed, we estimated the
amount that would have been paid to the physician in the office setting
under the PFS for practice expenses not associated with the
professional component of the service. As indicated in Table 9, this
amount reflected (1) the difference between the PFS nonfacility payment
rate and the PFS facility rate, (2) the technical component, or (3) in
instances where payment would have been made only to the facility or
only to the physician, the full nonfacility rate. This estimate ranged
from zero percent to 137.8 percent of the OPPS payment rate for a code.
Overall, the average (weighted by claim line volume times rate) of the
nonfacility payment rate estimate for the PFS compared to the estimate
for the OPPS for the 22 remaining major codes was 45 percent.
Table 9--Comparison of CY 2016 OPPS Payment Rate to CY 2016 PFS Payment Rate for Top Hospital Codes Billed Using
the ``PO'' Modifier
----------------------------------------------------------------------------------------------------------------
CY 2016
applicable PFS Col (5) as a
HCPCS code Code description Total claim CY 2016 OPPS technical percent of PFS estimate
lines payment rate payment amount OPPS
estimate
(1) (2)............. (3) (4) (5) (6)
----------------------------------------------------------------------------------------------------------------
96372....... Injection 338,444 $42.31 $25.42 60.1 Single rate paid
beneath the exclusively to
skin or into either
muscle for practitioner or
therapy, facility: Full
diagnosis, or nonfacility
prevention. rate.
71020....... X-ray of chest, 333,203 60.80 16.83 27.7 Technical
2 views, front component: Full
and side. nonfacility
rate.
93005....... Routine 318,099 55.94 8.59 15.4 Technical
electrocardiogr component: Full
am (EKG) with nonfacility
tracing using rate.
at least 12
leads.
96413....... Infusion of 254,704 280.27 136.41 48.7 Single rate paid
chemotherapy exclusively to
into a vein up either
to 1 hour. practitioner or
facility: Full
nonfacility
rate.
93798....... Physician 203,926 103.92 11.10 10.7 Nonfacility
services for rate--Facility
outpatient rate.
heart
rehabilitation
with continuous
EKG monitoring
per session.
96375....... Injection of 189,140 42.31 22.56 53.3 Single rate paid
different drug exclusively to
or substance either
into a vein for practitioner or
therapy, facility: Full
diagnosis, or nonfacility
prevention. rate.
93306....... Ultrasound 179,840 416.80 165.77 39.8 Technical
examination of component: Full
heart including nonfacility
color-depicted rate.
blood flow
rate,
direction, and
valve function.
77080....... Bone density 155,513 100.69 31.15 30.9 Technical
measurement component: Full
using dedicated nonfacility
X-ray machine. rate.
77412....... Radiation 137,241 194.35 267.86 137.8 Technical
treatment component (Full
delivery. nonfacility
rate) based on
weighted
averages for
the following
PFS codes:
G6011; G6012;
G6013; and
G6014.
[[Page 33981]]
90853....... Group 123,282 69.65 0.36 0.5 Nonfacility
psychotherapy. rate--Facility
rate.
96365....... Infusion into a 122,641 173.18 69.82 40.3 Nonfacility
vein for rate--Facility
therapy, rate.
prevention, or
diagnosis up to
1 hour.
20610....... Aspiration and/ 106,769 223.76 13.96 6.2 Nonfacility
or injection of rate--Facility
large joint or rate.
joint capsule.
11042....... Removal of skin 99,134 225.55 54.78 24.3 Nonfacility
and tissue rate--Facility
first 20 sq cm rate.
or less.
96367....... Infusion into a 98,930 42.31 30.79 72.8 Single rate paid
vein for exclusively to
therapy either
prevention or practitioner or
diagnosis facility: Full
additional nonfacility
sequential rate.
infusion up to
1 hour.
93017....... Exercise or drug- 96,312 220.35 39.74 18.0 Technical
induced heart component: Full
and blood nonfacility
vessel stress rate.
test with EKG
tracing and
monitoring.
77386....... Radiation 81,925 505.51 347.30 68.7 Technical
therapy component:
delivery. Nonfacility
rate for CPT
code G6015
(analogous code
used under the
PFS).
78452....... Nuclear medicine 79,242 1,108.46 412.82 37.2 Technical
study of component: Full
vessels of nonfacility
heart using rate.
drugs or
exercise
multiple
studies.
74177....... CT scan of 76,393 347.72 220.20 63.3 Technical
abdomen and component: Full
pelvis with nonfacility
contrast. rate.
71260....... CT scan chest 75,052 236.86 167.21 70.6 Technical
with contrast. component: Full
nonfacility
rate.
71250....... CT scan chest... 74,570 112.49 129.61 115.2 Technical
component: Full
nonfacility
rate.
73030....... X-ray of 71,330 60.80 19.33 31.8 Technical
shoulder, component: Full
minimum of 2 nonfacility
views. rate.
90834....... Psychotherapy, 70,524 125.04 0.36 0.3 Nonfacility
45 minutes with rate--Facility
patient and/or rate.
family member.
----------------------------------------------------------------------------------------------------------------
Weighted Average (claim line volume*rate) of the PFS payment compared to OPPS payment for the 45%
22 major codes:
----------------------------------------------------------------------------------------------------------------
As noted with the clinic visits, we recognized that there were
limitations to our data analysis, including that OPPS payment rates
include the costs of packaged items or services billed with the
separately payable code, and therefore the comparison to rates under
the PFS was not a one-to-one comparison. Also, we included only a
limited number of services, and noted that additional services may have
different patterns than the services described. After considering the
payment differentials for major codes billed by off-campus departments
of hospitals with the ``PO'' modifier and based on the data limitations
of our analysis, we adopted, with some exceptions noted below, a set of
PFS payment rates that were based on a 50-percent PFS Relativity
Adjuster to the OPPS payment rates (inclusive of packaging) for
nonexcepted items and services furnished by nonexcepted off-campus PBDs
in the CY 2017 interim final rule. Generally speaking, we arrived at
the 50 percent PFS Relativity Adjuster by examining the 45-percent
comparison noted above, the ASC payment rate--which was roughly 55
percent of the OPPS payment rate on average--and the payment rate
differential for the large number of OPPS and PFS evaluation and
management services, as described above. We recognized that the
equivalent PFS nonfacility rates may be higher or lower on a code-
specific basis than the rates that result from applying the overall PFS
Relativity Adjuster to the OPPS payment rates on a code specific basis.
However, we believed that, on the whole, the percentage reduction did
not underestimate the overall relativity between the OPPS and the PFS
based on the limited data that was available. We were concerned,
however, that the 50 percent PFS Relativity Adjuster might overestimate
PFS nonfacility payments relative to OPPS payments. For example, if we
were able at the time to sufficiently estimate the effect of the
packaging differences between the OPPS and PFS, we suspected that the
equivalent portion of PFS payments for evaluation and management codes,
and for PFS services on average, would likely have been less than 50
percent for the same services. We considered the 50 percent PFS
Relativity Adjuster for CY 2017 to be a transitional policy until such
time that we had more precise data to better
[[Page 33982]]
identify and value nonexcepted items and services furnished by
nonexcepted off-campus PBDs and billed by hospitals.
We established several significant exceptions to the application of
the 50 percent PFS Relativity Adjuster. For example, we did not apply
the 50 percent PFS Relativity Adjuster to services that are currently
paid under the OPPS based on payment rates from other Medicare fee
schedules (including the PFS) on an institutional claim. The items and
services that are assigned status indicator ``A'' in Addendum B to the
CY 2017 OPPS/ASC final rule with comment period (available on the CMS
Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html) continue to be reported on an
institutional claim and paid under the PFS, the CLFS, or the Ambulance
Fee Schedule (ASC) without a payment reduction. Similarly, drugs and
biologicals that are separately payable under the OPPS (identified by
status indicator ``G'' or ``K'' in Addendum B to the CY 2017 OPPS/ASC
final rule with comment period) are paid in accordance with section
1847A of the Act (that is, typically ASP + 6 percent), consistent with
payment rules in the physician office setting. Drugs and biologicals
that are unconditionally packaged under the OPPS and are not separately
payable (that is, those drugs and biologicals assigned status indicator
of ``N'' in Addendum B to the CY 2017 OPPS/ASC final rule with comment
period) are bundled into the PFS payment and are not separately paid to
hospitals billing for nonexcepted items and services furnished by
nonexcepted off-campus PBDs. The full range of exceptions and
adjustments to the otherwise applicable OPPS payment rate that were
adopted in the new PFS site-of-service payment rates in the CY 2017
interim final rule can be found on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-Status-Indicator.zip.
All nonexcepted items and services furnished by nonexcepted off-
campus PBDs and billed by a hospital on an institutional claim with
modifier ``PN'' (Nonexcepted service provided at an off-campus,
outpatient, provider-based department of a hospital) are currently paid
under the PFS at the rate established in the CY 2017 interim final
rule. Specifically, nonexcepted off campus PBDs must report modifier
``PN'' on each UB-04 claim line to indicate a nonexcepted item or
service, and otherwise continue to bill as they currently do. Further
billing instructions on the PN modifier can be found in the January
2017 OPPS Quarterly Update (transmittal 3685, Change Request 9930)
released December 22, 2016, available on the CMS Web site at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3685CP.pdf.
b. PFS Relativity Adjuster
As noted in the CY 2017 interim final rule, we considered the CY
2017 50 percent PFS Relativity Adjuster to be a transitional policy
until such time that we had more precise data to better identify and
value nonexcepted items and services furnished by nonexcepted off-
campus PBDs and billed by hospitals. At present, we do not have more
precise data than were available when we established the PFS Relativity
Adjuster in the CY 2017 interim final rule, and we do not anticipate
having such data until after the end of CY 2017, at the earliest.
However, in developing a proposed policy for CY 2018, we have continued
to explore options for modifying the calculation of the CY 2018 PFS
Relativity Adjuster.
There is no consensus among stakeholders regarding the appropriate
PFS Relativity Adjuster. Many stakeholders have suggested that making
separate facility fee payments to hospitals under the PFS for all
services that are separately paid under the OPPS itself undermines
site-neutral payment because practitioners are only paid a single
combined fee for many services when furnished in an office setting,
while there are two separate fees (professional and facility) paid when
the service is furnished in the hospital setting. We acknowledge that
there are many cases where single fees are paid to practitioners for
services furnished in an office setting while fees for comparable
services when furnished in the hospital setting are paid to both the
professional and facility entities. However, we do not agree that this
necessarily means that overall payment cannot be site neutral. We point
out that the sum of the professional and the facility portions of
payment for a service furnished in a nonexcepted off-campus PBD or in a
different institutional setting could be equivalent to a single fee
paid to the professional in the office setting. In the case of some
services, in fact, the single payment made under the PFS at the
nonfacility rate exceeds the sum of the separate payments Medicare
makes to the professional at the facility rate under the PFS and to the
facility under the OPPS. We also note that there are many separately
reportable services under the PFS (for example, the vast majority of
services described by add-on codes) for which separate payment is made
to physician offices but no separate payment is made under either the
OPPS or under the site-specific PFS payments made to hospitals billing
for nonexcepted items and services furnished by nonexcepted off-campus
PBDs. For these reasons, we believe that the overall total payment made
for services is more relevant to the goal of site neutrality than the
quantity of individual payments made. Nonetheless, we continue to
recognize and share stakeholders' concerns regarding the importance of
equivalent overall payment for services, regardless of setting.
In considering the appropriate PFS Relativity Adjuster for CY 2018,
we continue to believe that claims data from CY 2017, which are not yet
available, are needed to guide potential changes to our general
approach. In the absence of such data, however, we have continued to
consider the appropriate PFS Relativity Adjuster based on the
information that is available. In the analysis we used to establish the
PFS Relativity Adjuster for CY 2017, we attempted to identify the
appropriate value by comparing OPPS and PFS payment rates for services
frequently reported in PBDs and described by the same codes under the
two payment systems. As we acknowledged in the CY 2017 interim final
rule, that data analysis did not include the most frequently billed
service furnished in nonexcepted off-campus hospital PBDs, outpatient
visits. Outpatient visits are reported using a single code under the
OPPS and by one of ten different codes under the PFS.
Consistent with our previously stated concern that the PFS
Relativity Adjuster for CY 2017 might be too small, generally resulting
in greater overall payments to hospitals for services furnished by
nonexcepted off-campus PBDs than would otherwise be paid under the PFS
in the non-facility setting, we believe it is appropriate to propose
changing the PFS Relativity Adjuster in order to ensure that payment
made to these nonexcepted PBDs better aligns with these services that
are the most frequently furnished in this setting.
For CY 2018, we propose to revise the PFS Relativity Adjuster for
nonexcepted items and services furnished by nonexcepted off-campus PBDs
to be 25 percent of the OPPS payment rate. We arrived at this proposed
PFS Relativity Adjuster by making a code-level comparison for the
service most
[[Page 33983]]
commonly billed in the off-campus PBD setting under the OPPS: A clinic
visit reported using HCPCS code G0463. In order to determine the
analogous payment for the technical aspects of this service under the
PFS in nonfacility settings, we compared the CY 2017 OPPS national
payment rate for HCPCS code G0463 ($102.12) to the difference between
the nonfacility and facility PFS payment amounts under the PFS using CY
2017 rates for the weighted average of outpatient visits (CPT codes
99201-99205 and CPT codes 99211-99215) billed by physicians and other
professionals in an outpatient hospital place of service.
This proposed 25 percent PFS Relativity Adjuster is based solely on
the comparison for the visit services that reflect greater than 50
percent of services billed in off-campus PBDs. We continue to recognize
that the comparison between the OPPS and PFS rates for other services
varies greatly, and that there are other factors, including the
specific mix of services furnished by non-excepted PBDs, policies
related to packaging of codes under OPPS, and payment adjustments like
MPPRs and bundling under the PFS that rely on empirical information
about whether or not codes are billed on the same day, that contribute
to the differences in aggregate payment amounts for a broader range of
services. However, for CY 2018, as for CY 2017, we must set the PFS
Relativity Adjuster prior to studying the CY 2017 claims data that
might allow us to consider and incorporate many more factors, including
the ones stated above. When we established the 50 percent PFS
Relativity Adjuster for CY 2017, we stated that we did so with the goal
of ensuring adequate payment but remained concerned that the resulting
reduction was too small. For CY 2018, we are focused on ensuring that
we do not overestimate the appropriate overall payments for these
services. Until we are able to study claims data, we believe that the
comparison between PFS and OPPS payment for the most common services
furnished in off-campus PBDs, outpatient visits, is a better proxy than
our previous approach.
We welcome stakeholder input with regard to this analysis and the
resulting rate. We also request comment on whether we should adopt a
different PFS Relativity Adjuster, such as 40 percent, that represents
a relative middle ground between the CY 2017 PFS Relativity Adjuster,
selected to ensure adequate payment to hospitals and our proposed CY
2018 PFS Relativity Adjuster, selected to ensure that hospitals are not
paid more than others would be paid through the PFS nonfacility rate.
We intend to continue to study this issue and welcome comments
regarding potential future refinements to payment rates for non-
excepted items and services furnished by non-excepted off-campus PBDs
as we gain more experience with these new site-of-service PFS rates.
Finally, we note that for CY 2018, as in recent years, the proposed
annual update to OPPS payments exceeds the proposed annual update to
PFS payments. Because we are proposing to make a single, across-the-
board and, by necessity, imprecise adjustment to OPPS payment rates to
establish PFS payment rates for nonexcepted items and services
furnished by nonexcepted off-campus PBDs, we expect that the actual
difference between OPPS and PFS payment rates for nonexcepted items and
services furnished by nonexcepted off-campus PBDs falls in a range
which includes our proposed PFS Relativity Adjuster (that is, the
actual differential may differ from our proposed PFS Relativity
Adjuster). As such, taking into account the differential between the
OPPS and PFS annual updates by making an adjustment to the PFS
Relativity Adjuster our proposal for CY 2018 would presume a level of
precision in our estimates that is simply not present in our analysis.
Therefore, we will not adjust our proposal to reflect the relative
updates to PFS and OPPS between CY 2017 and CY 2018, and instead note
that the differential between the OPPS and PFS payment update for CY
2018 is a factor that suggests that the proposed PFS Relativity
Adjuster may overestimate PFS nonfacility payment relative to OPPS
payments; in future years, we intend to more precisely account for any
differential between these two update factors.
c. Geographic Adjustments
For CY 2017, we established class-specific geographic practice cost
indices (GPCIs) under the PFS exclusively used to adjust these site-
specific, technical component rates for nonexcepted items and services
furnished in nonexcepted off-campus PBDs. These class-specific GPCIs
are parallel to the geographic adjustments made under the OPPS based on
the hospital wage index. We believed it was appropriate to adopt the
hospital wage index areas for purposes of geographic adjustment because
non-excepted off-campus PBDs are still considered to be part of a
hospital, and the PFS payments to these entities will be limited to the
subset of PFS services furnished by hospitals. We also believed it was
appropriate, as an initial matter for CY 2017, to adopt the actual wage
index values for these hospitals in addition to the wage index areas.
The PFS GPCIs that would otherwise currently apply are not based on the
hospital wage index areas. For CY 2018, we are proposing to continue
using the authority under section 1848(e)(1)(B) of the Act to maintain
a class-specific set of GPCIs for these site-specific technical
component rates that are based both on the hospital wage index areas
and the hospital wage index value themselves. For purposes of payment
to hospitals, this means that the geographic adjustments used under the
OPPS continue to apply.
d. Coding Consistency
For most services, the same HCPCS codes are used to describe
services paid under both the PFS and the OPPS. There are two notable
exceptions that describe high-volume services. The first is the set of
codes that describe evaluation and management (E/M) services which are
reported under the PFS using the 5 levels of CPT codes describing new
or established patient visits (for a total of 10 codes). However, since
CY 2014, these visits have been reported under the OPPS using the
single HCPCS code G0463 (Hospital Outpatient Clinic Visit) (see 78 FR
75042). We are proposing to maintain the current PFS payment rate for
HCPCS code G0463 based on the OPPS payment rate modified by the PFS
Relativity Adjuster.
The second is a set of radiation treatment delivery and imaging
guidance services that are reported using different codes under the PFS
and the OPPS. CMS established HCPCS Level II G codes to describe
radiation treatment delivery services when furnished in the physician
office setting (see 79 FR 67666 through 67667). However, these HCPCS G
codes are not recognized under the OPPS; rather, CPT codes are used to
describe these services when furnished in the HOPD. Both sets of codes
were implemented for CY 2015 and were maintained for CY 2016. Under the
PFS, there is a particular statutory provision under section
1848(c)(2)(K) of the Act that required maintenance of the CY 2016
coding and payment inputs for these services for CY 2017 and also for
CY 2018. Accordingly, the proposed CY 2018 PFS rates for these services
are calculated based on the maintenance of the CY 2016 coding and
payment inputs. Because non-excepted items and services furnished by a
nonexcepted off-campus PBD are paid under the PFS, and we are required
to maintain the CY 2016 coding and payment inputs for these services
under
[[Page 33984]]
the CY 2018 PFS, we are proposing to maintain payment amounts for
nonexcepted items and services furnished by a nonexcepted off-campus
PBD consistent with the payments that would be made to other facilities
under the PFS. That is, nonexcepted off-campus PBDs submitting claims
for these nonexcepted items and services will continue to bill the
HCPCS G codes established under the PFS to describe radiation treatment
delivery services. Under this proposal, the nonexcepted off-campus PBD
must append modifier PN to each applicable claim line for these
nonexcepted items and services, even though the PFS Relativity Adjuster
will not apply. The payment amount for these services would be set to
reflect the technical component rate for the code under the PFS.
4. OPPS Payment Adjustments
In the CY 2017 interim final rule, we adopted the packaging payment
rates and multiple procedure payment reduction (MPPR) percentage that
applied under the OPPS to establish the PFS payment rates for
nonexcepted items and services furnished by nonexcepted off-campus PBDs
and billed by hospitals. That is, the claims processing logic that was
used for payments under the OPPS for comprehensive APCs (C-APCs),
conditionally and unconditionally packaged items and services, and
major procedures, was incorporated into the newly established PFS
rates. We continue to believe it is necessary to incorporate the OPPS
payment policies for C-APCs, packaged items and services, and the MPPR
in order to maintain the integrity of the PFS Relativity Adjuster
because the adjuster is intended in part to account for the
methodological differences between the OPPS and the PFS rates that
would otherwise apply. We also direct interested stakeholders to
related proposed policies under the OPPS, since prospective changes in
the applicable adjustments and policies would generally apply to non-
excepted items and services furnished by nonexcepted off-campus PBDs
for CY 2018. We are interested in comments regarding the applicability
of particular prospective OPPS adjustments to non-excepted items and
services.
In order to apply these OPPS payment policies and adjustments to
non-excepted items and services, we propose that hospitals continue to
bill on an institutional claim form that will pass through the
Outpatient Code Editor and into the OPPS PRICER for calculation of
payment. This approach will yield data based on claims for non-excepted
items and services furnished by nonexcepted off-campus PBDs, which can
be used to refine PFS payment rates for these services in future years.
There were several OPPS payment adjustments that we did not adopt
in the CY 2017 interim final rule, including, but not limited to,
outlier payments, the rural sole community hospital (SCH) adjustment,
the cancer hospital adjustments, transitional outpatient payments, the
hospital outpatient quality reporting payment adjustment, and the
inpatient hospital deductible cap to the cost-sharing liability for a
single hospital outpatient service. We believed these payment
adjustments were expressly authorized for, and should be limited to,
hospitals that are paid under the OPPS for covered OPD services in
accordance with section 1833(t) of the Act. We continue to believe that
these policies should not apply to non-excepted items and services
furnished by nonexcepted off-campus PBDs, and are not proposing that
they apply for CY 2018.
5. Partial Hospitalization Services
With respect to partial hospitalization programs (PHP) (intensive
outpatient psychiatric day treatment programs furnished to patients as
an alternative to inpatient psychiatric hospitalization or as a
stepdown to shorten an inpatient stay and transition a patient to a
less intensive level of care), section 1861(ff)(3)(A) of the Act
specifies that a PHP is a program furnished by a hospital, to its
outpatients, or by a CMHC. In the CY 2017 OPPS/ASC proposed rule (81 FR
45690), in the discussion of the proposed implementation of section 603
of Public Law 114-74, we noted that because CMHCs also furnish PHP
services and are ineligible to be provider-based to a hospital, a
nonexcepted off-campus PBD would be eligible for PHP payment if the
entity enrolls and bills as a CMHC for payment under the OPPS. We
further noted that a hospital may choose to enroll a nonexcepted off-
campus PBD as a CMHC, provided it meets all Medicare requirements and
conditions of participation.
Commenters expressed concern that without a clear payment mechanism
for PHP services furnished by nonexcepted off-campus PBDs, access to
partial hospitalization services would be limited, and pointed out the
critical role PHPs play in the continuum of mental health care. Many
commenters believed that Congress did not intend for partial
hospitalization services to no longer be paid for by Medicare when such
services are furnished by nonexcepted off-campus PBDs. Several
commenters disagreed with the notion of enrolling as a CMHC in order to
receive payment for PHP services. These commenters stated that
hospital-based PHPs and CMHCs are inherently different in structure,
operation, and payment, and noted that the conditions of participation
for hospital departments and CMHCs are different. Several commenters
requested that CMS find a mechanism to pay hospital-based PHPs in
nonexcepted off-campus PBDs.
Because we shared the commenters' concerns, in the CY 2017 OPPS/ASC
final rule with comment period and the CY 2017 interim final rule (81
FR 79727), we adopted payment for partial hospitalization items and
services furnished by nonexcepted off-campus hospital-based PBDs under
the PFS. When billed in accordance with the CY 2017 interim final rule,
these partial hospitalization services are paid at the CMHC per diem
rate for APC 5853, for providing three or more partial hospitalization
services per day (81 FR 79727).
In the CY 2017 OPPS/ASC proposed rule (81 FR 45681), the CY 2017
OPPS/ASC final rule with comment period, and the CY 2017 interim final
rule (81 FR 79727), we noted that when a beneficiary receives
outpatient services in an off-campus department of a hospital, the
total Medicare payment for those services is generally higher than when
those same services are provided in a physician's office. Similarly,
when partial hospitalization services are provided in a hospital-based
PHP, Medicare pays more than when those same services are provided by a
CMHC. Our rationale for adopting the CMHC per diem rate for APC 5853 as
the PFS payment amount for nonexcepted off-campus PBDs providing PHP
services is because CMHCs are freestanding entities that are not part
of a hospital, but they provide the same PHP services as hospital-based
PHPs (81 FR 79727). This is similar to the differences between
freestanding entities paid under the PFS that furnish other services
also provided by hospital-based entities. Similar to other entities
currently paid for their technical component services under the PFS, we
believe CMHCs would typically have lower cost structures than hospital-
based PHPs, largely due to lower overhead costs and other indirect
costs such as administration, personnel, and security. We believe that
paying for nonexcepted hospital-based partial hospitalization services
at the lower CMHC per diem rate aligns with section 603 of Pubic Law
114-74, while also preserving access to PHP services. In addition,
nonexcepted off-campus PBDs will not be required to enroll as CMHCs
[[Page 33985]]
in order to bill and be paid for providing partial hospitalization
services. However, a nonexcepted off-campus PBD that wishes to provide
PHP services may still enroll as a CMHC if it chooses to do so and
meets the relevant requirements. Finally, we recognize that because
hospital-based PHPs are providing partial hospitalization services in
the hospital outpatient setting, they can offer benefits that CMHCs do
not have, such as an easier patient transition to and from inpatient
care, and easier sharing of health information between the PHP and the
inpatient staff. We are not proposing to require these PHPs to enroll
as CMHCs but instead we are proposing to continue to pay non-excepted
off-campus PBDs providing PHP items and services under the PFS.
Further, we are proposing to continue to adopt the CMHC per diem rate
for APC 5853 as the PFS payment amount for nonexcepted off-campus PBDs
providing three or more PHP services per day in CY 2018.
6. Supervision Rules
The supervision rules that apply for hospitals continue to apply
for nonexcepted off-campus PBDs that furnish nonexcepted items and
services. The amendments made by section 603 of the Bipartisan Budget
Act of 2015 (Pub. L. 114-74, enacted November 2, 2015) did not change
the status of these PBDs, only the status of, and payment mechanism
for, the services they furnish. These supervision requirements are
specified in Sec. 410.27.
7. Beneficiary Cost-Sharing
Under the PFS, the beneficiary copayment is generally 20 percent of
the fee schedule amount, unless there is an applicable exception in
accordance with the statute. All cost-sharing rules that apply under
the PFS in accordance with section 1848(g) of the Act and section
1866(a)(2)(A) of the Act continue to apply for all nonexcepted items
and services furnished by nonexcepted off-campus PBDs, regardless of
the cost-sharing obligation under the OPPS.
8. CY 2019 and Future Years
We continue to believe the amendments made to the statute by
section 603 of the Bipartisan Budget Act of 2015 intended to eliminate
the Medicare payment incentive for hospitals to purchase physician
offices, convert them to off-campus PBDs, and bill under the OPPS for
items and services they furnish there. Therefore, we continue to
believe the payment policy under this provision should ultimately
equalize payment rates between nonexcepted off-campus PBDs and
physician offices to the greatest extent possible, while allowing
nonexcepted off-campus PBDs to bill in a straight-forward way for
services they furnish.
We note that a full year of claims data regarding the mix of
services reported using the ``PN'' modifier (from CY 2017) will first
be available for use in PFS ratesetting for CY 2019. Under the current
methodology, we would expect to use that data in order to ensure that
Medicare payment to hospitals billing for non-excepted items and
services furnished by nonexcepted off-campus PBDs under the PFS would
reflect the relative resources involved in furnishing the items and
services relative to other PFS services. We recognize that under our
current approach, the payment rates would not be equal on a procedure-
by-procedure basis, application of the PFS Relativity Adjuster would
move toward equalizing payment rates in the aggregate between physician
offices and nonexcepted off-campus PBDs to the extent appropriate.
Therefore, for certain specialties, service lines, and nonexcepted off-
campus PBD types, total Medicare payments for the same services might
be either higher or lower when furnished by a nonexcepted off-campus
PBD rather than in a physician office.
Depending on the mix of services for particular off-campus PBDs, we
remain concerned that such specialty-specific patterns in payment
differentials could result in continued incentives for hospitals to buy
certain types of physician offices and convert them to nonexcepted off-
campus PBDs; these are the incentives we believe Congress intended to
avoid. However, continuing a policy similar to the one we are proposing
in this proposed rule would allow hospitals to continue billing through
a facility claim form and would allow for continuation of the packaging
rules and cost report-based relative payment rate determinations under
OPPS, which we believe are preferable to using the current valuation
methodologies under the PFS that are not well-suited for nonexcepted
items and services furnished by nonexcepted off-campus PBDs. Therefore,
for CY 2019 and for future years, we intend to examine the claims data
in order to determine not only the appropriate PFS Relativity
Adjuster(s), but also to determine whether additional adjustments to
the methodology are appropriate--especially with the goal of attaining
site neutral payments to promote a level playing field under Medicare
between physician office settings and nonexcepted off-campus PBD
settings, without regard to the kinds of services furnished by
particular off-campus PBDs. We solicit comments on potential changes to
our methodology that would better account for these specialty-specific
patterns.
H. Proposed Valuation of Specific Codes
1. Background: Process for Valuing New, Revised, and Potentially
Misvalued Codes
Establishing valuations for newly created and revised CPT codes is
a routine part of maintaining the PFS. Since inception of the PFS, it
has also been a priority to revalue services regularly to make sure
that the payment rates reflect the changing trends in the practice of
medicine and current prices for inputs used in the PE calculations.
Initially, this was accomplished primarily through the 5-year review
process, which resulted in revised work RVUs for CY 1997, CY 2002, CY
2007, and CY 2012, and revised PE RVUs in CY 2001, CY 2006, and CY
2011. Under the 5-year review process, revisions in RVUs were proposed
and finalized via rulemaking. In addition to the 5-year reviews,
beginning with CY 2009, CMS and the RUC have identified a number of
potentially misvalued codes each year using various identification
screens, as discussed in section II.E.4 of this proposed rule.
Historically, when we received RUC recommendations, our process had
been to establish interim final RVUs for the potentially misvalued
codes, new codes, and any other codes for which there were coding
changes in the final rule for a year. Then, during the 60-day period
following the publication of the final rule, we accepted public comment
about those valuations. For services furnished during the calendar year
following the publication of interim final rates, we paid for services
based upon the interim final values established in the final rule. In
the final rule with comment period for the subsequent year, we
considered and responded to public comments received on the interim
final values, and typically made any appropriate adjustments and
finalized those values.
In the CY 2015 PFS final rule with comment period, we finalized a
new process for establishing values for new, revised and potentially
misvalued codes. Under the new process, we include proposed values for
these services in the proposed rule, rather than establishing them as
interim final in the final rule with comment period. Beginning with the
CY 2017 PFS proposed rule, the new process was applicable to all codes,
except for new codes that describe truly new services.
[[Page 33986]]
For CY 2017, we proposed new values in the CY 2017 PFS proposed rule
for the vast majority of new, revised, and potentially misvalued codes
for which we received complete RUC recommendations by February 10,
2016. To complete the transition to this new process, for codes where
we established interim final values in the CY 2016 PFS final rule with
comment period, we reviewed the comments received during the 60-day
public comment period following release of the CY 2016 PFS final rule
with comment period, and re-proposed values for those codes in the CY
2017 PFS proposed rule.
We considered public comments received during the 60-day public
comment period for the proposed rule before establishing final values
in the CY 2017 PFS final rule. As part of our established process we
will adopt interim final values only in the case of wholly new services
for which there are no predecessor codes or values and for which we do
not receive recommendations in time to propose values. For CY 2017, we
were not aware of any new codes that described such wholly new
services. Therefore, we did not establish any code values on an interim
final basis.
2. Methodology for Proposing Work RVUs
We conduct a review of each code identified in this section and
review the current work RVU (if any), RUC-recommended work RVU,
intensity, time to furnish the preservice, intraservice, and
postservice activities, as well as other components of the service that
contribute to the value. Our reviews of recommended work RVUs and time
inputs have generally included, but have not been limited to, a review
of information provided by the RUC, the Health Care Professionals
Advisory Committee (HCPAC), and other public commenters, medical
literature, and comparative databases, as well as a comparison with
other codes within the PFS, consultation with other physicians and
health care professionals within CMS and the federal government, as
well as Medicare claims data. We have also assessed the methodology and
data used to develop the recommendations submitted to us by the RUC and
other public commenters and the rationale for the recommendations. In
the CY 2011 PFS final rule with comment period (75 FR 73328 through
73329), we discussed a variety of methodologies and approaches used to
develop work RVUs, including survey data, building blocks, crosswalks
to key reference or similar codes, and magnitude estimation (see the CY
2011 PFS final rule with comment period (75 FR 73328 through 73329) for
more information). When referring to a survey, unless otherwise noted,
we mean the surveys conducted by specialty societies as part of the
formal RUC process. We have used the building block methodology to
construct, or deconstruct, the work RVU for a CPT code based on
component pieces of the code.
Components that we have used in the building block approach may
have included preservice, intraservice, or postservice time and post-
procedure visits. When referring to a bundled CPT code, the building
block components could be the CPT codes that make up the bundled code
and the inputs associated with those codes. Magnitude estimation refers
to a methodology for valuing work that determines the appropriate work
RVU for a service by gauging the total amount of work for that service
relative to the work for a similar service across the PFS without
explicitly valuing the components of that work. In addition to these
methodologies, we have frequently utilized an incremental methodology
in which we value a code based upon its incremental difference between
another code and another family of codes. The statute specifically
defines the work component as the resources in time and intensity
required in furnishing the service. Also, the published literature on
valuing work has recognized the key role of time in overall work. For
particular codes, we have refined the work RVUs in direct proportion to
the changes in the best information regarding the time resources
involved in furnishing particular services, either considering the
total time or the intraservice time.
Several years ago, to aid in the development of preservice time
recommendations for new and revised CPT codes, the RUC created
standardized preservice time packages. The packages include preservice
evaluation time, preservice positioning time, and preservice scrub,
dress and wait time. Currently there are preservice time packages for
services typically furnished in the facility setting (for example:
Preservice time packages reflecting the different combinations of
straightforward or difficult procedure, and straightforward or
difficult patient). Currently, there are three preservice time packages
for services typically furnished in the nonfacility setting.
We developed several standard building block methodologies to value
services appropriately when they have common billing patterns. In cases
where a service is typically furnished to a beneficiary on the same day
as an E/M service, we believe that there is overlap between the two
services in some of the activities furnished during the preservice
evaluation and postservice time. Our longstanding adjustments have
reflected a broad assumption that at least one-third of the work time
in both the preservice evaluation and postservice period is duplicative
of work furnished during the E/M visit. Accordingly, in cases where we
have believed that the RUC has not adequately accounted for the
overlapping activities in the recommended work RVU and/or times, we
have adjusted the work RVU and/or times to account for the overlap. The
work RVU for a service is the product of the time involved in
furnishing the service multiplied by the intensity of the work.
Preservice evaluation time and postservice time both have a long-
established intensity of work per unit of time (IWPUT) of 0.0224, which
means that 1 minute of preservice evaluation or postservice time
equates to 0.0224 of a work RVU.
Therefore, in many cases when we have removed 2 minutes of
preservice time and 2 minutes of postservice time from a procedure to
account for the overlap with the same day E/M service, we have also
removed a work RVU of 0.09 (4 minutes x 0.0224 IWPUT) if we have not
believed the overlap in time had already been accounted for in the work
RVU. The RUC has recognized this valuation policy and, in many cases,
now addresses the overlap in time and work when a service is typically
furnished on the same day as an E/M service.
We note that many commenters and stakeholders have expressed
concerns with our ongoing adjustment of work RVUs based on changes in
the best information we have had regarding the time resources involved
in furnishing individual services. We have been particularly concerned
with the RUC's and various specialty societies' objections to our
approach given the significance of their recommendations to our process
for valuing services and since much of the information we have used to
make the adjustments is derived from their survey process. We are
statutorily obligated to consider both time and intensity in
establishing work RVUs for PFS services. As explained in the CY 2016
PFS final rule with comment period (80 FR 70933), we recognize that
adjusting work RVUs for changes in time is not always a straightforward
process, so we have applied various methodologies to identify several
potential work values for individual codes.
[[Page 33987]]
We have observed that for many codes reviewed by the RUC,
recommended work RVUs have appeared to be incongruous with recommended
assumptions regarding the resource costs in time. This has been the
case for a significant portion of codes for which we have recently
established or proposed work RVUs that are based on refinements to the
RUC-recommended values. When we have adjusted work RVUs to account for
significant changes in time, we have begun by looking at the change in
the time in the context of the RUC-recommended work RVU. When the
recommended work RVUs have not appeared to account for significant
changes in time, we have employed the different approaches to identify
potential values that reconcile the recommended work RVUs with the
recommended time values. Many of these methodologies, such as survey
data, building block, crosswalks to key reference or similar codes, and
magnitude estimation have long been used in developing work RVUs under
the PFS. In addition to these, we have sometimes used the relationship
between the old time values and the new time values for particular
services to identify alternative work RVUs based on changes in time
components.
In so doing, rather than ignoring the RUC-recommended value, we
have used the recommended values as a starting reference and then
applied one of these several methodologies to account for the
reductions in time that we believe had not otherwise been reflected in
the RUC-recommended value. When we have believed that such changes in
time have already been accounted for in the RUC recommendation, then we
have not made such adjustments. Likewise, we have not arbitrarily
applied time ratios to current work RVUs to calculate proposed work
RVUs. We have used the ratios to identify potential work RVUs and
considered these work RVUs as potential options relative to the values
developed through other options.
We do not imply that the decrease in time as reflected in survey
values must equate to a one-to-one or linear decrease in newly valued
work RVUs. Instead, we have believed that, since the two components of
work are time and intensity, absent an obvious or explicitly stated
rationale for why the relative intensity of a given procedure has
increased, significant decreases in time should be reflected in
decreases to work RVUs. If the RUC recommendation had appeared to
disregard or dismiss the changes in time, without a persuasive
explanation of why such a change should not be accounted for in the
overall work of the service, then we have generally used one of the
aforementioned referenced methodologies to identify potential work
RVUs, including the methodologies intended to account for the changes
in the resources involved in furnishing the procedure.
Several stakeholders, including the RUC, in general have objected
to our use of these methodologies and deemed our actions in adjusting
the recommended work RVUs as inappropriate; other stakeholders have
also expressed concerns with CMS refinements to RUC recommended values
in general. In the CY 2017 PFS final rule (81 FR 80272 through 80277)
we responded in detail to several comments that we received regarding
this issue. In the CY 2017 PFS proposed rule, we requested comments
regarding potential alternatives to making adjustments that would
recognize overall estimates of work in the context of changes in the
resource of time for particular services; however, we did not receive
any specific potential alternatives as requested.
In developing proposed values for new, revised, and potentially
misvalued codes for CY 2018, we considered the lack of alternative
approaches to making the adjustments, especially since many
stakeholders have routinely urged us to propose and finalize the RUC
recommended values. We also considered the RUC's consistent reassurance
that these kinds of concerns (regarding changes in time, for example)
had already been considered, and either incorporated or dismissed, as
part of the development of their recommended values. These have led us
to shift our approach to reviewing RUC recommendations, especially as
we believe that the majority of practitioners paid under the PFS,
though not necessarily those in any particular specialty, would prefer
CMS rely more heavily on RUC recommended values in establishing payment
rates under the PFS.
For CY 2018, we have generally proposed RUC-recommended work RVUs
for new, revised, and potentially misvalued codes. We are proposing
these values based on our understanding that the RUC generally
considers the kinds of concerns we have historically raised regarding
appropriate valuation of work RVUs. During our review of these
recommended values, however, we identified some concerns similar to
those we have recognized in prior years. Given the relative nature of
the PFS and our obligation to ensure that the RVUs reflect relative
resource use, we have included descriptions of potential approaches we
might have taken in developing work RVUs that differ from the RUC
recommended values. We are seeking comment on both the RUC-recommended
values as well as the alternatives considered.
Table 10 contains a list of codes for which we proposed work RVUs;
this includes all codes for which we received RUC recommendations by
February 10, 2017. The proposed work RVUs, work time and other payment
information for all proposed CY 2018 payable codes are available on the
CMS Web site under downloads for the CY 2018 PFS proposed rule at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Table 10 also
contains the CPT code descriptors for all proposed, new, revised, and
potentially misvalued codes discussed in this section.
3. Methodology for Proposing the Direct PE Inputs To Develop PE RVUs
a. Background
On an annual basis, the RUC provides us with recommendations
regarding PE inputs for new, revised, and potentially misvalued codes.
We review the RUC-recommended direct PE inputs on a code by code basis.
Like our review of recommended work RVUs, our review of recommended
direct PE inputs generally includes, but is not limited to, a review of
information provided by the RUC, HCPAC, and other public commenters,
medical literature, and comparative databases, as well as a comparison
with other codes within the PFS, and consultation with physicians and
health care professionals within CMS and the federal government, as
well as Medicare claims data. We also assess the methodology and data
used to develop the recommendations submitted to us by the RUC and
other public commenters and the rationale for the recommendations. When
we determine that the RUC's recommendations appropriately estimate the
direct PE inputs (clinical labor, disposable supplies, and medical
equipment) required for the typical service, are consistent with the
principles of relativity, and reflect our payment policies, we use
those direct PE inputs to value a service. If not, we refine the
recommended PE inputs to better reflect our estimate of the PE
resources required for the service. We also confirm whether CPT codes
should have facility and/or nonfacility direct PE inputs and refine the
inputs accordingly.
Our review and refinement of RUC-recommended direct PE inputs
includes many refinements that are common
[[Page 33988]]
across codes, as well as refinements that are specific to particular
services. Table 11 details our proposed refinements of the RUC's direct
PE recommendations at the code-specific level. In this proposed rule,
we address several refinements that are common across codes, and
refinements to particular codes are addressed in the portions of this
section that are dedicated to particular codes. We note that for each
refinement, we indicate the proposed impact on direct costs for that
service. We note that, on average, in any case where the impact on the
direct cost for a particular refinement is $0.30 or less, the
refinement has no impact on the proposed PE RVUs. This calculation
considers both the impact on the direct portion of the PE RVU, as well
as the impact on the indirect allocator for the average service. We
also note that nearly half of the proposed refinements listed in Table
11 result in changes under the $0.30 threshold and are unlikely to
result in a change to the proposed RVUs.
We also note that the proposed direct PE inputs for CY 2018 are
displayed in the CY 2018 direct PE input database, available on the CMS
Web site under the downloads for the CY 2018 PFS proposed rule at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The inputs
displayed there have also been used in developing the proposed CY 2018
PE RVUs as displayed in Addendum B.
b. Common Refinements
(1) Changes in Work Time
Some direct PE inputs are directly affected by revisions in work
time. Specifically, changes in the intraservice portions of the work
time and changes in the number or level of postoperative visits
associated with the global periods result in corresponding changes to
direct PE inputs. The direct PE input recommendations generally
correspond to the work time values associated with services. We believe
that inadvertent discrepancies between work time values and direct PE
inputs should be refined or adjusted in the establishment of proposed
direct PE inputs to resolve the discrepancies.
(2) Equipment Time
Prior to CY 2010, the RUC did not generally provide CMS with
recommendations regarding equipment time inputs. In CY 2010, in the
interest of ensuring the greatest possible degree of accuracy in
allocating equipment minutes, we requested that the RUC provide
equipment times along with the other direct PE recommendations, and we
provided the RUC with general guidelines regarding appropriate
equipment time inputs. We continue to appreciate the RUC's willingness
to provide us with these additional inputs as part of its PE
recommendations.
In general, the equipment time inputs correspond to the service
period portion of the clinical labor times. We have clarified this
principle over several years of rulemaking, indicating that we consider
equipment time as the time within the intraservice period when a
clinician is using the piece of equipment plus any additional time that
the piece of equipment is not available for use for another patient due
to its use during the designated procedure. For those services for
which we allocate cleaning time to portable equipment items, because
the portable equipment does not need to be cleaned in the room where
the service is furnished, we do not include that cleaning time for the
remaining equipment items, as those items and the room are both
available for use for other patients during that time. In addition,
when a piece of equipment is typically used during follow-up post-
operative visits included in the global period for a service, the
equipment time would also reflect that use.
We believe that certain highly technical pieces of equipment and
equipment rooms are less likely to be used during all of the preservice
or postservice tasks performed by clinical labor staff on the day of
the procedure (the clinical labor service period) and are typically
available for other patients even when one member of the clinical staff
may be occupied with a preservice or postservice task related to the
procedure. We also note that we believe these same assumptions would
apply to inexpensive equipment items that are used in conjunction with
and located in a room with non-portable highly technical equipment
items since any items in the room in question would be available if the
room is not being occupied by a particular patient. For additional
information, we refer readers to our discussion of these issues in the
CY 2012 PFS final rule with comment period (76 FR 73182) and the CY
2015 PFS final rule with comment period (79 FR 67639).
(3) Standard Tasks and Minutes for Clinical Labor Tasks
In general, the preservice, intraservice, and postservice clinical
labor minutes associated with clinical labor inputs in the direct PE
input database reflect the sum of particular tasks described in the
information that accompanies the RUC-recommended direct PE inputs,
commonly called the ``PE worksheets.'' For most of these described
tasks, there are a standardized number of minutes, depending on the
type of procedure, its typical setting, its global period, and the
other procedures with which it is typically reported. The RUC sometimes
recommends a number of minutes either greater than or less than the
time typically allotted for certain tasks. In those cases, we review
the deviations from the standards and any rationale provided for the
deviations. When we do not accept the RUC-recommended exceptions, we
refine the proposed direct PE inputs to conform to the standard times
for those tasks. In addition, in cases when a service is typically
billed with an E/M service, we remove the preservice clinical labor
tasks to avoid duplicative inputs and to reflect the resource costs of
furnishing the typical service.
We refer readers to section II.B. of this proposed rule for more
information regarding the collaborative work of CMS and the RUC in
improvements in standardizing clinical labor tasks.
(4) Recommended Items that are not Direct PE Inputs
In some cases, the PE worksheets included with the RUC
recommendations include items that are not clinical labor, disposable
supplies, or medical equipment or that cannot be allocated to
individual services or patients. We have addressed these kinds of
recommendations in previous rulemaking (78 FR 74242), and we do not use
items included in these recommendations as direct PE inputs in the
calculation of PE RVUs.
(5) New Supply and Equipment Items
The RUC generally recommends the use of supply and equipment items
that already exist in the direct PE input database for new, revised,
and potentially misvalued codes. Some recommendations, however, include
supply or equipment items that are not currently in the direct PE input
database. In these cases, the RUC has historically recommended that a
new item be created and has facilitated our pricing of that item by
working with the specialty societies to provide us copies of sales
invoices. For CY 2018, we received invoices for several new supply and
equipment items. Tables 13 and 14 detail the invoices received for new
and existing items in the direct PE database. As discussed in section
II.B. of this proposed rule, we encourage stakeholders to review the
prices associated with these new and existing
[[Page 33989]]
items to determine whether these prices appear to be accurate. Where
prices appear inaccurate, we encourage stakeholders to provide invoices
or other information to improve the accuracy of pricing for these items
in the direct PE database during the 60-day public comment period for
this proposed rule. We expect that invoices received outside of the
public comment period would be submitted by February 10th of the
following year for consideration in future rulemaking, similar to our
new process for consideration of RUC recommendations.
We remind stakeholders that due to the relativity inherent in the
development of RVUs, reductions in existing prices for any items in the
direct PE database increase the pool of direct PE RVUs available to all
other PFS services. Tables 13 and 14 also include the number of
invoices received, as well as the number of nonfacility allowed
services for procedures that use these equipment items. We provide the
nonfacility allowed services so that stakeholders will note the impact
the particular price might have on PE relativity, as well as to
identify items that are used frequently, since we believe that
stakeholders are more likely to have better pricing information for
items used more frequently. A single invoice may not be reflective of
typical costs and we encourage stakeholders to provide additional
invoices so that we might identify and use accurate prices in the
development of PE RVUs.
In some cases, we do not use the price listed on the invoice that
accompanies the recommendation because we identify publicly available
alternative prices or information that suggests a different price is
more accurate. In these cases, we include this in the discussion of
these codes. In other cases, we cannot adequately price a newly
recommended item due to inadequate information. Sometimes, no
supporting information regarding the price of the item has been
included in the recommendation. In other cases, the supporting
information does not demonstrate that the item has been purchased at
the listed price (for example, vendor price quotes instead of paid
invoices). In cases where the information provided on the item allows
us to identify clinically appropriate proxy items, we might use
existing items as proxies for the newly recommended items. In other
cases, we have included the item in the direct PE input database
without any associated price. Although including the item without an
associated price means that the item does not contribute to the
calculation of the proposed PE RVU for particular services, it
facilitates our ability to incorporate a price once we obtain
information and are able to do so.
(6) Service Period Clinical Labor Time in the Facility Setting
Generally speaking, our proposed inputs did not include clinical
labor minutes assigned to the service period because the cost of
clinical labor during the service period for a procedure in the
facility setting is not considered a resource cost to the practitioner
since Medicare makes separate payment to the facility for these costs.
We address proposed code-specific refinements to clinical labor in the
individual code sections.
(7) Procedures Subject to the Multiple Procedure Payment Reduction
(MPPR) and the OPPS Cap
We note that the public use files for the PFS proposed and final
rules for each year display both the services subject to the MPPR lists
on diagnostic cardiovascular services, diagnostic imaging services,
diagnostic ophthalmology services and therapy services and the list of
procedures that meet the definition of imaging under section
1848(b)(4)(B) of the Act, and therefore, are subject to the OPPS cap
for the upcoming calendar year. The public use files for CY 2018 are
available on the CMS Web site under downloads for the CY 2018 PFS
proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html For more
information regarding the history of the MPPR policy, we refer readers
to the CY 2014 PFS final rule (78 FR 74261-74263). For more information
regarding the history of the OPPS cap, we refer readers to the CY 2007
PFS final rule (71 FR 69659-69662).
4. Proposed Valuation of Specific Codes for CY 2018
(1) Anesthesia Services for Gastrointestinal (GI) Procedures (CPT codes
007X1, 007X2, 008X1, 008X2, and 008X3)
In the CY 2016 PFS proposed rule (80 FR 41686), we discussed that
in reviewing Medicare claims data, a separate anesthesia service is
typically reported more than 50 percent of the time that various
colonoscopy procedures are reported. We discussed that given the
significant change in relative frequency with which anesthesia codes
are reported with colonoscopy services, we believed the relative values
of the anesthesia services should be reexamined and proposed to
identify CPT codes 00740 (Anesth upper gi visualize) and 00810 (Anesth
low intestine scope) as potentially misvalued. For CY 2018, the CPT
Editorial Panel is deleting CPT codes 00740 and 00810 and creating new
codes for anesthesia services furnished in conjunction with and in
support of gastrointestinal endoscopic procedures: Two codes for upper
GI procedures (007X1 and 007X2), two codes for lower GI procedures
(008X1 and 008X2), and one code for upper and lower GI procedures
(008X3).
For CY 2018, we are proposing the RUC-recommended base units
without refinement for CPT codes 007X1 (5.00 base units), 007X2 (6.00
base units), 008X1 (4.00 base units), 008X2 (4.00 base units) and 008X3
(5.00 base units). We considered 3.00 base units (the 25th percentile
survey result) for CPT code 008X2 (Anesthesia for lower intestinal
endoscopic procedures, endoscope introduced distal to duodenum;
screening colonoscopy), based on our comparison of the surveyed post-
induction anesthesia-intensity allocation for CPT code 008X2 to codes
with similar allocations (CPT code 01382 (Anesth dx knee arthroscopy)).
We found that CPT code 01382, which was also valued with 3.00 base
units, had similar allocations compared to the survey results for CPT
code 008X2. We are seeking comment on our proposed and alternative
value for CPT code 008X2.
(2) Acne Surgery (CPT code 10040)
CPT code 10040 was identified as potentially misvalued on a screen
of Harvard-valued codes with utilization over 30,000 in CY 2014. We are
proposing the RUC-recommended work RVU of 0.91 for CPT code 10040 and
the RUC-recommended work time values. We considered using the current
number of 0.5 post-procedure office visits of CPT code 99212 (Office/
outpatient visit est) rather than the RUC-recommended number of 1.0
post-procedure office visits. For CPT code 10040, the RUC states that
it is a low intensity service that can be performed by a nurse under a
physician's supervision, and that the average number of office visits
in the follow-up period of acne surgery is 0.4. We are seeking public
comments regarding the typical number of postoperative visits for this
code, considering there have been no changes made to the code
descriptor and we have not found evidence of changes to the typical
patient population.
We are proposing the RUC-recommended direct PE inputs for CPT code
10040 without refinement. We considered refinements to the clinical
[[Page 33990]]
labor for ``Assist physician in performing procedure'' from 10 minutes
to 3 minutes. CPT code 10040 previously used about one third of the
intraservice work time for this clinical labor activity (5 minutes out
of 14 minutes), and the RUC-recommended value of 10 minutes would have
increased this to 100 percent of the intraservice work time without
rationale for the change. We considered 3 minutes for this clinical
labor activity, which is about one third of the intraservice work time
(3 minutes out of 10 minutes) and would have maintained the current
ratio between clinical labor time and work time.
For CY 2018, we are proposing the RUC-recommended work RVUs and
direct PE inputs for CPT code 10040 and are seeking comment on our
proposed and alternative values.
(3) Muscle Flaps (CPT codes 15734, 15736, 15738, 157X1, and 157X2)
CPT codes 15732 and 15736 were identified via a screen of high
level E/M visits included in their global periods. This screen
identified that a CPT code 99214 office visit was included for CPT
codes 15732 and 15736 but not included in the other codes in this
family. During the review process for this family of codes, CPT code
15732 was deleted and replaced with two new codes, CPT codes 157X1 and
157X2, to better differentiate and describe the work of large muscle
flaps performed on patients with head and neck cancer depending on the
site where the service was performed.
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
codes 15734 (a work RVU of 23.00), 15736 (a work RVU of 17.04), 15738
(a work RVU of 19.04), 157X1 (a work RVU of 13.50), and 157X2 (a work
RVU of 15.68). For CPT code 157X1, we considered a work RVU of 12.03,
crosswalking to CPT code 36830 (Creation of arteriovenous fistula by
other than direct arteriovenous anastomosis (separate procedure);
nonautogenous graft (eg, biological collagen, thermoplastic graft)). We
have concerns because the RUC-recommended work RVU of 13.50 would
represent nearly double the intensity of CPT codes 15734 through 15738,
as well as nearly double the intensity of deleted CPT code 15732. The
RUC-recommended work RVU for CPT code 157X1 is also based on a direct
crosswalk to CPT code 36832 (Revision, open, arteriovenous fistula;
without thrombectomy, autogenous or nonautogenous dialysis graft
(separate procedure)), which has the same intraservice time, but with
20 additional minutes of total time. We considered a potential
crosswalk to another code in the same family, CPT code 36830, which
also shares the same intraservice time with CPT code 157X1 but differs
by only 8 minutes of total time. However, we seek comment on whether
the RUC recommendation is appropriate given the significant variation
in intensity among these services.
We considered a work RVU of 14.63 for CPT code 157X2 (survey 25th
percentile), crosswalking to CPT code 36833 (Revision, open,
arteriovenous fistula; with thrombectomy, autogenous or nonautogenous
dialysis graft (separate procedure)), which has the same intraservice
time, 1 minute of additional total time, and a work RVU of 14.50. We
are seeking comment on the effect that an alternative work RVU of 14.50
would have on relativity among the codes in this family.
We considered refining the clinical labor time for ``Check
dressings & wound/home care instructions'' for CPT code 157X1 from 10
minutes to 5 minutes. We are seeking comment on the typical time input
for checking dressings, and whether removing and replacing dressings,
would typically take place during the intraservice or postservice
period.
We are also seeking comments regarding the use of the new ``plate,
surgical, mini-compression, 4 hole'' (SD189) supply included in CPT
code 157X1, including whether use of this supply would be typical, and
if so, whether it should be included in the work description. We note
that SD189 is mentioned in the direct PE recommendations, but the
supply does not appear in the work description. In the work
description, the fixation screws are applied to the orbital rim and
lateral nasal wall, not the surgical plate.
(4) Application of Rigid Leg Cast (CPT code 29445)
CPT code 29445 appeared on a high growth screen of all services
with total Medicare utilization of 10,000 or more that increased by at
least 100 percent from 2008 through 2013. This screen also indicated
that the code was last surveyed more than 10 years previously, and that
the dominant specialty had changed during that time.
For CY 2018, we are proposing the RUC-recommended work RVU of 1.78
for CPT code 29445. For the direct PE inputs, we are proposing to
refine the clinical labor time for ``Check dressings & wound/home care
instructions'' from 5 minutes to 3 minutes. We believe that the
additional 2 minutes of clinical labor time that we are proposing to
remove would take place during the monitoring time following the
procedure and be accounted for in that clinical labor time.
We also considered refining the clinical labor time for ``Remove
cast'' from 22 minutes to 11 minutes: 1 minute for room prep, 10
minutes for assisting the physician, and 0 minutes for the additional
activities described in the RUC recommendations, which would have only
taken place during the initial casting. We have concerns that the RUC-
recommended clinical labor regarding the ``remove cast'' task is based
only on an initial visit where a new cast would be applied and 22
minutes may be an appropriate length of time. However, the RUC
recommendations suggest that four to twelve cast changes are common for
patients, and we are seeking comment on whether the initial application
of a new cast would be typical for CPT code 29445. We reviewed the
Medicare claims data for CPT code 29445 and found that three or more
castings took place for 52 percent of beneficiaries, which suggests
that three or more castings may be the typical case. A single casting
only took place for 30 percent of services reported with CPT code
29445.
(5) Strapping Multi-Layer Compression (CPT codes 29580 and 29581)
The RUC reviewed CPT code 29580 since it appeared on the screen for
high expenditure services and reviewed CPT code 29581 as part of this
family of codes. For CY 2018, the CPT Editorial Panel is deleting two
additional codes in the family: CPT codes 29582 (Application of multi-
layer compression system; thigh and leg, including ankle and foot, when
performed) and 29583 (Application of multi-layer compression system;
upper arm and forearm).
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
code 29580 (a work RVU of 0.55) and CPT code 29581 (a work RVU of
0.60).
However, we are concerned about the changes in preservice time
reflected in the specialty surveys compared to the RUC-recommended work
RVUs. For instance, for CPT code 29580, we considered a work RVU of
0.46, crosswalking to CPT code 98925 (Osteopathic manipulative
treatment (OMT); 1-2 body regions involved)), which has a work RVU of
0.46 and shares a similar intraservice time. Compared to the specialty
survey times, the RUC recommended a slight decrease (9 minutes) in
preservice time for CPT code 29580, with the intraservice and immediate
postservice times remaining unchanged.
[[Page 33991]]
For CPT code 29581, we considered a work RVU of 0.5 by using the
RUC-recommended work RVU increment between CPT codes 29580 and 29581
(+0.05), added to the work RVU we considered for CPT code 29580 (0.46),
and crosswalking to CPT code 97597 (Debridement (eg, high pressure
waterjet with/without suction, sharp selective debridement with
scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized
epidermis and/or dermis, exudate, debris, biofilm), including topical
application(s), wound assessment, use of a whirlpool, when performed
and instruction(s) for ongoing care, per session, total wound(s)
surface area; first 20 sq cm or less)), which has similar intraservice
and total times to the RUC-recommended services times for CPT code
29581. We are seeking comment on whether a work RVU of 0.51 would
improve relativity among the codes in this family.
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
codes 29580 and 29581 and are seeking comment on whether the
alternative values we considered would be more appropriate.
(6) Resection Inferior Turbinate (CPT Code 30140)
CPT code 30140 was identified as potentially misvalued on a screen
of Harvard-valued codes with utilization over 30,000 in CY 2014. During
the review process, the RUC re-surveyed the code as a 0-day global
period, based on the presence of a negative intensity value in the
initial survey and highly variable postoperative office visits.
For CY 2018, we are proposing the RUC-recommended work RVU of 3.00
for CPT code 30140 as a 0-day global code. We also considered a work
RVU of 2.68 for CPT code 30140 and are seeking comment on changes in
practice patterns since the code was previously reviewed, service times
of comparable services, and whether a work RVU of 2.68 would better
maintain relativity among similar codes. We note that the RUC-
recommended work RVU of 3.0 nearly doubles the derived intensity of the
code as currently valued. We note that the RUC recommendations
referenced services that had similar service times to CPT code 30140
(CPT code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa
resection), with a work RVU of 2.61; and CPT code 31295 (Nasal/sinus
endoscopy, surgical; with dilation of maxillary sinus ostium (eg,
balloon dilation), transnasal or via canine fossa), with a work RVU of
2.70).
We note that the initial survey for CPT code 30140 as a 90-day
global resulted in a RUC-recommended work RVU of 3.57, while the second
survey for the code as a 0-day global resulted in a RUC-recommended
work RVU of 3.00, despite the removal of two postoperative office
visits of CPT code 99212 and a half discharge visit of CPT code 99238.
These removed postoperative visits have a total work RVU of 2.58, which
is notably higher than the difference in the RUC-recommended work RVU
between the two surveys.
We are also proposing to create equipment codes for three new
equipment items based on invoices submitted with the RUC
recommendations for CPT code 30140. We are proposing to create three
new equipment codes based on the invoices submitted for this code
family: the 2mm reusable shaver blade (EQ383) at a price of $790, the
microdebrider handpiece (EQ384) at a price of $4,760, and the
microdebrider console (EQ385) at a price of $9,034.
(7) Control Nasal Hemorrhage (CPT Codes 30901, 30903, 30905, and 30906)
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
codes 30901 (a work RVU of 1.10), 30903 (a work RVU of 1.54), 30905 (a
work RVU of 1.97), and 30906 (a work RVU of 2.45). We are also
proposing to use the RUC-recommended direct PE inputs for CPT codes
30901, 30903, 30905, and 30906, with standard refinements to the
equipment times to account for patient monitoring times. We noted that
as part of its recommendation, the RUC informed us that the specialty
societies presented evidence stating that the 1995 valuations for these
services factored in excessive times, specifically to account for
infection control procedures that were necessary at that time due to
the prevalence of HIV/AIDS. The specialty societies also noted that
increased availability and use of blood thinner medications compared to
those available in 1995, has increased the difficulty and intensity of
these procedures. We are seeking additional information regarding the
presumption that the relative resource intensity of these services,
specifically, would be affected by the commercial availability of
additional blood thinner medications. We believe that blood thinner
medications were widely available before 1995 when these codes were
last valued. Additionally, we seek comments on the prevalence of HIV/
AIDS and whether the work related to infection control procedures would
be relative across many PFS services or specifically related to nasal
hemorrhage control procedures.
For CPT code 30901 (Control nasal hemorrhage, anterior, simple
(limited cautery and/or packing) any method), we considered a work RVU
of 1.00 (the 25th percentile survey result), crosswalking to CPT code
20606 (Drain/inj joint/bursa w/us), which has similar service times.
The median survey total time (24 minutes) dropped by 2 minutes (from
preservice time), to 24 minutes compared to the existing total time.
The difference in total time reflected a small decrease in preservice
time, with no change in intraservice time (10 minutes). Among codes
with similar service times, we found only three codes that had a higher
work RVU than the RUC-recommended value.
For CPT code 30903 (Control nasal hemorrhage, anterior, complex
(extensive cautery and/or packing) any method), we considered a work
RVU of 1.30 (the 25th percentile survey result), which would have been
further supported by CPT codes 36584 and 51710 which have similar
service times to the median survey results. The RUC recommended a
decreased total time of 39 minutes compared to the existing total time
(70 minutes), with intraservice time dropping from 30 to 15 minutes.
For CPT code 30905 (Control nasal hemorrhage, posterior, with
posterior nasal packs and/or cautery, any method; initial), we
considered a work RVU of 1.73, using the RUC-recommended work RVU
increment between CPT code 30903 and CPT code 30905 (0.43), added to
the work RVU we considered for CPT code 30903 (1.30), and crosswalking
to CPT code 45321 (Proctosigmoidoscopy volvul), which has similar
service times. The surveyed intraservice time dropped from 48 minutes
to 20 minutes. The RUC recommendations indicated that surveyed service
times for CPT code 30905 are longer than for CPT code 30903 since the
service is performed to control an arterial posterior bleed. According
to the specialty society, arterial posterior bleeds are more difficult
to treat and require a more extensive procedure in comparison to
services reported with CPT code 30903. We considered using the RUC-
recommended work RVU increment between CPT code 30903 and CPT code
30905 (0.43), added to the work RVU we considered for CPT code 30903
(1.30), resulting in a work RVU of 1.73. We are seeking comment on
whether a work RVU of 1.73 would potentially affect relativity among
the codes in this family.
[[Page 33992]]
For CPT code 30906 (Control nasal hemorrhage, posterior, with
posterior nasal packs and/or cautery, any method; subsequent), we
considered a work RVU of 2.21, using the RUC-recommended work RVU
increment between CPT codes 30905 and 30906 (0.48), added to the work
RVU we considered for CPT code 30905 (1.73), and crosswalking to
services with similar service times (CPT codes 19281 (Perq device
breast 1st imag), 51727 (Cystometrogram w/up), 49185 (Sclerotx fluid
collection), and 62305 (Myelography lumbar injection)). The surveyed
median intraservice time dropped from 60 minutes to 30 minutes. We are
seeking comment on whether a work RVU of 2.21 would potentially improve
relativity among the codes in this family.
Given the RUC's consensus for CY 2018, we are proposing the RUC-
recommended work RVUs for each code in this family and seeking comment
on whether our alternative values would be more appropriate.
(8) Nasal Sinus Endoscopy (CPT Codes 31254, 31255, 31256, 31267, 31276,
31287, 31288, 31295, 31296, 31297, 31XX1, 31XX2, 31XX3, 31XX4, and
31XX5)
In October 2016, the CPT Editorial Panel created five new codes
(CPT codes 31XX1, 31XX2, 31XX3, 31XX4 and 31XX5) and revised CPT codes
31238, 31254, 31255, 31276, 31287, 31288, 31296, and 31297. CPT codes
31XX2--31XX5 are newly bundled services representing services that are
frequently reported together. CPT code 31XX1 represents a new service.
The RUC reviewed this family of codes at their January 2017 meeting.
For CY 2018, we are proposing the RUC-recommended work RVUs for all 15
CPT codes in this family as follows: 4.27 for CPT code 31254, 5.75 for
CPT code 31255, 3.11 for CPT code 31256, 4.68 for CPT code 31267, 6.75
for CPT code 31276, 3.50 for CPT code 31287, 4.10 for CPT code 31288,
2.70 for CPT code 31295, 3.10 for CPT code 31296, 2.44 for CPT code
31297, 8.00 for CPT code 31XX1, 9.00 for CPT code 31XX2, 8.00 for CPT
code 31XX3, 8.48 for CPT code 31XX4, and 4.50 for CPT code 31XX5.
For CPT code 31296, we considered a work RVU of 2.82, supported by
a crosswalk to CPT code 36901 (Intro cath dialysis circuit) with an
intraservice time of 25 minutes and total time of 66 minutes, similar
to the service times for CPT code 31296. We are concerned about the
decrease in service time compared to the work RVU and we seek comment
on whether or not a work RVU of 2.82 might improve relativity with
other PFS services.
For CPT code 31256, we considered a work RVU of 2.80, supported by
a crosswalk to CPT code 43231 (Esophagoscopy, flexible, transoral; with
endoscopic ultrasound examination), which has 30 minutes of
intraservice time and 81 minutes of total time, similar to the RUC-
recommended service times. We are concerned about the difference in
total time between CPT code 31256 and the RUC-recommended crosswalk to
CPT code 43247. CPT code 43247 has 30 minutes intraservice time and 58
minutes total time), and CPT code 31256 (30 minutes intraservice time
and 83 minutes total time).
For CPT code 31254, we note the RUC's explanation that this service
is more intense than the functional endoscopic sinus surgery on the
maxillary or sphenoid sinuses due to the risk of major complications
such as injury to the eye muscles, bleeding into the eye or brain fluid
leak and, consequently, that the RUC concluded that it should be valued
higher than either CPT code 31256 or CPT code 31287. Since CPT code
31256 has the same total time (30 minutes) and intraservice time (30
minutes) as CPT code 31254, we considered whether the incremental
difference recommended by the RUC between these two codes (work RVU of
1.16) would reflect the intensity of the service. We considered a work
RVU of 2.80 for CPT code 31256, and also considered an alternative work
RVU of 3.97 for CPT code 31254.
For CPT code 31287, we considered a work RVU of 3.19 based on the
difference between the RUC-recommended work RVU for the maxillary sinus
surgery (CPT code 31256) and the sphenoid sinus surgery (CPT code
31287) (difference = 0.28) added to the work RVU that we considered for
the base code (CPT code 31256, a work RVU of 2.80). We note that the
magnitude of decreases in service times are greater than those for the
work RVU, which potentially could affect relativity among PFS services.
For CPT code 31255, we considered a work RVU of 5.30, based on a
crosswalk to CPT codes 36475 (Endovenous rf 1st vein) and 36478
(Endovenous laser 1st vein) since both of these services have the same
intraservice times, total times, and work RVUs). We note that there are
several CPT codes with similar total and intraservice times that have
lower work RVUs than the crosswalk to CPT code 36246 (Ins cath abd/l-
ext art 2nd) noted by the RUC, which has 45 minutes intraservice and 96
minutes total time, has work RVU of 5.02; CPT code 36475 (Endovenous rf
1st vein) has 94 minutes intraservice and 94 minutes total time and has
work RVU of 5.30).
For CPT code 31276 (Nasal/sinus endoscopy, surgical; with frontal
sinus exploration, including removal of tissue from frontal sinus, when
performed), we considered a work RVU of 6.30, which is similar to other
functional endoscopic surgeries. We note that the services reported
with CPT code 31276 are the most intense and complex of the functional
endoscopic surgeries due to the risks of working in the narrow confines
in the frontal recess. However, we have concerns that a crosswalk to
CPT code 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy;
with removal or manipulation of calculus (ureteral catheterization is
included)), and we seek comment on whether the RUC-recommended decrease
in service times is appropriate since CPT code 52352 has 20 minutes
more total time than CPT code 31276.
For CPT 31XX1 (nasal/sinus endoscopy, surgical; with ligation of
Sphenopalatine artery), we have concerns and seek comment regarding the
accuracy and applicability of the surveys as the RUC indicated that the
specialty society did not use the survey instrument that contains
questions about the number and types of visits and that this service
requires a half day discharge day management as the patients typically
stay overnight to be monitored for further bleeding. We seek comment on
whether inclusion of a half day discharge day visit is typical for this
service since services assigned 0-day global periods do not typically
include discharge visits. We considered reducing the total time from
142 minutes to 123 minutes by removing the half day discharge. Using
the alternative total time of 123 minutes, we found services with
similar total and intraservice time (60 minutes) and total time (123
minutes).
We considered a work RVU of 7.30 for CPT code 31XX1, supported by a
direct crosswalk to CPT code 36253 (Superselective catheter placement
(one or more second order or higher renal artery branches) renal artery
and any accessory renal artery(s) for renal angiography, including
arterial puncture, catheterization, fluoroscopy, contrast injection(s),
image postprocessing, permanent recording of images, and radiological
supervision and interpretation, including pressure gradient
measurements when performed, and flush aortogram when performed;
unilateral), since CPT code 36253 has a similar total time compared to
our alternative total time.
For CPT code 31XX3, we considered a work RVU of 7.30, based on a
crosswalk to CPT code 36253 (Superselective catheter placement (one
[[Page 33993]]
or more second order or higher renal artery branches) renal artery and
any accessory renal artery(s) for renal angiography, including arterial
puncture, catheterization, fluoroscopy, contrast injection(s), image
postprocessing, permanent recording of images, and radiological
supervision and interpretation, including pressure gradient
measurements when performed, and flush aortogram when performed;
unilateral). We have similar concerns regarding the service times for
this service, including the cited reference codes, compared to the
recommended work RVU. We are seeking comment on whether a work RVU of
7.30 for CPT code 31XX3 would improve consistency among the combined
CPT codes in this family.
CPT code 31XX4 is a new code representing a combination of the
services previously described by CPT codes 31255 and 31288. We note the
changes in overall service times compared to other codes in this family
and other PFS services. We considered a work RVU of 7.85 for CPT code
31XX4, crosswalking to CPT code 93461 (R&l hrt art/ventricle angio),
which has identical intraservice times. We are seeking comment on the
effect that this alternative work RVU might have on consistency and
rank order compared to the other bundled codes in this family.
CPT code 31XX5 represents a combination of CPT codes 31296 and
31297. We have concerns about the use of CPT codes 47532 and 58558,
which were used by the RUC as comparison codes, due to differences in
both intraservice and total time compared to the service times for CPT
code 31XX5. We considered a work RVU of 4.10 for CPT code 31XX5,
crosswalking to CPT code 44406 (Colonoscopy w/ultrasound), which has
similar service times.
For CY 2018, we are proposing the RUC-recommended work RVUs for
each code in this family and are seeking comment on our alternative
values.
Regarding the recommended direct PE inputs, we are concerned about
one of the supply items used in furnishing services for several CPT
codes in this family:, ``sinus surgery balloon (maxillary, frontal, or
sphenoid) kit'' (SA106). In the current recommendations, half of one
kit (each kit has sufficient supply for two sinuses) is included in the
practice expense inputs for CPT codes 31295, 31296, and 31297. The new
CPT code 31XX5 has one full kit, reflecting a service consisting of two
sinuses, according to the RUC's explanation. The price of the full kit
(two sinuses) of this disposable supply is $2599.06. Our analysis of
2016 Medicare claims data indicates that 48 percent of the time one of
the three CPT codes (31295, 31296, and 31297) is billed, it is reported
on a claim with either one or both of the other codes. Ten percent of
the time one of the three CPT codes is billed, it is reported on a
claim with both of the other two codes. Effectively, 10 percent of
claims reporting these CPT codes are being paid for three sinuses.
We are seeking comments on the number of units of this supply item
that are used for each service. We welcome suggestions about improved
methodologies for identifying the quantity of this disposable supply
used during these procedures and will continue to monitor utilization
and reporting of these services.
In reviewing the RUC recommendations for this family of CPT codes,
we note that CPT codes in this family are subject to the standard
payment adjustment for multiple surgeries. In our analysis of the
claims data, we noted that the average number of HCPCS codes in this
family reported together on a claim line is approximately 2.89. In
addition, about 15 percent of claims have two of the newly bundled CPT
codes reported together on a claim line. We are concerned about the
frequency with which the nasal sinus endoscopy CPT codes in this family
are billed together. We are seeking comments on whether we should
consider the endobase code adjustments as a better approach to
adjusting payment for these services instead of the current multiple
procedure reduction. For additional information about the payment
adjustment under the special rule for multiple endoscopic services, we
refer readers to the Medicare Claims Processing Manual, Chapter 23
(available on the CMS Web site at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf.).
We note that in developing the utilization crosswalk we use for
purposes of PFS ratesetting, for this complex set of newly bundled
codes, we adopted ratios that differ significantly from the ratios
accompanying the RUC recommendations to better account for the
reductions in overall reporting frequency. We direct readers to the
file called ``CY 2017 Analytic Crosswalk to CY 2018'' on the CMS Web
site under downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(9) Tracheostomy (CPT Codes 31600, 31601, 31603, 31605, and 31610)
CPT code 31600 was identified as part of a screen of high
expenditure services with Medicare allowed charges of $10 million or
more that had not been recently reviewed. CPT codes 31601, 31603,
31605, and 31610 were added and reviewed as part of the code family.
We are proposing the RUC-recommended work RVUs for all five codes
in this family. We are proposing a work RVU of 5.56 for CPT code 31600,
a work RVU of 8.00 for CPT code 31601, a work RVU of 6.00 for CPT code
31603, a work RVU of 6.45 for CPT code 31605, and a work RVU of 12.00
for CPT code 31610.
We considered a work RVU of 6.50 for CPT code 31601. We seek
comment on the effect that this alternative value would have on
relativity compared to other PFS services, especially since the survey
data does not suggest an increase in the time required to perform the
procedure.
We considered a work RVU of 4.77 for CPT code 31605, based on the
survey 25th percentile from the combined survey total. We also
considered an intraservice work time of 15 minutes, based on the median
intraservice work time from the combined survey total for CPT code
31605. We are seeking comments on the methodology used to determine the
RUC-recommended work RVU and intraservice work time. We are concerned
that the number of respondents (20) is below the threshold typically
required for submission of a survey, and the effect of using survey
results only from physicians who had personal experience performing the
procedure (20 respondents). CPT code 31605 has a lower intraservice and
total time, but a higher work RVU than comparable codes under the PFS.
We note that the next highest 0-day global code with 20 minutes of
intraservice time is CPT code 16035 (Escharotomy; initial incision) at
a work RVU of 3.74. All other 0-day global codes with a work RVU of
6.45 or greater have at least 40 minutes of intraservice time. We are
seeking comment on the effect that an alternative work RVU of 4.77
would have on the relativity of this service compared to other services
in this family of codes and compared to other PFS services, taking into
account that CPT code 31605 describes a difficult and dangerous life-
threatening emergency procedure.
We considered a work RVU of 6.50 for CPT code 31610 based on a
direct crosswalk to CPT code 31601 (Incision of windpipe). We
understand that the RUC considered the possibility of
[[Page 33994]]
recommending this code be assigned a 0-day global period based on
concerns about negative derived intensity. We share the RUC's concerns
with the current construction of CPT code 31610, particularly with the
242 minutes of work time included in the postoperative visits, which is
an unusually large amount for a procedure with only 45 minutes of
intraservice time. We did not identify any other comparable codes under
the PFS with 45 minutes of intraservice time and more than 300 minutes
of total time. We seek comment on whether the unusual volume of
physician work time included in the postoperative visits for CPT code
31610 contributed to the negative derived intensity reported by the
survey data. Considering that the other codes in this family have 0-day
global periods, we considered and are seeking comment on whether a 0-
day global period should be assigned to CPT code 31610. Removal of the
postoperative E/M visits from CPT code 31610 would result in an
intraservice time of 45 minutes and a total time of 125 minutes,
similar to CPT code 31601 with 45 minutes of intraservice time and 135
minutes of total time.
We are proposing the RUC-recommended direct PE inputs for all five
CPT codes in this family without refinements. As discussed earlier, we
considered a 0-day global period for CPT code 31610, which would also
have resulted in removal of the clinical labor associated with the
postoperative E/M visits, along with the supplies and equipment
utilized during those visits.
While we remain concerned about the global period assigned to CPT
code 31610 and the changes in service times reflected in the specialty
surveys compared to the RUC-recommended work RVUs, for CY 2018, we are
proposing the RUC-recommended work RVUs and direct PE inputs for each
code in this family and are seeking comment on our proposed and
alternative values.
(10) Bronchial Aspiration of Tracheobronchial Tree (CPT Codes 31645 and
31646)
CPT code 31645 was identified as potentially misvalued on a screen
of Harvard-valued codes with utilization over 30,000 in CY 2014. CPT
code 31646 was added for review as part of the family of codes, and
both were revised to reflect recent changes in how the services are
typically performed. For CY 2018, we are proposing the RUC-recommended
work RVU of 2.88 for CPT code 31645 and the RUC-recommended work RVU of
2.78 for CPT code 31646.
We considered a work RVU of 2.72 for CPT code 31645, crosswalking
to CPT code 45347 (Sigmoidoscopy, flexible; with placement of
endoscopic stent). We have concerns regarding the decrease in
intraservice and total time compared to the current values (we also
believe that it is important to note how these related codes have been
affected by the creation of separately billable codes for moderate
sedation (see CY 2017 PFS final rule (81 FR 80339)). The RUC-
recommended values CPT code 31645 higher than CPT code 31622
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed; diagnostic, with cell washing, when performed), which is the
base procedure for this wider group of codes. We agree that CPT code
31645 should be valued at a higher work RVU than CPT code 31622,
however, we are seeking comment on whether the work of moderate
sedation was inadvertently included in the development of the
recommended work RVU. We note that as part of the CY 2017 PFS final
rule (81 FR 80339), we finalized separate payment for moderate
sedation.
Following the creation of separately billable codes for moderate
sedation, CPT code 31622 is currently valued at a work RVU of 2.53, not
2.78 as it was previously valued, and we do not believe it would be
appropriate to continue to value CPT code 31645 as though moderate
sedation was still an inherent part of the work of this service. As a
result, we considered a direct crosswalk to CPT code 45347, which has
the same intraservice time and 8 additional minutes of total time, at a
work RVU of 2.72.
We considered a work RVU of 2.53 for CPT code 31646, crosswalking
to CPT code 31622 (Dx bronchoscope/wash). The RUC recommendation for
CPT code 31646 indicated that the code was comparable to CPT code
31622, since they share the same intraservice time and similar total
time, and that the recommended work RVU of 2.78 for CPT code 31646 was
equal to the work RVU of CPT code 31622 before the CY 2017 changes to
reporting of moderate sedation. We agree with the survey participants
that these two codes are comparable to one another, but have concerns
about valuation of CPT code 31646 using a cross reference to a code
that included moderate sedation. We considered crosswalking CPT code
31646 (Bronchoscopy reclear airway) using the current CY 2017 valuation
for CPT code 31622 (a work RVU of 2.53).
For the direct PE inputs, we are proposing to remove the oxygen gas
(SD084) from CPT code 31645. This supply is included in the separately
billable moderate sedation codes, and we are proposing to remove the
oxygen gas as recommended by the RUC's PE Subcommittee as part of the
removal of oxygen from non-moderate sedation post-procedure monitoring
codes. We are proposing to remove the equipment time for the IV
infusion pump (EQ032) from CPT code 31645. We do not agree that there
would typically be a need for a separate infusion pump in CPT code
31645, as the infusion pump is contained in the separately reportable
moderate sedation codes. We are also proposing to remove the equipment
time for the CO2 respiratory profile monitor (EQ004) and the
mobile instrument table (EF027) from CPT code 31645. These equipment
items are not contained in the current composition of the code, and
there was no rationale provided in the RUC recommendations for their
inclusion. As a result, we do not believe that their use would be
typical for CPT code 31645.
We are proposing to increase the equipment time for the flexible
bronchoscopy fiberscope (ES017) for CPT code 31645 consistent with
standard equipment times for scopes. We are also proposing to increase
the equipment time for the Gomco suction machine (EQ235) and the power
table (EF031) consistent with standard equipment times for non-highly
technical equipment.
For CY 2018, we are proposing the RUC-recommended work RVUs for
both codes in this family and are seeking comment on whether we should
finalize refined values consistent with the implementation of
separately billable codes for moderate sedation.
(11) Cryoablation of Pulmonary Tumor (CPT Codes 32998 and 32X99)
For CY 2018, the CPT Editorial Panel modified the descriptor for
CPT code 32998 (Ablation therapy for reduction or eradication of 1 or
more pulmonary tumor(s) including pleura or chest wall when involved by
tumor extension, percutaneous, including imaging guidance when
performed, unilateral; radiofrequency) to include imaging guidance. In
addition, the panel deleted Category III CPT Code 0304T and replaced it
with a new CPT code 32X99, to describe ablation therapy for reduction
of pulmonary tumor using cryoablation with imaging guidance. For CY
2018, we are proposing the RUC-recommended work RVUs for CPT codes
32998 (a work RVU of 9.03) and 32X99 (a work RVU of 9.03).
However, we have concerns about the descriptions of the codes and
the recommended valuations assuming that imaging guidance is inherent
to the
[[Page 33995]]
procedure. Based on our analysis of claims data from 2014, existing CPT
code 32998 is currently reported with one of the three imaging guidance
codes (CPT codes 76940, 77013, or 77022) less than 50 percent of the
time. We seek comment on whether there is additional information that
would help explain why the codes are being bundled despite what is
reflected in the Medicare claims data. We considered a work RVU of 7.69
for CPT code 32998, that included approximately one half the value of
the imaging guidance in the new codes that describe the work of both
the procedure and the image guidance (that is, the sum of the current
work RVU for CPT code 32998 and one-half of the work RVU for CPT code
77013 (the imaging guidance code most frequently billed with CPT code
32998 according to 2014 claims data)). We applied the same general
rationale regarding the use of imaging guidance for new CPT code 32X99.
Since the RUC recommended identical work RVUs for these codes, we also
considered a work RVU of 7.69 for CPT 32X99.
For CPT codes 32998 and 32X99, we are proposing to use the RUC-
recommended direct PE inputs with standard refinements.
For CY 2018, we are proposing the RUC-recommended work RVUs and
direct PE inputs for both codes and are seeking comment on our proposed
and alternative values.
(12) Artificial Heart System Procedures (CPT Codes 339X1, 339X2, and
339X3)
For CY 2018, the CPT Editorial Panel deleted Category III CPT Codes
0051T through 0053T and created CPT codes 339X1, 339X2, and 339X3 to
report artificial heart system procedures. We are proposing the RUC-
recommended work RVU of 49.00 for CPT code 339X1, and proposing to
assign contractor-priced status to CPT codes 339X2 and 339X3 as
recommended by the RUC.
We considered assigning contractor-priced status for CPT code
339X1. We have concerns regarding the accuracy of the RUC-recommended
work valuation for CPT code 339X1, due to its low utilization and the
resulting difficulties in finding enough practitioners with direct
experience of the procedure for the specialty societies to survey. We
seek comment on the sufficiency of the survey data, especially since
new technologies and those with lower utilization are typically
contractor-priced. For CY 2018, we are proposing the RUC-recommended
work RVUs for CPT code 339X1. We are seeking comment on alternative
pricing for this CPT code 339X1.
We are not proposing any direct PE inputs, as we did not receive
RUC-recommended PE information for CPT codes 339X1, 339X2, and 339X3.
These three codes will be placed on the RUC's new technology list and
will be re-reviewed by the RUC in 3 years.
(13) Endovascular Repair Procedures (CPT Codes 34X01, 34X02, 34X03,
34X04, 34X05, 34X06, 34X07, 34X08, 34X09, 34X10, 34X11, 34X12, 34X13,
34812, 34X15, 34820, 34833, 34834, 34X19, and 34X20)
The CPT/RUC joint workgroup on codes recommended in October 2015 to
bundle endovascular abdominal aortic aneurysm repair (EVAR) codes
together with radiologic supervision and interpretation codes, since
these codes were typically reported together at least 50 percent of the
time. The CPT Editorial Panel bundled these services together in
September 2016, creating 16 new codes, revising four existing codes,
and deleting 14 other codes related to endovascular repair procedures.
We are proposing the RUC-recommended work RVUs for all 20 codes in
this family. We are proposing a work RVU of 23.71 for CPT code 34X01, a
work RVU of 36.00 for CPT code 34X02, a work RVU of 26.52 for CPT code
34X03, a work RVU of 45.00 for CPT code 34X04, a work RVU of 29.58 for
CPT code 34X05, a work RVU of 45.00 for CPT code 34X06, a work RVU of
22.28 for CPT code 34X07, a work RVU of 36.50 for CPT code 34X08, a
work RVU of 6.50 for CPT code 34X09, a work RVU of 15.00 for CPT code
34X10, a work RVU of 6.00 for CPT code 34X11, a work RVU of 12.00 for
CPT code 34X12, a work RVU of 2.50 for CPT code 34X13, a work RVU of
4.13 for CPT code 34812, a work RVU of 5.25 for CPT code 34X15, a work
RVU of 7.00 for CPT code 34820, a work RVU of 8.16 for CPT code 34833,
a work RVU of 2.65 for CPT code 34834, a work RVU of 6.00 for CPT code
34X19, and a work RVU of 7.19 for CPT code 34X20.
We are also proposing the RUC-recommended direct PE inputs without
refinement for all 20 codes in the family.
We considered a work RVU of 32.00 for CPT code 34X02 based on the
survey 25th percentile, and further supported with a crosswalk to CPT
code 48000 (Placement of drains, peripancreatic, for acute
pancreatitis), which has the same intraservice time of 120 minutes and
a work RVU of 31.95. When we compared the RUC-recommended work RVU to
similar codes valued under the PFS, we were unable to find any 90-day
global services with 120 minutes of intraservice time and approximately
677 minutes of total time that had a work RVU greater than 36.00.
We considered a work RVU of 40.00 for CPT code 34X04 based on the
survey 25th percentile, crosswalking to CPT code 33534 (Coronary artery
bypass, using arterial graft(s); 2 coronary arterial grafts) which has
a work RVU of 39.88. CPT code 33534 has 193 minutes of intraservice
time, but a lower total time of 717 minutes. When we compared the RUC-
recommended work RVU for CPT code 34X04 to similar codes paid under the
PFS, we were unable to find any 90-day global services with 180 minutes
of intraservice time and approximately 737 minutes of total time that
had a work RVU greater than 45.00.
We considered a work RVU of 40.00 for CPT code 34X06 based on the
survey 25th percentile. CPT code 34X06 has nearly identical time values
to CPT code 34X04, with 2 fewer minutes of intraservice time and total
time, and the RUC-recommended work RVU was the same for both of these
codes. The survey respondents also believe that these two codes had a
comparable amount of work, as the survey 25th percentile work RVU is
40.00 for both codes.
We considered a work RVU of 30.00 for CPT code 34X08 based on the
survey 25th percentile and seek comment on whether a work RVU of 30.00
would improve relativity among the codes in this family. CPT code 34X08
has identical intraservice and total times as CPT code 34X02. However,
we note that the RUC-recommended work RVU of 36.50 for CPT code 34X08
is higher than the RUC-recommended work RVU of 36.00 for CPT code
34X02. This is the inverse of the relationship between CPT codes 34X07
and 34X01, which describe the same procedures in a non-emergent state
when a rupture does not take place. CPT code 34X07 has a RUC-
recommended work RVU of 22.28 while CPT code 34X01 has a RUC-
recommended work RVU of 23.71. We seek comment on whether the RUC-
recommended work RVUs would create a rank order anomaly within the
family by reversing the relationship between these paired codes when
performed in an emergent state. We note that if CPT codes 34X08 and
34X02 were valued at the survey 25th percentile, this potential rank
order anomaly disappears; in this scenario, we considered valuing CPT
code 34X08 at a work RVU of 30.00 and CPT code 34X02 at a work RVU of
32.00. We seek comment on whether these alternative work values would
improve relativity with the RUC-recommended work RVUs for CPT code
34X07 (22.28) and CPT code 34X01 (23.71), with an increment of
[[Page 33996]]
approximately 1.50 to 2.00 RVUs between the two code pairs.
For the eight remaining codes that describe endovascular access
procedures, we considered assignment of a 0-day global period, instead
of the RUC-recommended add-on (ZZZ) global period and subsequently
adding back the preservice and immediate postservice work time, and
increasing the work RVU of each code accordingly using a building block
methodology. We note that as add-on procedures, these eight codes would
not be subject to the multiple procedure payment discount. We are
concerned that the total payment for these services will be increasing
in the aggregate based on changes in coding that alter MPPR
adjustments, despite the information in the surveys that reflects a
decrease in the intraservice time required to perform the procedures,
and a decrease in their overall intensity as compared to the current
values.
We considered a work RVU of 3.95 for CPT code 34X13, based on the
RUC-recommended work RVU of 2.50 plus an additional 1.45 work RVUs.
This additional work results from the addition of 38 total minutes of
preservice work time and 30 minutes of postservice work time based on a
crosswalk to CPT code 37224 (Revascularization, endovascular, open or
percutaneous, femoral, popliteal artery(s), unilateral; with
transluminal angioplasty) as valued by using the building block
methodology. Using the same method, we considered a work RVU of:
6.48 for CPT code 34812 based on maintaining the current
75 minutes of preservice work time and the current 30 minutes of
postservice work time, with a total work RVU of 2.35, added to the RUC-
recommended work RVU of 4.13;
7.53 for CPT code 34X15 with the addition of 75 minutes of
preservice work time and 27 minutes of postservice work time to match
CPT code 34833;
9.46 for CPT code 34820 based on maintaining the current
80 minutes of preservice work time and the current 30 minutes of
postservice work time;
10.44 for CPT code 34833 based on maintaining the current
75 minutes of preservice work time and the current 27 minutes of
postservice work time;
5.00 for CPT code 34834 based on maintaining the current
70 minutes of preservice work time and the current 35 minutes of
postservice work time;
8.35 for CPT code 34X19 with the addition of 70 minutes of
preservice work time and 35 minutes of postservice work time to match
CPT code 34834; and
9.47 for CPT code 34X20 with the addition of 75 minutes of
preservice work time and 27 minutes of postservice work time to match
CPT code 34833.
(14) Selective Catheter Placement (CPT Codes 36215, 36216, 36217, and
36218)
CPT code 36215 was identified as potentially misvalued on a screen
of Harvard-valued codes with utilization over 30,000 in CY 2014, as
well as on a screen of high expenditure services across specialties
with Medicare allowed charges of over $10 million. CPT codes 36216,
36217, and 36218 were added to the family to be reviewed together with
CPT code 36215.
We are proposing the RUC-recommended work RVUs for each code in
this family as follows: A work RVU of 4.17 for CPT code 36215, a work
RVU of 5.27 for CPT code 36216, a work RVU of 6.29 for CPT code 36217,
and a work RVU of 1.01 for CPT code 36218.
We also considered refinements to the intraservice work time for
CPT code 36217 from 60 minutes to 50 minutes, consistent with the RUC's
usual use of the survey median intraservice work time. We have concerns
that the use of the recommended survey 75th percentile intraservice
work time will not be clinically appropriate for this code, as the 75th
percentile time was identical for both CPT code 36216 and 36217, and
therefore, the use of this value would not preserve the incremental,
linear consistency between the work RVU and the intraservice time
within the family.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Post-procedure doppler evaluation (extremity)''
activity from 3 minutes to 1 minute for CPT codes 36215, 36216, and
36217. We believe that 1 minute would be more typical for this task, as
the practitioner would be able to quickly evaluate if there was an
issue with the extremity because there would be visual signs of
arterial insufficiency resulting from the procedure.
We are proposing to remove the equipment time for the mobile
instrument table (EF027) from CPT codes 36215, 36216, and 36217. We
believe that the mobile instrument table would be used for moderate
sedation, which was removed from these procedures in CY 2017 (see CY
2017 PFS final rule (81 FR 80339)). While we recognize that 180 minutes
of post-procedure monitoring time remains in these codes during which
the stretcher (EF018), IV infusion pump (EQ032), and 3-channel ECG
(EQ011) would remain in use, we do not agree that the mobile instrument
table would typically be in use during this period of monitoring. As a
result, we are proposing to remove this equipment time from these three
codes.
While we remain concerned about the use of the survey 75th
percentile intraservice work time for CPT code 36217, for CY 2018, we
are proposing the RUC-recommended work RVUs for each code in this
family and seek comment on whether our alternative values would be more
appropriate.
(15) Treatment of Incompetent Veins (CPT Codes 36470, 36471, 364X3,
364X4, 364X5, and 364X6)
In September 2016, the CPT Editorial Panel created four new codes
to describe the treatment of incompetent veins, and revised existing
CPT codes 36470 and 36471. These six codes were reviewed together as
part of the same family of procedures. For CY 2018, we are proposing
the RUC-recommended work RVU for all six codes as follows: A work RVU
of 0.75 for CPT code 36470, a work RVU of 1.50 for CPT code 36471, a
work RVU of 3.50 for CPT code 364X3, and a work RVU of 1.75 for CPT
code 364X4, a work RVU of 2.35 for CPT code 364X5, and a work RVU of
3.00 for CPT code 364X6.
We considered a work RVU of 4.38 for CPT code 364X3, which would
have been based on the RUC-recommended work RVU of 3.50 plus half of
the RUC-recommended work RVU of CPT code 364X4. We also considered
assigning CPT code 364X4 a status indicator of ``bundled.'' The
services that would be reported using CPT codes 364X3 and 364X4 in CY
2018, are currently reported with unlisted CPT code 37799 (Unlisted
procedure, vascular surgery). We have concerns about the frequency that
the current services include treatment of an initial vein (CPT code
364X3) as compared to the treatment of initial and subsequent veins
(CPT codes 364X3 and 364X4 together). It may be more accurate to
describe these services through the use of a single code, as in the
rest of this code family, instead of a base code and add-on code pair.
Under this potential scenario, we looked at the RUC-recommended
crosswalk and noted that the add-on CPT code 364X4 was estimated to be
billed 50 percent of the time together with CPT code 364X3. We
therefore considered adding half of the RUC-recommended work RVU of CPT
code 364X4 (0.88) to the RUC-recommended work RVU of CPT code 364X3
(3.50), resulting in a work RVU of 4.38.
We are proposing to remove the 2 minutes of clinical labor for the
``Setup scope'' (CA015) activity and add the same 2 minutes of clinical
labor for the ``Prepare room, equipment and
[[Page 33997]]
supplies'' (CA013) activity for CPT codes 364X3, 364X5, and 364X6. The
RUC-recommended materials stated that these 2 minutes were a proxy for
setting up the ultrasound machine, and we believe that this 2 minutes
is more accurately described by the ``Prepare room, equipment and
supplies'' (CA013) activity code, since there is no scope equipment
utilized in these procedures. We are proposing to maintain the Vascular
Tech (L054A) clinical labor type for these 2 minutes. We are also
proposing to refine the clinical labor for the ``Check dressings,
catheters, wounds'' (CA029) activity for CPT codes 36470, 36471, 364X3,
364X5, and 364X6, consistent with the standard times for this clinical
labor activity.
We are proposing to remove the six individual 4x4 sterile gauze
(SG055) supplies and replace them with a 4x4 sterile gauze pack of 10
(SG056) for CPT codes 36470, 36471, 364X3, 364X5, and 364X6. The pack
of 10 sterile gauze is cheaper than six individual pieces of sterile
gauze, and we do not agree that it would be typical to pay a higher
cost for fewer supplies. We are also proposing to create three new
supply codes in response to the invoices submitted for this family of
codes. We are proposing to establish a price of $1495 for the Venaseal
glue (SD323) supply, a price of $3195 for the Varithena foam (SD324)
supply, and a price of $40 for the Varithena admin pack (SA125) supply.
We are proposing to adjust the equipment times for the surgical
light (EF014), the power table (EF031), and the portable ultrasound
unit (EQ250) for CPT codes 364X3, 364X5, and 364X6 consistent with the
standards for non-highly technical equipment and to reflect the changes
in the clinical labor described in this section of the proposed rule.
While we remain concerned about the creation of a base code and
add-on code pairing (CPT codes 364X3 and 364X4) out of services that
are currently reported using an unlisted code, for CY 2018, we are
proposing the RUC-recommended work RVUs for each code in this family
and are seeking comment on whether our alternative values would be more
appropriate.
(16) Therapeutic Apheresis (CPT Codes 36511, 36512, 36513, 36514,
36516, and 36522)
CPT code 36516 was nominated as potentially misvalued in the CY
2016 PFS proposed rule. The CPT Editorial Panel deleted CPT code 36515
and made revisions to CPT code 36516 to include immunoabsorption. CPT
codes 36511, 36512, 36513, 36514, and 36522 were added to CPT code
36516 to be reviewed together as part of the therapeutic apheresis
family.
For CY 2018, we are proposing the RUC-recommended work RVU for all
six codes in the family as follows: A work RVU of 2.00 for CPT code
36511, a work RVU of 2.00 for CPT 36512, a work RVU of 2.00 for CPT
code 36513, a work RVU of 1.81 for CPT code 36514, a work RVU of 1.56
for CPT code 36516, and a work RVU of 1.75 for CPT code 36522.
We are proposing to use the RUC-recommended direct PE inputs for
these codes without refinement. We considered refining the clinical
labor time for the ``Prepare room, equipment, supplies'' activity from
20 minutes to 10 minutes for CPT codes 36514 and 36522, and from 30
minutes to 10 minutes for CPT code 36516. We also considered refining
the clinical labor for the ``Prepare and position patient/monitor
patient/set up IV'' activity from 15 minutes to 10 minutes for these
same three codes. In both cases, we considered maintaining the current
clinical labor time for CPT codes 36514 and 36516, and adjusting the
clinical labor time for CPT code 36522 to match the other two codes in
the family. We have concerns about the lack of a rationale provided for
these changes in clinical labor time, and whether these clinical labor
tasks would typically require this additional time.
We are proposing the RUC-recommended work RVUs and to use the RUC-
recommended direct PE inputs for each code in this family and seeking
comment on whether our alternative values would be more appropriate. We
are also seeking comment on whether these procedures are creating a new
point of venous access or utilizing a previously placed access.
(17) Insertion of Catheter (CPT Codes 36555, 36556, 36620, and 93503)
CPT code 36556 was identified as part of a screen of high
expenditure services with Medicare allowed charges of $10 million or
more that had not been recently reviewed. CPT codes 36555, 36620, and
93503 were added for review as part of the code family. We are
proposing the RUC-recommended work RVUs for each code in this family as
follows: A work RVU of 1.93 for CPT code 36555, a work RVU of 1.75 for
CPT code 36556, a work RVU of 1.00 for CPT code 36620, and a work RVU
of 2.00 for CPT code 93503.
We are proposing to remove the clinical labor time for the
``Monitor pt. following procedure'' activity and the equipment time for
the 3-channel ECG (EQ011) for CPT code 36555. CPT code 36555 no longer
includes moderate sedation as part of the procedure (see CY 2017 PFS
final rule (81 FR 80339). We are proposing to remove the direct PE
inputs related to moderate sedation from CPT code 36555 as they would
now be included in the separately reported moderate sedation services.
We are also proposing to refine the equipment times for the exam table
(EF023) and the exam light (EQ168) to reflect changes in the clinical
labor time.
(18) Insertion of PICC Catheter (CPT Code 36569)
CPT code 36569 was identified as part of a screen of high
expenditure services with Medicare allowed charges of $10 million or
more that had not been recently reviewed. For CY 2018, we are proposing
the RUC-recommended work RVU of 1.70 for CPT code 36569.
We are proposing to remove the equipment time for the exam table
(EF023), as this equipment item is a component part of the
radiographic-fluoroscopic room (EL014) included in CPT code 77001
(Fluoroscopic guidance for central venous access device placement,
replacement (catheter only or complete), or removal). Because CPT code
36569 is typically billed together with CPT code 77001, we believe that
the additional equipment time for the exam table would be duplicative.
(19) Bone Marrow Aspiration (CPT Codes 38220, 38221, 382X3, and 2093X)
CPT code 38221 was identified as part of a screen of high
expenditure services with Medicare allowed charges of $10 million or
more that had not been recently reviewed. The descriptors for CPT codes
38220 and 38221 were revised to reflect changes in practice patterns,
and two new CPT codes (382X3 and 2093X) were created to more accurately
describe new services that are now available. For CY 2018, we are
proposing the RUC-recommended work RVUs for each code in this family as
follows: A work RVU of 1.20 for CPT code 38220, a work RVU of 1.28 for
CPT code 38221, a work RVU of 1.44 for CPT code 382X3, and a work RVU
of 1.16 for CPT code 2093X.
We also received a recommendation from the RUC to change the global
period for CPT codes 38220, 38221, and 382X3 from XXX global periods to
0-day global periods, even though these codes were surveyed under the
XXX global period. We agree with the recommendation that for these
three particular codes, their services are more accurately described
when assigned 0-day global periods as opposed to the XXX global status.
Therefore, we propose to assign a 0-day global period
[[Page 33998]]
to all three codes in this family. We note, however, that we believe
that global period changes must be addressed on an individual basis,
especially when the routine survey methodologies rely on assumptions
regarding global periods for particular codes. Subsequently, we are
proposing to refine the preservice work time from 15 minutes of
evaluation time to 9 minutes of evaluation time, 1 minute of
positioning time, and 5 minutes of scrub, dress, and wait time. We are
proposing these refinements to the work times for these three codes to
more closely align with the preservice times of other recently reviewed
0-day global procedures, such as CPT code 30903 (Control nasal
hemorrhage, anterior, complex (extensive cautery and/or packing) any
method). We also note that given our proposal to value CPT code 382X3,
we are proposing to eliminate payment using HCPCS code G0364 for CY
2018 since the changes to the set of CPT codes will now accurately
describe the services currently reported by G0364. For CPT code 2093X,
we considered a work RVU of 1.00 based on a direct crosswalk to CPT
codes 64494 (Injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that
joint) with image guidance (fluoroscopy or CT), lumbar or sacral;
second level) and 64495 (Injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that
joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third
and any additional level(s)). CPT code 2093X is a global ZZZ add-on
code for CPT code 38220, and we are concerned with maintaining
relativity among PFS services, considering that an add-on code
typically has significantly less intraservice time and total time
compared to the base code. We considered an alternative crosswalk to
CPT codes 64494 and 64495, which share the same intraservice and total
time with CPT code 2093X and have a work RVU of 1.00.
We are also proposing to refine the clinical labor for ``Lab Tech
activities'' from 12 minutes to 9 minutes for CPT code 38220, from 7.5
minutes to 7 minutes for CPT code 38221, and from 12.5 minutes to 10
minutes for CPT code 382X3. We are maintaining the current time value
for the two existing codes, as we have no reason to believe that the
typical duration has increased for these lab activities. We are
assigning 10 minutes for CPT code 382X3 based on the statement in the
RUC-recommended materials for the direct PE inputs that this activity
takes 0.5 minutes longer than it does in the current version of CPT
code 38220. We are also proposing to remove the breakout lines for the
lab activities. We believe that the breakout of activities into
numerous subactivities generally tends to inflate the total time
assigned to clinical labor activities and results in values that are
not consistent with the analogous times for other PFS services.
We considered refining the clinical labor for ``Provide preservice
education/obtain consent'' for CPT codes 38220, 38221, and 382X3 from
12 minutes to 6 minutes. We have concerns regarding whether 12 minutes
would be typical for education and consent prior to these procedures,
as much of the patient education takes place following the procedure,
in the clinical labor activity described under the ``Check dressings &
wound/home care instructions'' heading.
We are proposing the RUC-recommended work RVUs for each code in
this family and are seeking comment on whether our alternative values
would be more appropriate.
(20) Esophagectomy (CPT Codes 43107, 43112, 43117, 432X5, 432X6, and
432X7)
CPT codes 432X5, 432X6, and 432X7 were created by the CPT Editorial
Panel to report esophagectomy via laparoscopic and thoracoscopic
approaches. CPT codes 43107, 43112, and 43117 were also reviewed as
part of the family with the three new codes. CPT code 43112 was revised
to clarify the nature of the service being performed. We are proposing
the RUC-recommended work RVUs and work times for all six codes in the
family as follows: A work RVU of 52.05 for CPT code 43107, a work RVU
of 62.00 for CPT code 43112, a work RVU of 57.50 for CPT code 43117, a
work RVU of 55.00 for CPT code 432X5, a work RVU of 63.00 for CPT code
432X6, and a work RVU of 66.42 for CPT code 432X7.
We are also proposing the RUC-recommended work times for all six
codes in this family. We considered removing 20 minutes from the
preservice evaluation work time from all six of the codes in this
family. We have concerns as to whether this additional evaluation time
should be included for surgical procedures, due to the lack of evidence
indicating that it takes longer to review outside imaging and lab
reports for surgical services than for non-surgical services. We also
considered refining the preservice positioning work time and the
immediate postservice work time for all six of the codes in this family
consistent with standard preservice and postservice work times
allocated to other PFS services.
We have concerns about the presence of two separate surveys
conducted for the three new codes. We note that CPT codes 432X5, 432X6,
and 432X7 were surveyed initially in January 2016, and then were
surveyed again in October 2016 together with CPT codes 43107, 43112,
and 43117 due to concerns about the description of the typical patient
in the original vignette and a change in the codes on the reference
service list (RSL). We note that CPT codes 432X5 and 432X6 had the same
median intraservice time on both surveys, while CPT code 432X7 had a
median intraservice time that was an hour longer on its second survey
(420 minutes) as compared to its first survey (360 minutes). We also
note that the total survey time for CPT code 432X5 decreased from 1058
minutes in the first survey to 972 minutes in the second survey, while
the median work RVU increased from 50.00 to 65.00. We do not understand
how the survey median intraservice time could increase so significantly
from the first survey to the second survey for CPT code 432X7, or how
the surveyed times for CPT code 432X5 could be decreasing while the
work RVU was simultaneously increasing by 15.00 work RVUs.
Based on our analysis, it appears that the accompanying RSL is the
main difference between the two surveys; the codes on the initial RSL
had a median work RVU of 44.18, while the codes on the second RSL had a
median work RVU of 59.64. This increase of 15.00 work RVUs between the
two RSLs that accompanied the surveys appears to account for the
increase in the work RVUs for the three new codes. We are concerned
that the second survey may have overestimated the work required to
perform these procedures, as the 25th percentile work RVU of the second
survey is higher than the median work RVU of the initial survey for all
three codes, despite no change in the median intraservice work time for
CPT codes 432X5 and 432X6.
Given these concerns, we considered a work RVU of 50.00 for CPT
code 432X5, a work RVU of 60.00 for CPT code 432X6, and a work RVU of
61.00 for CPT code 432X7, by using the survey median work RVU from the
first survey for the three new codes. For CPT codes 43107 and 43117, we
considered employing the intraservice time ratio between the
laparoscopic version of the procedure represented by the new code and
the open version of the same procedure represented by the existing
code.
[[Page 33999]]
We considered a work RVU of 45.00 for CPT code 43107 based on the
intraservice time ratio with CPT code 432X5 and a work RVU of 55.00 for
CPT code 43117 based on the intraservice time ratio with CPT code
432X6. CPT code 43107 has 270 minutes of intraservice time as compared
with 300 minutes of intraservice time for CPT code 432X5, which
produces a ratio of 0.9, and when multiplied by a work RVU of 50.00
(CPT code 432X5), results in the proposed work RVU of 45.00. We
considered using the same methodology for CPT codes 43117 and 432X6.
Finally, we considered a work RVU of 58.94 for CPT code 43112 based
on a direct crosswalk to CPT code 46744 (Repair of cloacal anomaly by
anorectovaginoplasty and urethroplasty, sacroperineal approach). We
note that the intraservice time ratio when applied to CPT codes 43112
and 432X7, the paired McKeown esophagectomy procedures, would have
produced a potential work RVU of 52.29, creating a rank order anomaly
within the family by establishing a higher work RVU for CPT code 43117
than CPT code 43112, and are concerned with whether this is an
appropriate valuation for the code. We are seeking comment on whether
the alternative work RVUs that we considered may reflect the relative
difference in work more accurately between the six codes in the family.
We note, for example, that these valuations correct the rank order
anomaly between CPT codes 43112 and 43121 as noted in the RUC
recommendations.
We are proposing the RUC-recommended direct PE inputs for all six
codes in the family without refinement. We considered changing the
preservice clinical labor type for all six codes from an RN (L051) to
an RN/LPN/MTA blend (L037D). We have concerns about whether the use of
RN clinical labor would be typical for filling out referral forms or
for scheduling space and equipment in the facility. We also considered
removing the additional clinical labor time for the ``Additional
coordination between multiple specialties for complex procedures (eg,
tests, meds, scheduling)'' activity, consistent with preservice
standards for codes with 90-day global periods. We are concerned that
this time would not typically be included in non-surgical procedures
performed by other specialties even when additional coordination is
required.
We are seeking comment regarding the changes in the valuation
between the two surveys, the preservice and immediate postservice work
times, and the RN staffing type employed for routine preservice
clinical labor.
(21) Transurethral Electrosurgical Resection of Prostate (CPT Code
52601)
CPT code 52601 appeared on a screen of potentially misvalued codes
which indicated that it was performed less than 50 percent of the time
in the inpatient setting, yet included inpatient hospital E/M services
within the global period. For CY 2018, we are proposing the RUC-
recommended work RVU of 13.16 for CPT code 52601 and proposing to use
the RUC-recommended direct PE inputs without refinements.
We considered a work RVU of 12.29 for CPT code 52601 based on a
direct crosswalk to CPT code 58541 (Laparoscopy, surgical,
supracervical hysterectomy, for uterus 250 g or less), which is one of
the reference codes. CPT code 58541 may potentially be a more accurate
crosswalk for CPT code 52601 than the RUC-recommended direct crosswalk
to CPT code 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis).
Although all three of these codes share the same intraservice time of
75 minutes, CPT code 58541 is a closer match in terms of the total time
at only 10 minutes difference. CPT code 58541 also shares the same
postoperative office visits as CPT code 52601, a pair of CPT code 99213
office visits, while CPT code 29828 also contains two CPT code 99212
office visits that are not present in the reviewed code.
We note that if we were to use a reverse building block methodology
for CPT code 52601 and subtract out the value of the E/M visits being
removed, the proposed work RVU would be 11.21. We are not proposing
this work RVU, however, because as we noted in the CY 2017 PFS final
rule (81 FR 80274), we agree that the per-minute intensity of work is
not necessarily static over time or even necessarily during the course
of a procedure. Instead, we utilize time ratios and building block
methodologies to identify potential values that account for changes in
time and compare these values to other PFS services for estimates of
overall work. When the values we develop reflect a similar derived
intensity, we agree that our values are the result of our assessment
that the relative intensity of a given service has remained similar.
For CPT code 52601, we are concerned as to how the RUC-recommended
derived intensity of the procedure could be increasing by 30 percent
over the current derived intensity, while at the same time the typical
site of service is changing from inpatient to outpatient status. In
other words, if it is now typical for CPT code 52601 to be performed on
an outpatient basis, then we would generally expect the intensity of
the procedure to be decreasing, not increasing. We considered a work
RVU of 12.29 for CPT code 52601 based on a direct crosswalk to CPT code
58541 (Lsh uterus 250 g or less), and seek comment on whether this
alternative value might better reflect relativity.
(22) Peri-Prostatic Implantation of Biodegradable Material (CPT Code
55X87)
In October 2016, the CPT Editorial Panel deleted CPT Category III
code 0438T and created a new CPT code 55X87 (Transperineal placement of
biodegradable material, peri-prostatic, single or multiple
injection(s), including image guidance, when performed). For CY 2018,
we are proposing the RUC-recommended work RVU of 3.03 for CPT code
55X87.
In reviewing the RUC recommendations, we noted a decrease in
preservice time (30 minutes) compared to the current value. In order to
account for this change in time, we considered calculating the
intraservice time ratio between the key reference code (CPT code
49411), which has an intraservice time of 40 minutes, and the RUC-
recommended intraservice time (30 minutes) and multiplying that against
the work RVU for CPT code 49411 (3.57), which would have resulted in a
work RVU of 2.68. A work RVU of 2.68 would have been further supported
by a bracket of two crosswalk codes, CPT code 65779 (Placement of
amniotic membrane on the ocular surface; single layer, sutured) which
has a work RVU of 2.50 and CPT code 43252 (Esophagogastroduodenoscopy,
flexible, transoral; with optical endomicroscopy), which has a work RVU
of 2.96. Compared with CPT code 55X87, these codes have identical
intraservice and similar total times. We are seeking comment on whether
these alternative values should be considered, especially given the
changes in time reflected in the survey data.
We received invoices with pricing information regarding two new
supply items: ``endocavity balloon'' and ``biodegradeable material
kit--periprostatic''. The invoice for endocavity balloon was $399.00
and the input price on the PE spreadsheet for this supply item was
noted as such. We believe the input price noted on the PE spreadsheet
was an error, given that the invoice noted that the price of $399.00
was for a box of ten and the specialty society requested a single unit
of this supply item. Therefore, we are proposing to use this
information to propose for supply item ``endocavity balloon'' a price
of $39.90. The invoice
[[Page 34000]]
for the ``biodegradeable material kit--periprostatic'' totaled
$2850.00. We are proposing to use this information to propose for the
supply item ``biodegradeable material kit--periprostatic'' a price of
$2850.00. We also received an invoice with pricing information
regarding the new equipment item ``endocavitary US probe'' which
totaled $16,146.00. We are proposing to use this information to propose
for equipment item ``endocavitary US probe'', a per-minute price of
$0.0639. We question, given an invoice price of $29,999.00 for this
existing equipment item EQ250 (portable ultrasound unit), whether this
equipment item includes probes. We are seeking public comments related
to whether equipment item EQ250 (portable ultrasound) includes probes.
(23) Colporrhaphy With Cystourethroscopy (CPT Codes 57240, 57250, 57260
and 57265)
In October 2015, CPT code 57240 was identified by analysis of the
Medicare data from 2011-2013 that indicated that services reported with
CPT code 57240 were performed less than 50 percent of the time in the
inpatient setting, yet include inpatient hospital E/M services within
the global period. The RUC recommended that CPT codes 57240 (Anterior
colporrhaphy, repair of cystocele with or without repair of
urethrocele), 57250 (Posterior colporrhaphy, repair of rectocele with
or without perineorrhaphy), 57260 (Combined anteroposterior
colporrhaphy), and 57265 (Combined anteroposterior colporrhaphy; with
enterocele repair) be referred to the CPT Editorial Panel. In September
2016, the CPT Editorial Panel revised 57240, 57260 and 57265 to
preclude separate reporting of follow up cystourethroscopy after
colporrhaphy (CPT code 52000).
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
code 57240 (a work RVU of 10.08), CPT code 57250 (a work RVU of 10.08),
CPT code 57260 (a work RVU of 13.25), and CPT code 57265 (a work RVU of
15.00).
We note that there were changes in service times reflected in the
specialty surveys compared to the RUC-recommended work RVUs for CPT
code 57240. Specifically, we note that the RUC recommended a 48 minute
decrease in total time, compared to the specialty survey total time of
259 minutes. The difference in total time reflected a decrease in
preservice time (29 minutes) and inpatient visits (0.5 visits = 19
minutes). We considered a work RVU of 9.77 for CPT code 57240,
crosswalking to CPT code 50590 (Lithotripsy, extracorporeal shock
wave), which has similar service times. We are seeking comment on
whether CPT code 57250 would be a relevant comparator for CPT code
57240, based on the described elements of each service and existing or
surveyed service times, compared to CPT code 57240.
We considered a work RVU of 11.47 for CPT code 57265, crosswalking
to CPT code 47563 (Laparoscopy, surgical; cholecystectomy with
cholangiography) with similar service times. We seek comment on how an
alternative work RVU of 11.47 for CPT code 57265 would affect
relativity among PFS services, and on whether CPT code 57260 is a
relevant comparator for CPT code 57265, considering differences in the
described procedures and service times.
We are proposing the RUC-recommended direct PE inputs for CPT codes
57240, 57250, 57260 and 57265 without refinements.
(24) Nerve Repair With Nerve Allograft (CPT Codes 64910, 64911, 64X91
and 64X92)
The CPT Editorial Panel created two new CPT Category I codes (64X91
and 64X92) to report the repair of a nerve using a nerve allograft. CPT
codes 64910 and 64911 were also reviewed as part of this code family.
CPT codes 64X91 and 64X92 will be placed on the new technology list to
be re-reviewed by the RUC in 3 years to ensure correct valuation and
utilization assumptions.
For CY 2018, we are proposing the RUC-recommended work RVUs for the
following codes: A work RVU of 10.52 for CPT code 64910, a work RVU of
14.00 for CPT code 64911, a work RVU of 12.00 for CPT code 64X91, and a
work RVU of 3.00 for CPT code 64X92.
We noted a decrease in preservice time (7 minutes) for CPT code
64910 and considered an alternate work RVU of 10.15, crosswalking to
CPT code 15120 (Split-thickness autograft, face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits;
first 100 sq cm or less, or 1 percent of body area of infants and
children (except 15050)), which has similar service times. We seek
comments on whether an alternative work RVU of 10.15 for CPT code 64910
would better reflect relativity among PFS services with similar service
times.
For CPT code 64911 (Nerve repair; with autogenous vein graft
(includes harvest of vein graft), each nerve)), we considered a work
RVU of 13.50, crosswalking to CPT code 31591 (Laryngoplasty,
medicalization, unilateral), which has similar service times. We seek
comments on whether a work RVU of 13.50 for CPT code 64911 would better
reflect relativity among other PFS services with similar service times.
The new coding structure for these services increases granularity
by including add-on codes that describe each strand of nerve repair.
While we recognize that additional granularity may be important and
useful for purposes of data collection, the advantages to Medicare for
such granularity for purposes of payment are unclear, especially since
we are unaware of a payment-related reason for such coding complexity.
We considered proposing a bundled status to the new add-on codes and
incorporating the relative resources in furnishing the add-on code (CPT
code 64X92) into the base code (CPT code 64X91) based on the
utilization assumptions that accompanied the RUC recommendations. The
RUC estimated that CPT code 64X91 would have 750 Medicare allowed
services in CY 2018, and that the corresponding add-on CPT code 64X92
would have 150 Medicare allowed services in CY 2018. Therefore, the RUC
estimates that CPT code 64X91 will be billed without add-on CPT code
64X92 for 80 percent (750/900) of the Medicare allowed services, and
that CPT code 64X91 will be billed with add-on CPT code time 64X92 for
20 percent (150/900) of the Medicare allowed services in CY 2018. To
account for the additional work involved in 20 percent of the allowed
services, we added a work RVU of 0.60 (20 percent of a work RVU of 3.00
for CPT code 64X92) to the work RVU of 12.00 for CPT code 64X91, to get
to an alternate work RVU of 12.60 for CPT code 64X91 and increased the
intraservice time by 6 minutes to account for the bundling of services
from CPT code 64X92. The alternative work RVU of 12.60 would have been
further supported by a crosswalk to CPT code 14301 (Adjacent tissue
transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm),
which has similar intraservice and total times.
We are proposing the RUC-recommended direct PE inputs for CPT codes
64910, 64911, 64X91 and 64X92 without refinements.
(25) CT Soft Tissue Neck (CPT Codes 70490, 70491, and 70492)
CPT codes 70490 and 70492 were identified through the high
expenditure services across specialties with Medicare allowed charges
of $10 million or more screen. CPT code 70491 was also included for
review as part of this code family. For CY 2018, we are proposing the
RUC-recommended work RVUs of 1.28 for CPT code 70490, 1.38
[[Page 34001]]
for CPT code 70491, and 1.62 for CPT code 70492.
For CPT code 70490, we considered a work RVU of 1.07 based on a
crosswalk to CPT code 72125 (Computed tomography, cervical spine;
without contrast material). CPT code 72125 is a non-contrast CT service
on a similar anatomical area and has identical intraservice and total
times to those recommended by the RUC for CPT code 70490. We also
considered work RVUs of 1.17 for CPT code 70491 and 1.41 for CPT code
70492. We are seeking comment on how relativity among other CT services
paid under the PFS would be affected by applying the alternative work
RVUs described above for CPT codes in this family.
(26) Magnetic Resonance Angiography (MRA) Head (CPT Codes 70544, 70545,
and 70546)
CPT code 70544 was identified by a screen of services across
specialties with Medicare allowed charges of $10 million or more.
Subsequently, CPT codes 70545 and 70546 were also reviewed as part of
this code family. We are proposing the RUC-recommended work RVUs of
1.20 for CPT code 70544, 1.20 for CPT code 70545, and 1.48 for CPT code
70546.
We are also proposing the following refinements to the RUC-
recommended direct PE inputs. For the service period clinical labor
activity ``Provide preservice education/obtain consent,'' we are
proposing 5 minutes for CPT code 70544, 7 minutes for CPT code 70545,
and 7 minutes for CPT code 70546 so that the times for this activity
are consistent with other magnetic resonance (MR) services performed
without-contrast materials, with-contrast materials, and without-and-
with contrast materials, respectively. For the clinical labor task
``Acquire images,'' we are proposing to use the RUC-recommended
clinical time of 26 minutes for CPT code 70544. We considered proposing
20 minutes of clinical time to maintain the relativity among the three
codes in this family and for consistency with other MRA and magnetic
resonance imaging (MRI) codes, which do not typically assign more
clinical labor time to this task for services without contrast material
than for services with contrast material. We seek comments as to the
appropriate time value for this clinical labor task.
(27) Magnetic Resonance Angiography (MRA) Neck (CPT Codes 70547, 70548,
and 70549)
CPT code 70549 was identified through a high expenditure screen.
CPT codes 70547 and 70748 were also reviewed as part of this family of
codes. We are proposing the RUC-recommended work RVUs of 1.20 for CPT
code 70547, 1.50 for CPT code 70548, and 1.80 for CPT code 70549.
We are also proposing several refinements to the RUC-recommended
direct PE inputs for these services. For the service period clinical
labor activity ``Provide preservice education/obtain consent'', we are
proposing 5 minutes for CPT code 70547, 7 minutes for CPT code 70548,
and 7 minutes for CPT code 70549 so that the times for this activity
are consistent with other MR services performed without contrast
material, with contrast material, and without-and-with contrast
material, respectively.
For the intraservice clinical labor task acquire images, for CPT
code 70547, we are proposing to use the RUC-recommended 26 minutes. We
considered applying 20 minutes to this clinical labor task, which would
have maintained consistency with the 20 minutes recommended by the RUC
for CPT code 70548 (the service that includes with-contrast material).
We are concerned about the lack of evidence that a non-contrast MRA
would require more clinical labor time than the with-contrast MRA
service. We are seeking comment as to the appropriate time value for
this clinical labor task.
(28) CT Chest (CPT Codes 71250, 71260, and 71270)
CMS identified this code family through the high expenditures
screen. We are proposing the RUC-recommended work RVUs of 1.16 for CPT
code 71250, 1.24 for CPT code 71260, and 1.38 for CPT code 71270.
For CPT code 71250, we considered maintaining the CY 2017 work RVU
of 1.02. We are concerned with the lack of evidence that the physician
time or intensity of furnishing this service has changed since it was
last valued. In addition, a comparison to other CT codes indicates that
the RUC-recommended work values could be overvalued relative to other
CT services and compared to similar, non-contrast CT studies such as
CPT codes 72131 (Computed tomography, lumbar spine; without contrast
material) and 73700 (Computed tomography, lower extremity; without
contrast material), both of which have work RVUs of 1.00.
For CPT code 71260, we considered proposing a work RVU of 1.10 by
applying the RUC-recommended increment between CPT code 71250 and 71260
(0.08) to CPT code 71260. For CPT code 71270, we considered a work RVU
of 1.24 by applying the RUC-recommended increment between CPT codes
71260 and 71270 (0.22) to CPT code 71270. In addition to maintaining
relatively among the codes in this family, we considered further
supporting these alternative values based on a comparison to other CT
studies, such as with-contrast material CT studies, and without-and-
with contrast CT studies.
While we have concerns about the RUC-recommended work RVUs for
these codes, for CY 2018, we are proposing the RUC recommended work
RVUs for CPT code 71250, 71260, and 71270 and are seeking comment on
whether our alternative values would improve relativity.
(29) MRI of Abdomen and Pelvis (CPT Codes 72195, 72196, 72197, 74181,
74182, and 74183)
CPT codes 74182 and 72196 were identified as part of the screen of
high expenditure services across specialties with Medicare allowed
charges of $10 million or more. CPT codes 74181, 74183, 72195, and
72197 were also reviewed as part of this code family. We are proposing
the RUC-recommended work RVUs of 1.46 for CPT code 72195, 1.73 for CPT
code 72196, 2.20 for CPT code 72197, 1.46 for CPT code 74181, 1.73 for
CPT code 74182, and 2.20 for CPT code 74183.
While we are proposing the RUC-recommended direct PE inputs, we
considered 30 minutes for clinical labor task ``Acquire images'' for
CPT codes 74181 and 74182, which appears to be more consistent with the
codes in this family and more consistent with other MR codes. We also
note that for CPT codes 74181 and 74182, the clinical labor time for
acquired images appears to have been developed through a consensus
panel from the specialty society over 15 years ago. Given that these
times are estimates based on expert panel consensus rather than survey
data, we seek comments on whether using a structure that matches other
MR code families would be more appropriate to value these clinical
labor times.
(30) MRI Lower Extremity (CPT Codes 73718, 73719, and 73720)
CPT codes 73718 and 73720 were identified as part of the screen of
high expenditure services, and CPT code 73719 was included for review
as part of the code family. We are proposing the RUC-recommended work
RVUs of 1.35 for CPT code 73718, 1.62 for CPT code 73719, and 2.15 for
CPT code 73720.
We are also proposing the following refinements to the RUC-
recommended direct PE inputs. For the service period clinical labor
activity ``Provide preservice education/obtain consent,''
[[Page 34002]]
we are proposing 5 minutes for CPT code 73718, 7 minutes for CPT code
73719, and 7 minutes for CPT code 73720. Likewise, for the service
period task ``Prepare room, equipment, supplies,'' we are proposing 3
minutes for CPT code 73718, 5 minutes for CPT code 73719, and 5 minutes
for CPT code 73720. We are proposing these changes to maintain
consistency with other MR services without contrast materials, with
contrast materials, and without-and-with contrast materials,
respectively.
(31) Abdominal X-ray (CPT Codes 74022, 740X1, 740X2, and 740X3)
CPT codes 74000 (Radiologic examination, abdomen; single
anteroposterior view) and 74022 (Radiologic examination, abdomen;
complete acute abdomen series, including supine, erect, and/or
decubitus views, single view chest) were identified via a high
expenditure screen. The CPT Editorial Panel created CPT codes 740X1,
740X2, and 740X3 to replace CPT codes 74000, 74010, and 74020. For CY
2018, we are proposing the RUC-recommended work values for these codes.
As part of their recommendations, the RUC's utilization crosswalk
suggests that 25 percent of services currently reported with CPT code
74010 will be reported with CPT code 740X2 and 75 percent will be
reported with CPT code 740X3; and 75 percent of services currently
reported with CPT code 74020 will be reported with CPT code 740X2 and
25 percent will be reported with CPT code 740X3. However, we did not
identify evidence or a rationale for these assumptions. For purposes of
calculating the proposed RVUs, we used an even distribution of services
previously reported as CPT codes 74010 and 74020 to CPT codes 740X2 and
740X3 instead of the RUC-recommended distribution because we think that
the services previously reported with codes 74010 and 74020 will be
reported in equal volume between the code representing two views and
the code representing three views. We seek comment on information that
would help us improve on this distribution for purposes of developing
final RVUs, including rationale for the distribution reflected in the
RUC's utilization crosswalk.
(32) Angiography of Extremities (CPT Codes 75710 and 75716)
This code family was identified through the $10 million or more
screen of high expenditure services. We are proposing the RUC-
recommended work RVUs of 1.75 for CPT code 75710 and 1.97 for CPT code
75716. We are also proposing to use the RUC-recommended direct PE
inputs for both CPT codes 75710 and 75716, with the following
refinements. For the clinical labor task ``Technologist QC's images in
PACS, checking for all images, reformats, and dose page,'' we are
proposing refinements consistent with the standard clinical labor times
for tasks associated with the PACS Workstation.
We are also proposing to refine the clinical labor by removing the
2 minutes associated with the task ``prepare room, equipment, and
supplies.'' CPT codes 75710 and 75716, which represent radiological
supervision and interpretation, are billed with codes that include
activities such as needle placement and imaging, and the ``prepare
room, equipment, supplies,'' activity will be accounted for with the
codes that are billed with these interpretation codes.
(33) Ophthalmic Biometry (CPT Codes 76516, 76519, and 92136)
In the CY 2016 PFS final rule with comment period, CMS identified
CPT codes 76519 and 92136 as potentially misvalued on the high
expenditure screen. For CY 2018, we are proposing the RUC-recommended
work RVUs for each code in this family as follows: A work RVU of 0.40
for CPT code 76516, a work RVU of 0.54 for CPT code 76519, and a work
RVU of 0.54 for CPT code 92136.
For both CPT codes 76519 and 92136, the RUC recommended adding an
additional 8 minutes of immediate postservice time for dictating the
report of the procedure for the medical record, review and sign report,
communicate results to the patient, discussing lens implant options for
desired post-operative refractive result, and entering an order for the
intraocular lens implant. We considered time and work values that would
not include the additional 8 minutes of immediate postservice time in
either of these codes, due to the concern that the additional time may
not reflect the typical case. Were we to not include those 8 minutes,
each of these procedures would have a total time of 14 minutes. We
considered applying the total time ratio (decrease from 17 minutes to
14 minutes; ratio of 0.824) to the RUC-recommended work RVU of 0.54,
which would have resulted in a work RVU of 0.44 for both CPT codes
76519 and 92136. We are seeking comment on whether these alternative
values would improve relativity.
(34) Ultrasound of Extremity (CPT Codes 76881 and 76882)
The RUC identified CPT codes 76881 and 76882 for review of PE
inputs. For CPT code 76881, we are proposing the recommended inputs
with refinements. We are proposing to remove 1 minute from the clinical
labor task ``Exam documents scanned into PACS. Exam completed in RIS
system to generate billing process and to populate images into
Radiologist work queue,'' because this code does not include any
equipment time for the PACS workstation proxy or professional PACS
workstation. We note that the RUC-recommended inputs shift the general
ultrasound room from the PE inputs for CPT code 76881 to the PE inputs
for CPT code 76882. We are proposing to make this change, consistent
with the RUC recommendations. We are also seeking comment on whether a
portable ultrasound unit would be a more accurate PE input for both
codes, given that the dominant specialty for both of these services is
podiatry based on available 2016 Medicare claims data. However, we are
proposing that these codes would not be subject to the phase-in of
significant RVU reductions given the significance of this shift of
resource costs between codes in the same family. In the CY 2016 PFS
final rule (80 FR 70927 through 70931), we finalized a policy to
identify services that are not subject to the phase-in because they are
new or revised codes. We excluded as new and revised codes those codes
that describe a different set of services in the update year when
compared to the current year by virtue of changes in other related
codes or codes that are part of a family with significant coding
revisions. Significant coding revisions within a family of codes can
change the relationships among codes to the extent that it changes the
way that all services in the group are reported, even if some
individual codes retain the same number or, in some cases, the same
descriptor. Moving the general ultrasound room input from CPT code
76881 to CPT code 76882 as recommended by the RUC would represent a
significant shift in direct PE due to the high cost nature of this
equipment item. As a result, these codes describe different services in
the update year than in the current year, producing a substantial
revision in the valuation of the coding. We are seeking comment on this
proposed application of the phase-in policy.
(35) Radiation Therapy Planning (CPT Codes 77261, 77262, and 77263)
CPT code 77263 was identified through a screen of high expenditure
services across specialties. CPT codes 77261 and 77262 were included
for review. For CY 2018, we are proposing the RUC-recommended work RVUs
of
[[Page 34003]]
1.30 for CPT code 77261, 2.00 for CPT code 77262, and 3.14 for CPT code
77263.
However, we have concerns regarding the RUC-recommended work RVUs
given the decreases in service times as recommended by the RUC and
reflected in the survey data compared to the current values. For CPT
code 77263, we considered a work RVU of 2.60 based on a crosswalk to
CPT code 96111 (Developmental testing, (includes assessment of motor,
language, social, adaptive, and/or cognitive functioning by
standardized developmental instruments) with interpretation and
report), which has an identical intraservice time, and similar total
time to the RUC-recommended time values for CPT code 77263. We are
concerned that despite a 15 minute decrease in intraservice time, the
RUC did not recommend a work RVU decrease.
We note that the majority of the utilization among the codes in
this family would be reported with CPT code 77263. Therefore, we
considered using a work RVU of 2.60 for CPT code 77263 as a base for
alternative valuations for CPT codes 77261 and 77262 by applying the
ratio of the crosswalk work RVU of CPT code 96111 (Developmental test
extend) to the RUC-recommended work RVU of CPT code 77263 (that is,
2.60/3.14 = 0.83) to the RUC-recommended work RVU for CPT code 77261
(that is, 0.83 x 1.30 = 1.08) and CPT code 77262 (that is, 0.83 x 2.0 =
1.66), which would have resulted in work RVUs of 1.08 for CPT code
77261 and 1.66 for CPT code 77262. We seek comments on whether the
alternative valuation would be more appropriate for these codes.
(36) Pathology Consultation during Surgery (CPT Codes 88333 and 88334)
CPT codes 88333 and 88334 were surveyed for both work and PE for
the CY 2018 rule cycle. We are proposing the RUC-recommended work RVU
of 1.20 for CPT code 88333 and the RUC-recommended work RVU of 0.73 for
CPT code 88334. For the direct PE inputs, we are proposing to remove
the clinical labor for the ``Prepare room. Filter and replenish stains
and supplies (including setting up grossing station with colored
stains)'' activity from CPT code 88333. This clinical labor is not
currently included in the direct PE inputs for CPT code 88333, and we
continue to believe that this is a form of indirect PE that is not
individually allocable to a particular patient for a particular
service. While we agree that replenishing stains and supplies is a
necessary task, under the established methodology, it is more
appropriately classified as indirect PE.
We are proposing to refine the clinical labor time for ``Clean
room/equipment following procedure'' activity for CPT code 88333,
consistent with the standard clinical labor time assigned for room
cleaning when used by laboratory services. We seek comments related to
the equipment time assigned to the ``grossing station w-heavy duty
disposal'' (EP015) for both CPT codes 88333 and 88334. Although the
recommended equipment time of 10 minutes maintains the current
equipment time assigned to the grossing station, and we have no reason
to believe that this time is incorrect, it is unclear to us how this
equipment time is derived.
(37) Tumor Immunohistochemistry (CPT Codes 88360 and 88361)
CPT codes 88360 and 88361 appeared on a high expenditure services
screen across specialties with Medicare allowed charges of over $10
million. We are proposing the RUC-recommended work RVU of 0.85 for CPT
code 88360 and the RUC-recommended work RVU of 0.95 for CPT code 88361.
We are proposing to refine the clinical labor time for the ``Enter
patient data, computational prep for antibody testing, generate and
apply bar codes to slides, and enter data for automated slide stainer''
activity for both codes, consistent with the standard time for this
clinical labor activity across different pathology services. For CPT
code 88361, we are also proposing to remove the 1 minute of clinical
labor time from the ``Performing instrument calibration, instrument qc
and start up and shutdown'' and the ``Gate areas to be counted by the
machine'' activities. These clinical labor activities do not appear in
other recently reviewed computer-assisted pathology codes. We believe
that these clinical labor activities would not be typical for CPT code
88361 and are already included in the allocation of indirect PE
consistent with our established methodology.
We are proposing to remove the clinical labor time for ``Clean
room/equipment following procedure'' for CPT codes 88360 and 88361, as
we believe that this clinical labor is duplicative of the 4 minutes of
clinical labor assigned to ``Clean equipment and work station in
histology lab''. We are also proposing to remove the clinical labor
time for the ``Verify results and complete work load recording logs''
and the ``Recycle xylene from tissue processor and stainer'' activities
for CPT codes 88360 and 88361. As we have stated in previous rules,
such as in the CY 2017 PFS final rule (81 FR 80319), we believe these
clinical labor activities to be already included in the allocation of
indirect PE consistent with our established methodology.
We are proposing to refine the equipment time for the ``Benchmark
ULTRA auto slide prep & E-Bar Label system'' (EP112) from 18 minutes to
16 minutes for both codes. The RUC-recommended equipment time of 18
minutes was an increase of 3 minutes from the current EP112 equipment
time to incorporate the equipment time of the ``E-Bar II Barcode Slide
Label System'' (EP113), which the recommended materials have clarified
is part of the EP112 equipment item. We are proposing to add 1 minute
over the current value of 15 minutes to the EP112 equipment time to
reach the aforementioned 16 minutes, as we believe that this would be
more typical for the slide labeling taking place.
For CPT code 88361, we are proposing to maintain the current price
of $195,000.00 for the DNA image analyzer (EP001) equipment, as the
submitted invoice contains a series of unrelated items that have been
crossed out, making it difficult to determine the cost of the
equipment. We considered refining the equipment time for the DNA image
analyzer from 30 minutes to 5 minutes. The equipment literature for the
DNA image analyzer states that the machine can run 50 slides per hour,
and CPT code 88361 only requires 3 slides per procedure. This works out
to 3.6 minutes of equipment usage (3 slides divided by 50 slides per
hour multiplied by 60 minutes in an hour), to which we considered
adding 1 minute for preparing the slides. The resulting figure of 4.6
minutes would then round up to 5 minutes, which we considered as the
potential equipment time for EP001 assigned to CPT code 88361. We seek
comments on additional pricing information for the EP001 DNA image
analyzer equipment, specifically invoices solely for this equipment
containing a rationale for each component part, as well as the
appropriate equipment time typically required for use in CPT code
88361.
(38) Cardiac Electrophysiology Device Monitoring Services (CPT Codes
93279, 93281, 93282, 93283, 93284, 93285, 93286, 93287, 93288, 93289,
93290, 93291, 93292, 93293, 93294, 93295, 93296, 93297, 93298, and
93299)
As part of the CY 2016 PFS final rule (80 FR 70914), several
services in this family (reported with CPT codes 93288, 93293, 93294,
93295, and 93296) were identified as potentially misvalued through the
high expenditure by
[[Page 34004]]
specialty screen. Seven of the 21 services in this family involve
remote monitoring of cardiovascular devices, and two of these services
(reported with CPT codes 93296 and 93299) are valued for practice
expense only. For CY 2018, we are proposing the RUC-recommended work
RVUs for the 19 CPT codes in this family that are valued with physician
work as follows: 0.65 for CPT code 93279, 0.77 for CPT code 93280, 0.85
for CPT code 93281, 0.85 for CPT code 93282, 1.15 for CPT code 93283,
1.25 for CPT code 93284, 0.52 for CPT code 93285, 0.30 for CPT code
93286, 0.45 for CPT code 93287, 0.43 for CPT code 93288, 0.75 for CPT
code 93289, 0.43 for CPT code 93290, 0.37 for CPT code 93291, 0.43 for
CPT code 93292, 0.31 for CPT code 93293, 0.60 for CPT code 93294, 0.74
for CPT code 93295, 0.52 for CPT code 93297, and 0.52 for CPT code
93298.
For CPT code 93293, we considered a work RVU of 0.91 (25th
percentile survey result) and seek comment on whether this alternative
work RVU for this service would better maintain relativity between
single and dual lead pacemaker systems and cardioverter defibrillator
services. We considered reducing the work RVU for CPT code 93282 by
0.11 work RVUs and seek comments on whether this alternative value
would better reflect relativity between the single and dual lead
systems that exist within pacemaker services and within cardioverter
defibrillator services. We also noted that there is a difference of
0.10 work RVUs between the RUC-recommended values for CPT codes 93289
and 93282. Therefore, we considered a proportionate reduction for CPT
code 93289 to a work RVU of 0.69. For CPT code 93283, we considered a
work RVU of 0.91, consistent with the 25th percentile from the survey
results, and seek comment on whether this value would improve
relativity.
As noted in this section of the proposed rule, several of the CPT
codes (99392, 99294, 99295, 99297, and 99298) reviewed by the RUC in
January 2017 involve remote monitoring services for cardiac devices. We
agree with the RUC that these services are difficult to value
considering that the monitoring duration (number of days between 30 and
90) and the average number of transmissions vary. We also note that
these codes were surveyed twice, and in both cases the intraservice and
total times were considered by the specialty societies to be
inconsistent with existing times. The RUC explained that they
extrapolated total and intraservice time data for these codes and
warned against making comparisons. Without additional information about
the methods and sources used for extrapolation, however, we have no
basis for assuming the imputed values are of higher quality and/or
accuracy than those from the survey. We do not agree, therefore, that
survey results should not be used as a point of comparison in the
context of other factors, particularly when they are used to support
other considerations.
Although we are proposing the RUC-recommended work RVUs for each of
these CPT codes, we considered alternative values. The RUC recommended
a work RVU of 0.31 for CPT code 93293, which is 0.01 work RVUs lower
than the existing work RVU for this code. We have concerns that the
amount of the reduction in the work RVU recommended by the RUC may not
be consistent with the decrease in total time of 7 minutes. We
considered an alternative crosswalk for CPT code 93293 (Pm phone r-
strip device eval) (5 minutes intraservice time and 13 minutes total
time) to CPT code 94726 (Pulm funct tst plethysmograp), which has 5
minutes intraservice time and 15 minutes total time and a work RVU of
0.26. We seek comments our proposed and alternative valuations for this
code.
For CPT code 93294, we considered a work RVU of 0.55, crosswalking
from CPT code 76706 (Us abdl aorta screen aaa), and we seek comments on
whether it would better align with the RUC-recommended service times.
We are concerned that a work RVU of 0.60 may not account for the
difference between existing service times and the RUC-recommended
service times. Similarly, the RUC recommended a work RVU for CPT code
93294 of 0.60, which is 0.05 work RVUs less than the existing work RVU.
The total time for furnishing services reported with CPT code 93294
decreased by 10 minutes, however, and we believe this reduction in time
may not be appropriately reflected by a decrease of 0.05 work RVUs.
Compared to services with similar total and intraservice times, we
identified CPT code 76706 (Us abdl aorta screen aaa) as potentially a
more appropriate crosswalk. CPT code 76706 has identical intraservice
and total service times as CPT code 93294, with a work RVU of 0.55. We
seek comments on whether our alternative value would better reflect the
time and intensity involved in furnishing this service.
For CPT code 93295, we considered a work RVU of 0.69, crosswalking
to CPT code 76586, which has identical intraservice and total times
compared to CPT code 93295. We considered using a work RVU of 0.69 to
maintain the differential between CPT code 93295 and the work RVU we
considered for the previous code in this family (a work RVU of 0.11 for
CPT code 93295). We are concerned about the decrease in service time
compared to the work RVU. We note that the existing intraservice time
is 22.5 minutes, compared to the RUC-recommended intraservice time of
10 minutes. We seek comments on whether our alternative value would
better reflect the time and intensity involved in furnishing this
service.
For CPT code 93298, the RUC recommended a work RVU of 0.52, which
is unchanged from the current work RVU for this code. We are concerned
about that recommendation given the reduction in both intraservice and
total time for this service. The intraservice time decreased from 24 to
7 minutes, while total time decreased from 44 to 17 minutes. We
acknowledge that the current times for this CPT code and others in this
family are extrapolations. However, without additional information
about the extrapolation of data from survey results, we question
whether the survey results should be excluded from consideration
altogether. We considered a work RVU of 0.37 for CPT code 93297,
crosswalking to CPT code 96446 (Chemotx admn prtl cavity). We also
considered a work RVU of 0.37 for CPT code 93298 based on a crosswalk
to CPT code 96446, since the RUC indicated that the work RVUs for CPT
codes 93297 and 93298 should be the same. We are seeking comment on our
proposed valuation and whether our alternative valuation would be more
appropriate for this code.
We propose the RUC-recommended direct PE inputs with the following
refinements. We propose to remove 2 minutes for ``review charts'' from
CPT codes 93279, 93281, 93282, 93283, 93284, 93285, 93286, 93287,
93288, 93289, 93290, 93291, and 93292 to maintain relativity since it
is not typically incorporated for similar PFS codes. We also propose
removing 2 minutes for ``complete diagnostic forms, lab & X-ray
requisitions'' for the labor category ``med tech/asst'' (L026A) for
these services because we believe the same activity is being performed
by labor category RN/LPN/MTA (L037D). We seek comments regarding
whether this row was included in error. Also for the same group of CPT
codes, we also propose standard refinements for the time for equipment
items EF023 and EQ198.
We propose to use the RUC-recommended direct practice expense
inputs and times for all other CPT codes in this family (CPT codes
93293, 93294,
[[Page 34005]]
93295, 93296, 93297, 93298, and 93299) without refinement.
(39) Transthoracic Echocardiography (TTE) (CPT Codes 93306, 93307, and
93308)
In the CY 2016 PFS final rule with comment period (80 FR 70914),
CMS identified CPT code 93306 through the high expenditures screen.
Subsequently, the RUC reviewed CPT codes 93307 and 93308, in addition
to CPT code 93306 as part of this family of codes that describe
transthoracic echocardiograms. For CY 2018, we are proposing the RUC-
recommended work RVUs for CPT codes 99306 (a work RVU of 1.50), 99307
(a work RVU of 0.92), and 99308 (a work RVU of 0.53), and proposing the
RUC-recommended direct PE inputs for CPT codes 93306, 93307, and 93308
without refinement.
For CPT code 93306 (Echocardiography, transthoracic, real-time with
image documentation (2D), includes M-mode recording, when performed,
complete, with spectral Doppler echocardiography, and with color flow
Doppler echocardiography), we considered maintaining the CY 2017 work
RVU of 1.30. The surveyed total time for this code dropped slightly due
to changes in the immediate postservice time. The median preservice and
intraservice time remained unchanged.
For CPT code 93307 (Echocardiography, transthoracic, real-time with
image documentation (2D), includes M-mode recording, when performed,
complete, without spectral or color Doppler echocardiography), we
considered a work RVU of 0.80, crosswalking to services with similar
service times (CPT codes 93880 (Extracranial bilat study), 93925 (Lower
extremity study), 93939, 93976 (Vascular study), and 93978 (Vascular
study)). The surveyed total time dropped 3 minutes (from the
intraservice time) compared to the existing service times for this
code.
For CPT code 93308 (Echocardiography, transthoracic, real-time with
image documentation (2D), includes M-mode recording, when performed,
follow-up or limited study), we considered a work RVU of 0.43,
crosswalking to CPT code 93292 (Wcd device interrogate) based on
similar service times. The surveyed total time dropped by 5 minutes
(from the intraservice time) compared to the existing service times for
this code.
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
codes 93306, 93307, and 93308 and seek comments on whether our
alternative values would better reflect the time and intensity of these
services.
(40) Stress Transthoracic Echocardiography (TTE) Complete (CPT Codes
93350 and 93351)
CPT code 93351 was identified as potentially misvalued and the RUC
reviewed CPT code 93350 as part of the same code family. For CY 2018,
we are proposing the RUC-recommended work RVUs for CPT codes 93350 (a
work RVU of 1.46) and 93351 (a work RVU of 1.75).
We are proposing the following refinements to the RUC-recommended
direct PE inputs for CPT codes 93350 and 93351. For both codes, we
applied the standard formula in developing the minutes for equipment
item ED053 (professional PACS workstation), which results in 18 minutes
for CPT code 93350 and 25 minutes for CPT code 93351. We are also
proposing standard clinical labor times for providing preservice
education/obtaining consent. We are not proposing to include clinical
labor time for the task setup scope since there is no scope used in the
procedure and we do not agree with the RUC's statement that this
replicates 5 minutes in CPT code 93015 when the RN prepares patients
for 10-lead ECG. We have found that there is no corresponding time of 5
minutes for setup scope in the PE inputs for CPT code 93015. We are
proposing refinements to the equipment time for ED050 (PACS workstation
proxy) for CPT code 93351, consistent with our standard equipment times
for PACS Workstation Proxy.
(41) Peripheral Artery Disease (PAD) Rehabilitation (CPT Code 93668)
We have issued a national coverage determination (NCD) for Medicare
coverage of supervised exercise therapy (SET) for the treatment of
peripheral artery disease (PAD). Information regarding the NCD can be
found on the CMS Web site at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=287. For the remainder of
CY 2017, we anticipate that CPT code 93668, currently assigned PROCSTAT
N (noncovered service by Medicare), will be payable before the end of
CY 2017, retroactive to the effective date of the NCD to implement
payment under the NCD.
For CY 2018, we are proposing to make payment for Medicare-covered
SET for the treatment of PAD, consistent with the NCD, reported with
CPT code 93668. For CPT code 93668, we are proposing to use the most
recent RUC-recommended work and direct PE inputs. We are also seeking
comment on the coding structure and valuation assumptions. Since the
RUC has not reviewed CPT code 93668 since 2001, we seek comments on the
direct PE inputs assigned to the code, which appear in the direct PE
input database. We also note that CPT code 93668 is a PE only code and
does not include physician work.
CPT prefatory language states that CPT code 93668 may be separately
reported with appropriate E/M services, including office and/or
outpatient services (CPT codes 99201 through 99215), initial hospital
care (CPT codes 99221 through 99223), subsequent hospital care (CPT
codes 99231 through 99233), and critical care services (CPT codes 99291
through 99292). Our understanding of CPT's prefatory language is that
these E/M codes may only be billed when review or exam of the patient
is medically indicated and must conform to all existing E/M
documentation requirements. E/M visit codes should not be billed to
account for supervision of SET for the treatment of PAD by a physician
or other qualified healthcare practitioner. We seek comments on whether
to develop professional coding to reflect the supervision of clinical
staff, and on the potential overlap with CPT code 99211 (Office or
other outpatient visit for the evaluation and management of an
established patient, that may not require the presence of a physician
or other qualified health care professional. Usually, the presenting
problem(s) are minimal. Typically, 5 minutes are spent performing or
supervising these services.) and any distinctions between time spent by
clinical staff for CPT code 99211 and time spent by clinical staff for
CPT code 93668.
(42) Pulmonary Diagnostic Tests (CPT Codes 94621, 946X2, and 946X3)
CPT code 94620 was identified as part of a screen of high
expenditure services with Medicare allowed charges of $10 million or
more that had not been recently reviewed. CPT code 94621 was added to
the family for review. The CPT Editorial Panel deleted CPT code 94620
and split it into two new codes, CPT codes 946X2 and 946X3, to describe
two different tests commonly performed for evaluation of dyspnea. We
are proposing the RUC-recommended work RVUs of 1.42 for CPT code 94621,
0.70 for CPT code 946X2, and 0.48 for CPT code 946X3.
We are proposing to refine the clinical labor time for the
``Provide preservice education/obtain consent'' activity from 10
minutes to 5 minutes for CPT code 94621, which is the current time
assigned for this task. While we agree that CPT code 94621 requires
additional time above the standard for this clinical
[[Page 34006]]
labor activity, we do not believe that double the current time would be
typical for this procedure. We are also proposing to refine the
clinical labor time for the ``Prepare and position patient/monitor
patient/set up IV'' activity from 5 minutes to 3 minutes for the same
code. The standard time for this activity is 2 minutes, and we are
proposing a value of 3 minutes to reflect 1 minute of additional
preparation time above the standard. We believe that additional
clinical labor time used for preparation would be included under the 10
minutes assigned to the ``Prepare room, equipment, supplies'' activity
for this code.
We are proposing to refine the clinical labor time for the
``Complete diagnostic forms, lab & X-ray requisitions'' activity,
consistent with the standard clinical labor time for this activity. We
also propose to refine the equipment times for CPT codes 94621 and
946X2 to account for 1:4 patient monitoring time, and to refine the
equipment times for CPT code 946X3 consistent with standards for non-
highly technical equipment.
We considered refining the clinical labor time for the ``pre
exercise ECG, VC, Min Vent. Calculation'' activity from 27 minutes to
15 minutes for CPT code 94621. We considered proposing this value of 15
minutes based on assigning 5 minutes apiece for the ECG, the MVV, and
the spirometry. We believe that each of these three components of this
clinical labor activity would typically take no longer than 5 minutes
based on a comparison to the use of these tasks in other CPT codes. We
also considered refining the clinical labor time for the ``Clinical
staff performs procedure'' activity from 55 minutes to 35 minutes for
CPT code 946X2 and from 14 minutes to 12 minutes for CPT code 94621.
The RUC-recommended materials for the PE inputs state that this
clinical labor task consists of performing 5 spirometries at 9 minutes
each plus 10 minutes of exercise time for CPT code 946X2; we believe
that the spirometries typically take 5 minutes each, which would reduce
this activity from 55 minutes to 35 minutes. For CPT code 94621, we
considered maintaining the current value of 12 minutes due to a lack of
justification for increasing the time to 14 minutes.
While we remain concerned about the intraservice period clinical
labor times, for CY 2018, we are proposing the RUC-recommended work
RVUs for each code in this family and seek comment on whether our
alternative clinical labor times would better reflect the work and
times for these services.
(43) Percutaneous Allergy Skin Tests (CPT Code 95004)
In the CY 2016 PFS proposed rule (80 FR 41706), CPT code 95004 was
identified through the high expenditures screen as potentially
misvalued. The RUC suggested in its comments on the CY 2016 PFS
proposed rule (80 FR 41706), that CPT code 95004 should be removed from
the list of potentially misvalued codes because it has a work RVU of
0.01 and that it would serve little purpose to survey physician work
for this code. The RUC and CMS previously determined that there is
physician work involved in providing this service since the physician
must interpret the test and prepare a report. In the CY 2016 PFS final
rule with comment period (80 FR 70913), CMS reiterated an interest in
the review of work and PE for this service. We note that our interest
in stakeholder review of a particular code should not be considered a
directive for survey under the RUC process. We intend to more clearly
state our interests in the future, so that under similar circumstances,
such effort need not be undertaken based on a mistaken impression. To
reiterate, we believe that whether or not a code should be surveyed in
response to our interest in receiving recommendations regarding the
work RVUs should be at the RUC and the specialties' discretion. In many
cases, we have used recommendations developed through means other than
surveys in developing RVUs. For example, for many PFS services, the
direct PE inputs are the primary drivers of overall RVUs and Medicare
payment. In most of these cases, the recommended inputs are not derived
from survey data. In some cases, especially for resource-intensive and
highly technical services, we have expressed some concern about the
lack of survey or other broad-based data that we have relied on in
developing rates across the PFS for many years.
For CY 2018, we are proposing the RUC-recommended work RVU of 0.01
for CPT code 95004.
Regarding direct PE inputs, we are proposing to refine the
equipment times for exam table (EF023) and mayo stand (EF015) to 79
minutes each to account for clinical 1:4 patient monitoring time. We
received invoices with new pricing information for two supplies: SH101
``negative control, allergy test'' ($5.17) and SH102 ``positive
control, allergy test'' ($26.12). Using this information, we are
proposing a price of $0.03 per test for supply item SH101 and a price
of $0.13 per test for supply item SH102.
(44) Continuous Glucose Monitoring (CPT Codes 95250 and 95251)
CPT codes 95250 (Ambulatory continuous glucose monitoring of
interstitial tissue fluid via a subcutaneous sensor for a minimum of 72
hours; sensor placement, hook-up, calibration of monitor, patient
training, removal of sensor, and printout of recording) and 95251
(Ambulatory continuous glucose monitoring of interstitial tissue fluid
via a subcutaneous sensor for a minimum of 72 hours; interpretation and
report) are used to report the technical and professional component for
continuous glucose monitoring. In April 2013, CPT code 95251 was
identified through the high volume growth services screen and
subsequently this code family was reviewed at the RUC's October 2016
meeting.
For CY 2018, we are proposing the RUC-recommended work RVU of 0.70
for CPT code 95251. However, we are concerned and seek comments on
whether the 2 minutes of physician preservice time is necessary. Since
CPT code 95251 is typically billed with an E/M service on the same day,
we believe the 2 minutes of preservice time may be duplicative.
Furthermore, we seek comment on whether it would be typical for the
physician to spend 2 minutes to obtain the CGM reports for review since
we believe the report would typically be obtained by clinical staff on
behalf of the physician.
For the direct PE inputs, the RUC submitted 19 invoices to update
the price of the medical supply item ``glucose monitoring
(interstitial) sensor'' (SD114) for CPT code 95250. We are proposing to
use these invoice prices for the glucose monitoring (interstitial)
sensor (SD114), with an average cost of $53.08. Therefore, we are
proposing to use the average price of $53.08 for this supply item.
As part of our review of this service, we obtained publicly
available pricing information for the CGM system (EQ125). We reviewed
the information provided in a study titled, ``The cost-effectiveness of
continuous glucose monitoring in type 1 diabetes,'' (Huang, SE.,
O'Grady, M., Basu, A. et al., Diabetes Care. June 2010), which
indicated the price of CGM technology (without sensors) from 3
different vendors, reflective of full retail prices with no insurer
discounts, to be $600.00, $1119.00, and $1250.00, which equated to an
average cost of $1016.00 for the CGM system. In addition, we obtained
publicly available pricing information for two vendors. This
information indicated the price of a
[[Page 34007]]
CGM system to be $1061.90 and $1279.17, which equated to an average
cost of $1170.54. For CY 2018, we are proposing to price supply items
SD114 at $53.08 and EQ125 at $1170.54. We seek comments on current
pricing for equipment item ``continuous glucose monitoring system''
(EQ125).
(45) Parent, Caregiver-Focused Health Risk Assessment (CPT Codes 96160
and 96161)
In the CY 2017 PFS final rule (81 FR 80330), we discussed that in
October 2015, the CPT Editorial Panel created two new PE-only codes,
CPT code 96160 (Administration of patient focused health risk
assessment instrument (e.g., health hazard appraisal) with scoring and
documentation, per standardized instrument) and CPT code 96161
(Administration of caregiver-focused health risk assessment instrument
(e.g., depression inventory) for the benefit of the patient, with
scoring and documentation, per standardized instrument). We assigned an
active payment status to both codes for CY 2017 and finalized use of
the RUC-recommended values for these codes. We also assigned an add-on
code status to both of these services. As add-on codes, CPT codes 96160
and 96161 describe additional resource components of a broader service
furnished to the patient that are not accounted for in the valuation of
the base code.
The RUC submitted updated recommendations for the direct PE inputs
for CPT codes 96160 and 96161 after reviewing new specialty society
surveys. The RUC recommended 7 total minutes of clinical staff time,
and we are proposing to adopt this number of minutes in valuing the
services. The PE worksheet included several distinct tasks with minutes
for each; however, in keeping with the standardization of clinical
labor tasks, we are proposing to designate all 7 minutes under
``administration, scoring, and documenting results of completed
standardized instrument'' rather than dividing the minutes into the
four categories as shown in the RUC recommendations.
(46) Chemotherapy Administration (CPT codes 96401, 96402, 96409, and
96411)
In the CY 2016 PFS proposed rule, CPT codes 96401 (Chemotherapy
administration, subcutaneous or intramuscular; non-hormonal anti-
neoplastic), 96402 (Chemotherapy administration, subcutaneous or
intramuscular; hormonal anti-neoplastic), 96409 (Chemotherapy
administration; intravenous, push technique, single or initial
substance/drug), and 96411 (Chemotherapy administration; intravenous,
push technique, each additional substance/drug (List separately in
addition to code for primary procedure)) were identified through the
high expenditure services screen across specialties with Medicare
allowed charges of over $10 million.
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
code 96401 (a work RVU of 0.21), CPT code 96402 (a work RVU of 0.19),
CPT code 96409 (a work RVU of 0.24) and CPT code 96411 (a work RVU of
0.20).
For CPT code 96402, we are proposing the RUC-recommended equipment
times with refinements for the biohazard hood (EP016) and exam table
(EF023) from 31 minutes to 34 minutes to reflect the service period
time associated with this code. We are proposing the RUC-recommended
direct PE inputs for CPT codes 96401, 96409, and 96411 without
refinements.
(47) Photochemotherapy (CPT Code 96910)
CPT code 96910 appeared on a high expenditure services screen
across specialties with Medicare allowed charges of over $10 million,
which is a PE-only code that does not have work RVUs.We are proposing
to refine the clinical labor time for the ``Provide preservice
education/obtain consent'' from 3 minutes to 1 minute for CPT code
96910. We believe that 1 minute would be typical for patient education,
as CPT code 96910 is a repeat procedure where there would not be a need
to obtain consent again. We are also proposing to remove the 2 minutes
of clinical labor for the ``Complete diagnostic forms, lab & X-ray
requisitions'' activity, as this item is considered indirect PE
consistent with our established methodology. We are also proposing to
create a new supply code (SB054) for the sauna suit, and proposing to
price at $9.99 based on the submitted invoice. Finally, we are also
proposing to adjust the equipment times to reflect changes in the
clinical labor for CPT code 96910.
We are proposing the RUC-recommended clinical labor time of 15
minutes for the ``Prepare and position patient/monitor patient/set up
IV'' activity, the RUC-recommended clinical labor time of 16 minutes
for the ``Monitor patient during procedure'' activity, and the RUC-
recommended clinical labor time of 15 minutes for the ``Clean room/
equipment by physician staff'' activity, but seeking additional
information regarding the rationale for these values. Given the lack of
explanation, we considered using the current clinical labor time of 7
minutes for the ``Prepare and position patient/monitor patient/set up
IV'' activity, the current clinical labor time of 4 minutes for the
``Monitor patient during procedure'' activity, and the current clinical
labor time of 10 minutes for the ``Clean room/equipment by physician
staff'' activity. We seek comment on whether maintaining the current
values would improve relativity.
We considered removing the ``Single Patient Discard Bag, 400 ml''
(SD236) supply and replacing it with the ``biohazard specimen transport
bag'' (SM008). We are concerned about whether the single patient
discard bag is the appropriate size for storing the sauna suit used in
this procedure, and whether use of a biohazard specimen transport bag
would be typical. We seek comments on our proposed and alternative
values for these direct PE inputs.
(48) Photodynamic Therapy (CPT Codes 96567, 96X73, and 96X74)
CPT code 96567 was identified as potentially misvalued through a
CMS screen for codes with high expenditures. This code describes a
service furnished by clinical staff and does not include physician
work. For CY 2018, the CPT Editorial Panel created two new codes, CPT
codes 96X73 and 96X74, to describe photodynamic therapy by external
application of light to destroy premalignant skin lesions, including
the physician work involved in furnishing the service. CPT codes 96567,
96X73, and 96X74 were reviewed during the RUC's January 2017 meeting.
For CY 2018, we are proposing the RUC-recommended work RVUs for CPT
code 96X73 (a work RVU of 0.48) and CPT code 96X74 (a work RVU of
1.01).
We are proposing the RUC-recommended PE inputs with refinements due
to inconsistencies between the stated description of clinical
activities and the submitted spreadsheets. First, we propose to add
assist physician clinical staff time to CPT codes 96X73 (10 minutes)
and 96X74 (16 minutes), which is equivalent to the physician
intraservice times for these services. For both CPT codes 96X73 and
96X74, we propose a reduction from 35 minutes to 17 minutes for
clinical activity in the postservice time, consistent with the
description of clinical work in the summary of recommendations, which
states that the patient receives activation of the affected area with
the BLU-U Photodynamic Therapy Illuminator for approximately 17
minutes. For CPT codes 96X73 and 96X74, we are
[[Page 34008]]
proposing to refine equipment formulas for two items: Power table
(EF031) and LumaCare external light with probe set (EQ169), consistent
with standards for nonhighly technical equipment. An explanation of the
standards and formulas for equipment related to direct PE inputs is in
the CY 2014 PFS final rule with comment period (79 FR 67557).
We identified several vendors with publically available prices
available for supply item LMX 4 percent cream (SH092) for significantly
less than the existing $1.60 per gram. Based on our research of
vendors, we are proposing to set the price of supply item SH092 to
$0.78 per gram. Other CPT codes affected by the proposed change in the
price of supply item LMX 4 percent cream (SH092) are: CPT code 46607
(Anoscopy; with high-resolution magnification (HRA) (eg, colposcope,
operating microscope) and chemical agent enhancement, with biopsy,
single or multiple), CPT code 17000 (Destruction (eg, laser surgery,
electrosurgery, cryosurgery, chemosurgery, surgical curettement),
premalignant lesions (eg, actinic keratoses); first lesion), CPT code
17003 (Destruction (eg, laser surgery, electrosurgery, cryosurgery,
chemosurgery, surgical curettement), premalignant lesions (eg, actinic
keratoses); second through 14 lesions, each (List separately in
addition to code for first lesion)), and CPT code 17004 (Destruction
(eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical
curettement), premalignant lesions (eg, actinic keratoses), 15 or more
lesions)).
In addition, the RUC forwarded an invoice for a new supply item,
safety goggles, at $6.00 and requested three goggles each for CPT codes
96X73 and 96X74. Because we do not have a basis for distinguishing the
requested new goggles from the existing UV-blocking goggles, we
consider this invoice to be an additional price point for SJ027 rather
than an entirely new item. We propose a price of $4.10 for supply item
SJ027 (the average of the two prices for this supply item ($2.30 +
$6.00)/2=$4.10)). Other CPT codes affected by the proposed change in
the price of supply item UV-blocking goggles (SJ027) are: CPT code
36522 (Photopheresis, extracorporeal), CPT code 96910
(Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or
petrolatum and ultraviolet B), CPT code 96912 (Photochemotherapy;
psoralens and ultraviolet A (PUVA)), and CPT code 96913
(Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive
dermatoses requiring at least 4-8 hours of care under direct
supervision of the physician (includes application of medication and
dressings)), CPT code 96920 (Laser treatment for inflammatory skin
disease (psoriasis); total area less than 250 sq cm), CPT code 96921
(Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm
to 500 sq cm), and CPT code 96922 (Laser treatment for inflammatory
skin disease (psoriasis); over 500 sq cm). We seek comments on our
proposed PE refinements, including our proposed supply item prices.
(49) Physical Medicine and Rehabilitation (PM&R) (CPT Codes 97012,
97016, 97018, 97022, 97032, 97033, 97034, 97035, 97110, 97112, 97113,
97116, 97140, 97530, 97533, 97535, 97537, 97542, and HCPCS code G0283)
In our CY 2015 PFS final rule (79 FR 67576) and CY 2016 PFS final
rule (80 FR 70917), we identified a total of ten codes through the high
expenditure by specialty screen for services primarily furnished by
physical and occupational therapists: CPT codes 97032, 97035, 97110,
97112, 97113, 97116, 97140, 97530, 97535, and HCPCS code G0283. An
additional nine codes in this PM&R family were identified for review by
the physical therapy (PT) and occupational therapy (OT) specialty
societies: CPT codes 97012, 97016, 97018, 97022, 97033, 97034, 97533,
97537, and 97542. Many of these code values had not been reviewed since
they were established in 1994, 1995 or 1998.
After review during its January 2017 meeting, the HCPAC submitted
recommendations for all 19 codes. While the HCPAC included
recommendations for CPT code 97014, we note that this is a code we have
not recognized for PFS payment since 2002 when we implemented our wound
care electrical stimulation policies. For payment under the PFS,
instead of CPT code 97014, we recognize HCPCS code G0281 for wound care
electrical stimulation and HCPCS code G0283 for all other electrical
stimulation scenarios, when covered. For CY 2018, we are proposing the
HCPAC recommendations for CPT code 97014, HCPCS code G0283, and HCPCS
code G0281.
CMS considers all 19 codes as ``always therapy'' which means they
are always considered to be furnished under a physical therapy (PT),
occupational therapy (OT), or speech-language pathology (SLP) plan of
care regardless of who furnishes them and the payment amounts are
counted towards the appropriate statutory therapy cap--either the
therapy cap for PT and SLP services combined, or the single therapy cap
for OT services. These always therapy codes are also subject to the
therapy MPPR.
For CY 2018, we are proposing the HCPAC's recommended work RVUs for
CPT codes 97012, 97016, 97018, 97022, 97032, 97033, 97533, 97034,
97035, 97110, 97112, 97113, 97116, 97140, 97530, 97533, 97535, 97537,
97542, and G0283 (97014).
For supervised modality services reported with CPT codes 97012,
97016, 97018, and 97022, and HCPCS code G0283 (97014), we considered
maintaining the current values for these codes rather than the HCPAC
recommendations. We note that the work times recommended by the HCPAC
reflect use of the survey data even though the HCPAC explained in its
recommendations that the survey results were not deemed credible
because of a lack of evidence to support higher work RVUs of each
survey's 25th percentile or median values. We note total time decreases
among these codes ranging from 1 to 8 minutes.
While we are proposing the HCPAC-recommended work RVUs and work
times for each code in this family, we seek comments on whether
maintaining the current times, given the HCPAC's lack of confidence in
the survey data, would better reflect the work times for these
services.
We are proposing to maintain the existing CY 2017 PE inputs for all
19 codes. We note that section 1848(b)(7) of the Act requires a 50
percent therapy MPPR instead of the 25 percent therapy MPPR established
during CY 201l PFS rulemaking. One of the primary rationales for the
MPPR policy developed through the rulemaking process was that the
direct PE inputs for these services did not fully recognize the
redundant inputs when these services were furnished together, or in
multiple units. After reviewing the recommended direct PE inputs, it is
evident that they were developed based on an acknowledgement of the
efficiencies of services typically furnished together as well as codes
billed in multiple units. Given this assessment, we believe that were
we to use the recommended inputs to develop the PE RVUs, the 50 percent
MPPR on the PE for these services, as required by current law, would
functionally duplicate the payment adjustments to account for
efficiencies that had already been addressed through code-level
valuation. Therefore, for CY 2018, we are proposing to retain the
existing CY 2017 PE inputs for these services and seek comments on
whether there is an
[[Page 34009]]
alternative approach that would avoid duplicative downward payment
adjustments while still allowing for the direct PE inputs to be updated
to better reflect current practice.
We note that we believe that the always therapy codes subject to
the therapy MPPR on PE are unique from other therapeutic and diagnostic
procedure codes paid under the PFS and subject to MPPRs. For example,
unlike most surgical services, these ``always therapy'' codes are
typically billed either with other therapy codes or in multiple units,
or both. Generally, MPPRs are used when codes are often, but not
typically, furnished with other particular codes. When full sets of
related codes are almost all typically billed with other codes, or
billed in multiple units, coding and valuation have changed to reflect
these practices. For example, new codes have been introduced to
describe combined services or some related services are described by
add-on codes. In other cases, the MPPR is considered in the valuation
for individual services.
(50) Management and/or Training: Orthotics and Prosthetics (CPT Codes
97760, 97761, and 977X1)
For CY 2018, the CPT Editorial Panel revised the set of codes that
comprise the CPT manual's PM&R subsection for orthotic management and
prosthetic management at its September 2016 meeting. According to the
CPT Editorial Panel, these revisions were made at the request of the
specialty societies representing physical and occupational therapists
to differentiate between the initial and subsequent encounters and to
describe the ongoing management and/or training that is involved in
subsequent encounters. These changes include:
Revising the code descriptors by adding the term ``initial
encounter'' to CPT code 97760 (Orthotic(s) management and training
(including assessment and fitting when not otherwise reported), upper
extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s)
encounter, each 15 minutes), and CPT code 97761 (Prosthetic(s)
training, upper and/or lower extremity(ies), initial prosthetic(s)
encounter, each 15 minutes);
Creating a new CPT code 977X1 (Orthotic(s)/prosthetic(s)
management and/or training, upper extremity(ies), lower extremity(ies),
and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15
minutes); and
Deleting CPT code 97762 (checkout for orthotic/prosthetic
use, established patient, each 15 minutes).
Intended for the management and/or training of patients with
orthotics and/or prosthetics, CPT codes 97760 and 97761 were previously
used to report both the initial and subsequent encounters, that, when
furnished under the Medicare outpatient therapy services benefit,
included services occurring during the same PT or OT episode of care.
CPT code 97762 was used to separately report the assessment and fitting
(including any adjustments) of an orthotic or prosthetic for an
established patient when these services were not bundled into another
code or service. For CY 2018, CPT codes 97760 and 97761 are intended to
be reported only for the initial encounter, and CPT code 977X1 is
intended to be reported for all other orthotic and/or prosthetic
services for an established patient that occur on a ``subsequent
encounter'' or a different date of service from that of the initial
encounter service.
The HCPAC submitted work and PE recommendations for CPT codes
97760, 97761, and 977X1 from their January 2017 meeting. For CY 2018,
we propose the HCPAC recommended work RVU of 0.5 for CPT code 97760, a
work RVU of 0.5 for CPT code 97761, and a work RVU of 0.48 for CPT code
977X1. We note that for budget neutrality purposes, the HCPAC
recommendations also included utilization crosswalks for each of the
three codes that were each assigned a one-to-one crosswalk to the
utilization of the prior codes: All the prior services of CPT codes
97760 and 97761 were each crosswalked to the same newly revised codes;
and, all the utilization from CPT code 97762 was crosswalked to the new
CPT code 977X1.
For CPT code 977X1, we considered a work RVU of 0.33, crosswalking
to CPT code 92508 (Speech/hearing therapy), which has a similar total
therapist time (22 minutes). We are concerned and seek comments on the
HCPAC one-to-one utilization crosswalk recommendations for all three
codes in this family since the utilization assumptions are potentially
flawed when viewed in the context of the new CPT code descriptors. For
instance, for CPT code 977X1, the new descriptor indicates that the
services inherent to CPT code 97762 (over 14,000 in 2015), as well as
the new services for subsequent encounters previously reported via CPT
codes 97760 and 97761 will also be encompassed, although it is
difficult to estimate the number of additional services the latter
represents. We are concerned that the HCPAC's valuation is inconsistent
with the submitted information regarding how services will be reported
under the new coding. We seek comments on our proposed and alternative
values for CPT code 977X1. We are also interested in receiving comments
from stakeholders and clinicians with expertise in furnishing these
orthotic management and/or prosthetics training services about the
utilization and types of services that would be furnished under the new
CPT coding structure, particularly those of the newly created CPT code
977X1 and how these services differ from the services reported with the
predecessor CPT code 97762.
We propose to maintain the current PE inputs for CPT codes 97760,
97761, and 977X1, as we discussed in our proposals for the PM&R codes
discussed above; the same therapy MPPR applies. We are proposing the
current direct PE inputs for CPT code 97762 and for new CPT code 977X1,
though we are seeking comment as to whether or not a different
crosswalk or other adjustment would be appropriate given the change in
code descriptor.
We also note that these codes are designated as always therapy,
meaning that they always represent therapy services regardless of who
furnishes them; and that a GO or GP therapy modifier is always required
to indicate that the services are furnished under an OT or PT plan of
care, respectively. As always therapy, these codes are subject to the
therapy MPPR and the statutory therapy caps.
(51) Cognitive Function Intervention (CPT Code 97X11)
We received HCPAC recommendations for new CPT code 97X11 that
describes services currently reported under CPT code 97532 (Development
of cognitive skills to improve attention, memory, problem solving
(includes compensatory training), direct (one-on-one) patient contact,
each 15 minutes). CPT code 97532 is scheduled to be deleted for CY 2018
and replaced by CPT code 97X11.
The existing code is reported per 15 minutes and the new code is
reported once. Under current coding, Medicare utilization for these
services is heterogeneous and indicates that practitioners of different
disciplines incur significantly different resource costs (especially in
time) when furnishing these services to Medicare beneficiaries. As
described by both the existing and new code, the service might be
appropriately furnished both by therapists under the outpatient therapy
(OPT) services benefit (includes physical therapy (PT), occupational
therapy (OT) or speech-language pathology (SLP)); and outside the
therapy benefit by physicians, certain
[[Page 34010]]
NPPs, and psychologists. As an OPT service, it can (1) be billed by
physicians, certain NPPs, or private practice therapists including
physical therapists (PT-PPs), occupational therapists (OT-PPs) and
speech-language pathologists (SLP-PPs) in private practice, or (2) be
billed by institutional providers (for example, skilled nursing
facilities, rehabilitation agencies, outpatient hospitals, etc.) when
furnished by therapists working for the institutional providers.
According to the HCPAC, professional claims data indicate that CPT
code 97532 was most often billed in 4 units. The HCPAC recommended a
work RVU of 1.50 for CPT code 97X11, which is only 3.4 times greater
than the work RVU for the predecessor code (0.44). Assuming
professional billing patterns remain the same, the recommended coding
and valuation could result in a significant reduction in overall
Medicare payment under the PFS.
However, our analysis of the claims data indicates that the number
of units typically reported for the current code suggests a significant
difference in the amount of time spent with the patient, depending on
which discipline (and implicitly under which benefit) bills Medicare
for services described by this single code.
Based on our review of claims data by specialty, SLP-PPs, OT-PPs
and PT-PPs furnishing the same services under the OPT benefit would
receive overall payment increases due simply to the change in coding
because they typically bill for fewer than 4 units, while overall
payment for clinical psychologists furnishing therapeutic interventions
for cognitive function would decrease because they typically bill in
units of four or more.
We are seeking additional information regarding the potential
impact of this coding and payment change prior to proposing its use
under the PFS. For CY 2018, we are proposing to maintain the current
coding and valuation for these cognitive function services. If the CPT
Editorial Panel deletes the existing CPT code for CY 2018, we would
effectuate this proposal through use of a new a G-code, GXXX1, which
would maintain the descriptor and values from existing CPT code 97532.
Under this proposal, new CPT code 97X11 would be given a procedure
status of ``I'' (Invalid for Medicare).
We also note that this change in coding and payment could have
significant impact for payment to Medicare institutions for OPT
services. Under section 1834(k) of the Act, when reported by Medicare
institutional providers, OPT services are paid at PFS non-facility
payment rates. Institutional claims data for CPT code 97532 when
furnished by the three therapist disciplines show a much higher
utilization overall than that for professional claims but significantly
fewer 15 minute units reported. This suggests that professionals
generally spend significantly less time with patients in the
institutional setting. Use of the new CPT code could therefore result
in significant additional expenditure to the Medicare program, as well
as other payers, including Medicaid programs, based on the change in
coding alone.
(52) INR Monitoring (CPT Codes 993X1 and 993X2)
In October 2015, AMA staff assembled a list of all services with
total Medicare utilization of 10,000 or more that have increased by at
least 100 percent from 2008 through 2013 and these services were
identified on that list. The RUC recommended that HCPCS codes G0248,
G0249 and G0250, which describe related INR monitoring services, be
referred to the CPT Editorial Panel to create Category I codes to
describe these services. For CY 2018, the CPT Editorial Panel is
deleting CPT codes 99363 and 99364 and creating new CPT codes 993X1
(Patient/caregiver training for initiation of home INR monitoring under
the direction of a physician or other qualified health care
professional, including face-to-face, use and care of the INR monitor,
obtaining blood sample, instructions for reporting home INR test
results, and documentation of patient's/caregiver's ability to perform
testing and report results) and 993X2 (Anticoagulant management for a
patient taking warfarin, must include review and interpretation of a
new home, office, or lab International Normalized Ratio (INR) test
result, patient instructions, dosage adjustment (as needed), and
scheduling of additional test(s) when performed). CPT code 993X1 is a
technical component-only code. With the creation CPT codes 993X1 and
993X2, the RUC recommended that CMS delete HCPCS codes G0248, G0249 and
G0250.
For CPT code 993X2, we are proposing the RUC-recommended work RVU
of 0.18. Because HCPCS codes G0248, G0249 and G0250 are used to report
related services under a national coverage determination, we do not
intend to delete the G-codes.
In reviewing the recommended PE inputs for these services, we
obtained updated invoices for prices for particular items. We are
proposing to use the invoices to update the price of the supply ``INR
test strip'' (SJ055). We obtained publically available pricing
information from two vendors. The pricing from one vendor indicated the
price for a box of 24 of supply item SJ055 item (INR test strip) to be
$150.00, which equated to a unit price of $6.25. Pricing from a second
vendor indicated the price of a box of 48 of the supply item SJ055 to
be $233.00, which equated to a unit price of $5.06. The average price
of these two unit prices is $5.66.
Therefore, we are proposing to re-price SJ055 from $21.86 to $5.66
for CPT code 993X1. We are seeking public comments on current pricing
for the INR test strip supply.
(53) Psychiatric Collaborative Care Management Services (CPT Codes
994X1, 994X2, 994X3, and HCPCS Code G0507)
In the CY 2017 PFS final rule (81 FR 80230), we established
separate payment for three services (HCPCS codes G0502, G0503, and
G0504) under the psychiatric collaborative care model that paralleled
CPT codes that were being created to report these services as well as a
G-code for general behavioral health integration (BHI) services (HCPCS
code G0507).
For CY 2018, the CPT Editorial Panel is creating CPT codes 994X1,
994X2, 994X3, and 99XX5 to describe these services. We are proposing
the RUC-recommended work RVUs for each of these services, which are
identical to the current values for HCPCS codes G0502, G0503, G0504,
and G0507.
We are proposing the RUC-recommended PE inputs, with one
refinement. The RUC-recommended values included clinical labor inputs
in the facility setting, but we are not proposing to include these
minutes in developing the facility PE RVUs.
Were we to develop facility PE RVUs for these services that
included clinical staff time, when a practitioner working in a
provider-based department of a hospital was furnishing these services,
both the professional and the hospital would be paid for the same
clinical labor costs. We presume that this aspect of the RUC's
recommendation reflects the circumstance where the patient receiving
the services spends a significant period of time in a facility setting,
but the billing practitioner is nonetheless incurring the cost
associated with the non-face-to-face clinical staff time over the
course of a month. We recognize that the binary site of service
differential may not recognize the different models of this kind of
care and may not be appropriate in some cases. We seek comments on how
to best address this valuation issue for these and other monthly care
[[Page 34011]]
management services. We could consider a range of options for future
rulemaking, including allowing separate billing for the professional,
technical, and global components of these services to allow
practitioners to bill the component of the service they furnish.
We stated in the CY 2017 PFS final rule (81 FR 80236) that the
general BHI code (CPT code 99XX5) may be used to report a range of
models of BHI services and that we expected this code to be refined
over time as we receive more information about other BHI models in use.
We remain interested in how this code is being used and look forward to
hearing from stakeholders regarding its use in reporting different
models of BHI services. Additionally, we have received inquiries from
stakeholders about whether or not professionals who cannot report E/M
services to Medicare might nonetheless serve as a primary hub for BHI
services. For example, stakeholders have suggested that a clinical
psychologist might serve as the primary practitioner that integrates
medical care and psychiatric expertise. For purposes of future
rulemaking, we are seeking comment on the circumstances under which
this model of care is happening and whether additional coding would be
needed to accurately describe and value other models of care.
(54) Hyperbaric Oxygen Therapy (HCPCS Code G0277)
In the CY 2016 PFS final rule (80 FR 71005), we discussed the CY
2015 valuation of hyperbaric oxygen therapy services (79 FR 67677).
Prior to CY 2015, CPT code 99183 was used to report both the
professional attendance and supervision, and the costs associated with
treatment delivery were included in the nonfacility direct PE inputs
for the code. We created HCPCS code G0277 to be used to report the
treatment delivery separately, consistent with the OPPS coding
mechanism, to allow the use of the same coding structure across
settings. In establishing interim final direct PE inputs for HCPCS code
G0277, we used the RUC-recommended direct PE inputs for CPT code 99183,
which assumed a 120-minute treatment interval and adjusted them to
align with the 30-minute treatment interval of HCPCS code G0277. We
observed that the quantity of oxygen increased significantly relative
to the previous inputs for CPT code 99183.
To better understand why the oxygen supply increased, we reviewed
the instruction manual for the Sechrist Model 3600E Hyperbaric Chamber,
which was the model noted on the invoice that was included with the RUC
recommendations for use in pricing the capital equipment. The
instruction manual for the Sechrist 3600E model provided guidance
regarding the quantity of oxygen to be used in furnishing the service
described by HCPCS code G0277. Based on our review at that time, we
determined that 12,000 liters, rather than 47,000 liters, was the
typical number of units for the oxygen gas. Therefore, in aligning the
direct PE inputs as described in this section of the proposed rule, we
first adjusted the units of oxygen to 12,000 liters for the recommended
120 minute time, and subsequently adjusted it to align with the 30-
minute G-code by dividing by 4. We stated that we agreed that an
initial high purge flow rate is needed to reach maximum pressure/
O2; however, we still had not seen data that demonstrated
the need to continue the high purge flow rate throughout the entire
session. According to the manufacturer's instruction manual for this
model, ``once the nitrogen has been purged from the chamber and the
internal oxygen concentration has exceeded 95 percent, high flows are
no longer needed to maintain the patient's saturation level.'' The
manual also stated that ``the plateau purge flow can be set to 80
liters per minute (lpm).'' We calculated that 13 minutes at 400 lpm
plus 120 minutes at 80 lpm equals 14,800 liters of oxygen. We stated
that based on information in the manufacturer's manual that was
publicly available at the time, we believed that this represented the
typical usage for a 120-minute treatment. That amount represented an
increase from the interim final amount of 12,000 liters. We aligned
this total oxygen requirement to the 30-minute G-code by dividing
14,800 liters of oxygen by 4 and stated we were updating the direct PE
inputs to 3,700 liters of oxygen for HCPCS code G0277.
For CY 2018, we received requests from stakeholders to update the
direct PE inputs for HCPCS code G0277. In the CY 2016 PFS final rule
(80 FR 71005), we explained that we had previously established values
for this service based on information suggesting that the Sechrist
Model 3600E Hyperbaric Chamber was typically used in furnishing the
service in the non-facility setting. As we noted in that rule, we
established the amount of oxygen used in furnishing the service based
on use of the equipment item described as part of the RUC
recommendation, instead of the RUC-recommended amount of oxygen, which
appeared to be based on use of a different equipment product, the
Sechrist Model 3200. Based on information received from stakeholders,
we are proposing to update both the equipment item and the amount of
oxygen so that the amount of oxygen conforms to the RUC-recommended
value of 47,600 liters of oxygen, which we divided by 4 to conform to
the 30-minute service period for HCPCS code G0277, and that the
equipment item is consistent with that recommendation. The proposed
direct PE inputs for HCPCS code G0277 are displayed in the proposed CY
2018 direct PE input database, available on the CMS Web site under the
downloads for the CY 2018 PFS proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
We are also proposing to exclude this change in direct PE inputs
from calculation of the misvalued code target since we view this
proposed change as a refinement of a single recommendation over several
years. Since the initial recommendation (79 FR 67677) was undertaken in
a year without the misvalued code target, we believe it would be
consistent with our previously established policy (80 FR 70923) to
exclude this change from the calculation. We note that this change
would represent an increase from the current PE RVUs for this service.
(55) Physician Coding for Insertion and Removal of Subdermal Drug
Implants for the Treatment of Opioid Addiction (HCPCS Codes GDDD1,
GDDD2, and GDDD3)
We met with representatives from the American Society of Addiction
Medicine (ASAM) in April 2016 to discuss the possibility of making
separate payment for insertion and removal of buprenorphine
hydrochloride, formulated as a 4-rod, 80 mg, long-acting subdermal drug
implant for the treatment of opioid addiction. There are existing CPT
codes that broadly describe the insertion and removal of non-
biodegradable drug delivery implants (CPT codes 11981 through 11983).
However, ASAM contended that the resources associated with the
administration of this particular drug are greater than that of other
drug delivery implants, stating that the physician must insert four
rods using a newly designed applicator and obturator and use a
specially designed clamp to remove the four rods, which in some cases
requires careful shaving of tissue that has attached to the rods during
the 6-month period that the rods have been inserted. They noted that
these procedures can have unique
[[Page 34012]]
challenges associated with treating patients with opioid addiction, who
often have complications and/or co-morbidities. They also noted that
the FDA has recognized the complexity of the technology and patient
needs by establishing regulatory standards to adhere to the protocol
and imposing special training requirements on physicians. ASAM
indicated that they would pursue an application to the CPT Editorial
Panel for new CPT codes.
ASAM informed CMS that the CPT Editorial Panel did not approve
their application; therefore, they repeated their request that CMS
establish separate payment for the insertion, removal, and removal with
reinsertion of the buprenorphine subdermal implants.
To improve payment accuracy, for CY 2018, we are proposing to make
separate payment for the insertion, removal, and removal with
reinsertion of Buprenorphine subdermal implants using HCPCS G codes:
HCPCS code GDDD1: Insertion, non-biodegradable drug
delivery implants, 4 or more.
HCPCS code GDDD2: Removal, non-biodegradable drug delivery
implants, 4 or more.
HCPCS code GDDD3: Removal with reinsertion, non-
biodegradable drug delivery implants, 4 or more.
For HCPCS code GDDD1, ASAM states that performing the procedure
according to the FDA-required Risk Evaluation and Mitigation Strategies
(REMS) program takes approximately 23-25 minutes for the a physician
who is not a trainer/proctor for this procedure. They state that in
developing crosswalk recommendations for physician work values, they
used a total time of 35-40 minutes, which is based on a preservice time
of 10 minutes, an intraservice time of 20-25 minutes, and a postservice
time of 5 minutes. Based on ASAM's recommendations, we are proposing a
work RVU of 1.82 for HCPCS code GDDD1, which is supported by a direct
crosswalk to CPT code 64644 (Chemodenervation of one extremity; 5 or
more muscles).
For HCPCS code GDDD2, ASAM states that data from physicians who
perform this procedure indicated that it takes approximately 15-20
additional minutes compared to the insertion procedure (HCPCS code
GDDD1) based on the FDA-required REMS program for removal of the
implant. They note that this procedure is of a higher intensity
compared to CPT code 11982 as this service requires identification and
removal of multiple subdermal implants. They state that in developing
crosswalk recommendations for physician work values, they used a total
time of 45-60 minutes, which is based on a preservice time of 10
minutes, an intraservice time of 30-45 minutes, and a postservice time
of 5 minutes. Based on ASAM's recommendations, we are proposing a work
RVU of 2.10 for HCPCS code GDDD2, which is supported by a direct
crosswalk to CPT code 96922 (Laser treatment for inflammatory skin
disease (psoriasis); over 500 sq cm).
For HCPCS code GDDD3, ASAM indicated that there is minimal
consolidation of effort since the removal of the implants from one arm
is followed by insertion of a new set of implants in the contralateral
arm. Physician data from those who have performed this procedure
indicated that it takes approximately 70 minutes of total intra-service
time. They state that in developing crosswalk recommendations for
physician work values, they assumed a preservice evaluation time of 10
minutes (7 minutes for removal and 3 minutes for insertion),
positioning of 4 minutes (2 minutes for each arm), and wait time of 2
minutes (1 minute for each arm). They state that using the multiple
surgical procedure rule, they calculated an intraservice time of 40-58
minutes based on 100 percent of the intraservice time for HCPCS code
GDDD2 (30-45 minutes) and 50 percent of the intraservice time for HCPCS
code GDDD1 (0.5 x (20 - 25) = 10 - 13). They used a postservice time of
8 minutes based on 100 percent of the postservice time for the removal
arm and 50 percent of the postservice time for the insertion arm,
equaling a total time of 58-76 minutes. Based on ASAM's
recommendations, we are proposing a work RVU of 3.55 for HCPCS code
GDDD3, which is supported by a direct crosswalk to CPT code 31628
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed; with transbronchial lung biopsy(s), single lobe).
We are proposing to use the direct PE inputs requested by ASAM for
HCPCS codes GDDD1, GDDD2, and GDDD3, which are reflected in the Direct
PE Inputs public use files for clinical labor, supplies, and equipment,
available on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
In addition to seeking comment on the proposal to make separate
payment for these services using HCPCS G codes, we are also seeking
comment on the appropriateness and accuracy of our proposed work RVUs
and direct PE inputs.
(56) Superficial Radiation Treatment Planning and Management (HCPCS
Code GRRR1)
In the CY 2015 PFS final rule with comment period (79 FR 67666
through 67667), we noted that changes to the CPT prefatory language
limited the codes that could be reported when describing services
associated with superficial radiation treatment (SRT) delivery,
described by CPT code 77401 (radiation treatment delivery, superficial
and/or ortho voltage, per day). The changes effectively meant that many
other related services were bundled with CPT code 77401, instead of
being separately reported. For example, CPT guidance clarified that
certain codes used to describe clinical treatment planning, treatment
devices, isodose planning, physics consultation, and radiation
treatment management cannot be reported when furnished in association
with superficial radiation treatment. Stakeholders stated that these
changes to the CPT prefatory language prohibited them from billing
Medicare for codes that were previously frequently billed in addition
to CPT code 77401. We solicited comments as to whether the coding for
SRT allowed for accurate reporting of the associated services.
In the CY 2016 PFS final rule with comment period (80 FR 70955), we
noted that the RUC did not review the inputs for superficial radiation
therapy procedures, and therefore, did not assess whether changes in
its valuation were appropriate in light of the bundling of associated
services. In addition, we solicited recommendations from stakeholders
regarding whether or not it would be appropriate to add physician work
for this service, even though physician work is not included in other
radiation treatment services. As commenters were not in agreement as to
whether the service should be valued with physician work, we introduced
the possibility of creating a HCPCS G code to describe total work
associated with the course of treatment for these services.
The 2016 National Correct Coding Initiative (NCCI) Policy Manual
for Medicare Services states that radiation oncology services may not
be separately reported with E/M codes. While this edit is no longer
active, stakeholders have stated that MACs have denied claims for E/M
services associated with SRT based on the NCCI policy manual language.
According to stakeholders, the bundling of services associated with
SRT, as well as the confusion regarding the appropriate use of E/M
coding to report associated physician work, means
[[Page 34013]]
that practitioners are not being accurately paid for planning and
treatment management associated with furnishing SRT.
In recognition of these concerns, we are proposing to make separate
payment for the professional planning and management associated with
SRT using HCPCS code GRRR1 (Superficial radiation treatment planning
and management related services, including but not limited to, when
performed, clinical treatment planning (for example, 77261, 77262,
77263), therapeutic radiology simulation-aided field setting (for
example, 77280, 77285, 77290, 77293), basic radiation dosimetry
calculation (for example, 77300), treatment devices (for example,
77332, 77333, 77334), isodose planning (for example, 77306, 77307,
77316, 77317, 77318), radiation treatment management (for example,
77427, 77431, 77432, 77435, 77469, 77470, 77499), and associated
evaluation and management per course of treatment). We intend for this
code to describe the range of professional services associated with a
course of SRT, including services similar to those not otherwise
separately reportable under CPT guidance and the NCCI manual.
To value this code, we are including the physician work and work
time associated with radiation management-related services that we
think would be typical for a course of SRT treatment. These services
include: CPT code 77261 (Therapeutic radiology treatment planning;
simple), CPT code 77280 (Therapeutic radiology simulation-aided field
setting; simple), CPT code 77300 (Basic radiation dosimetry
calculation, central axis depth dose calculation, TDF, NSD, gap
calculation, off axis factor, tissue inhomogeneity factors, calculation
of non-ionizing radiation surface and depth dose, as required during
course of treatment, only when prescribed by the treating physician),
CPT code 77306 (Teletherapy isodose plan; simple (1 or 2 unmodified
ports directed to a single area of interest), includes basic dosimetry
calculation(s)), CPT code 77332 (Treatment devices, design and
construction; simple (simple block, simple bolus)), and CPT code 77427
(Radiation treatment management, 5 treatments). Therefore, for CY 2018,
we are proposing a work RVU of 7.93 for HCPCS code GRRR1.
To develop the proposed direct PE inputs for this code, we are
proposing to use the RUC-recommended direct PE inputs from the
aforementioned codes with several adjustments. We are proposing to
apply the staff type ``RN/LPN/MTA'' for all of the clinical labor
inputs for this code because we believe that the typical office
performing SRT will be staffed with this labor type, rather than with
another clinical labor type such as radiation therapists, and we seek
comments as to the appropriateness of the staff type ``RN/LPN/MTA'' for
this SRT-related service. Some stakeholders have suggested that many
services related to SRT are personally performed by the billing
practitioner rather than by clinical staff.
We are proposing to remove the supply items ``gown, patient'' and
``pillow case'' that are associated with CPT code 77280, as these items
are included in the minimum multi-specialty visit pack that is
associated with CPT code 77427. We are not proposing to include the
equipment items ``radiation virtual simulation system,'' ``room, CT''
and ``PACS Workstation Proxy'' that are associated with CPT code 77280,
as we do not believe that a typical office furnishing SRT uses this
kind of equipment. Instead, we are including additional time for the
capital equipment used in delivering SRT in the proposed direct PE
inputs. For ``radiation dose therapy plan,'' we are proposing to apply
the clinical labor time that is associated with CPT code 77300 to HCPCS
code GRRR1 for purposes of developing a proposed value, but we seek
comments as to whether the clinical staff would typically perform the
radiation dose therapy planning for this service, or if the physician
would perform this and/or other tasks, and, in the case of the latter,
what the appropriate physician time would be. Likewise, we are
soliciting comment as to whether the clinical labor associated with the
teletherapy isodose plan would be performed by the physician. We are
proposing to assign 14 minutes each to the equipment items ``radiation
therapy dosimetry software (Argus QC)'', ``computer workstation'', and
``3D teletherapy treatment planning'' as these are the times assigned
to these equipment items for CPT code 77300.
We are not proposing to include inputs related to radiation physics
consultation, described by CPT code 77336, as we think that a typical
course of SRT would not require this service, and the typical
practitioner providing SRT would not be performing physics
consultation, and we are seeking comment as to whether inputs
associated with this code or other inputs used in furnishing analogous
services should be included. We are not proposing to include the post-
operative office visits included in the valuation of CPT code 77427, as
we do not believe that a typical course of SRT will require post-
operative visits; however, we are seeking comment regarding the amount
of face-to-face time typically spent by the practitioner with the
patient for radiation treatment management associated with SRT.
As discussed in the CY 2016 PFS final rule (80 FR 70924 through
70927), in the case of new codes that describe services that were
previously included in the payment for other codes, we finalized the
policy that these new codes are excluded from the misvalued code target
when they were previously bundled into a set of broadly reported E/M
codes and services that include E/M visits. We noted that we did not
believe that the change to separate payment for these kinds of services
should be counted as increases that are included in calculating ``net
reductions'' in expenditure attributable to adjustments for misvalued
codes. Therefore, we are proposing to exclude HCPCS code GRRR1 from the
misvalued code target.
(57) Payment Accuracy for Prolonged Preventive Services (HCPCS Codes
GYYY1 and GYYY2)
Most services paid under the PFS are coded to reflect differential
resource costs associated with different levels of care. However, this
level of granularity is not applied evenly across the PFS. For example,
there are far fewer Evaluation and Management (E/M) visit codes than
there are codes that describe procedures. While not a comprehensive
solution to address the differential resource costs of certain E/M
visits, prolonged services codes can be used to report medically
necessary E/M visits that require additional amounts of time. Like E/M
visit codes, many of the Medicare-covered preventive services codes
describe a service that has an atypically broad range of potential
resource costs, including differential amounts of time required to
furnish services. However, unlike for most E/M visit codes, there are
not prolonged services codes that apply to Medicare-covered preventive
services.
Some stakeholders have expressed concerns to CMS that there is no
coding mechanism for practitioners to report the additional time
sometimes required to appropriately furnish care to a patient receiving
a Medicare-covered preventive service. We note that Medicare covers a
broad range of preventive services, such as a ``Welcome to Medicare
Preventive Visit'', yearly wellness visits, cancer screenings, and many
types of counseling. Medicare beneficiary coinsurance and deductible
payments are not applicable for certain Medicare-covered preventive
services. Additional information about preventive services
[[Page 34014]]
covered under Medicare, including whether beneficiary coinsurance or
deductible apply, is available on the CMS Web site at https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf. To more accurately reflect the
differential resource costs when additional time is required to furnish
a Medicare-covered preventive service, we are proposing to make payment
for prolonged preventive services using two new HCPCS G codes that
could be billed along with the Medicare-covered preventive service
codes, when a clinician provides a prolonged Medicare-covered
preventive service.
GYYY1: Prolonged preventive service(s) (beyond the typical
service time of the primary procedure) in the office or other
outpatient setting requiring direct patient contact beyond the usual
service; first 30 minutes (List separately in addition to code for
preventive service)), and
GYYY2: Prolonged preventive service(s) (beyond the typical
service time of the primary procedure) in the office or other
outpatient setting requiring direct patient contact beyond the usual
service; each additional 30 minutes (List separately in addition to
code for preventive service)). These proposed services (HCPCS codes
GYYY1 and GYYY2) are only permitted to be billed with Medicare-covered
preventive services. Beneficiary coinsurance and deductible would not
be applicable for HCPCS codes GYYY1 and GYYY2 because the codes can
only be reported to describe prolonged portions of services where
beneficiary coinsurance and deductible are not applicable.
We are proposing to use prolonged services codes in 30-minute
increments instead of the 60-minute increments that apply for the
parallel office/outpatient prolonged services codes, since some
Medicare-covered preventive services have a shorter duration than E/M
visits. For purposes of valuation for both initial and additional 30
minute codes, we are proposing to use one half of the current work RVUs
and direct PE inputs for CPT code 99354 (Prolonged evaluation and
management or psychotherapy service(s) beyond the typical service time
of the primary procedure) in the office or other outpatient setting
requiring direct patient contact beyond the usual service; first hour
(List separately in addition to code for office or other outpatient
Evaluation and Management or psychotherapy service)). CPT code 99354
has a total time of 60 minutes and a work RVU of 2.33. Therefore, we
are proposing a work RVU of 1.17 and 30 minutes of total work time for
HCPCS codes GYYY1 and GYYY2. We are proposing to use one half of the
direct PE inputs for CPT code 99354, which results in a proposal of 7
minutes of clinical labor type L037D (RN/LPN/MTA) and 15 minutes for
equipment type EF031 (table, power) for HCPCS code GYYY1 and HCPCS code
GYYY2 as the best reflection of typical direct PE costs. We understand
that these specific clinical labor and equipment types may be
functioning as proxy inputs for some Medicare-covered preventive
services.
As described in this section of the rule, we propose that HCPCS
codes GYYY1 and GYYY2 be billed for prolonged preventive services
beyond the typical service time of the primary procedure. For
preventive services with both physician work and practice expense, we
are considering the typical service time of the primary procedure to be
the intraservice work time used for the purposes of ratesetting. For
Medicare-covered preventive services with no face-to-face physician
work, the typical time is the service period clinical staff time that
best represents the face-to-face time with the patient. The counted
time requirements (derived from the typical times assumed for
ratesetting) for all eligible companion Medicare-covered preventive
services are available in the file called ``CY 2018 Preventive Services
Billed with Prolonged Preventives Code'' on the CMS Web site under
downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Table 10--Proposed CY 2018 Work RVUs for New, Revised and Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
Current RUC work CMS work
HCPCS Descriptor work RVU RVU RVU CMS time refinement
----------------------------------------------------------------------------------------------------------------
007X1.................... Anesthesia for upper NEW 0.00 0.00 No.
gastrointestinal
endoscopic procedures,
endoscope introduced
proximal to duodenum; not
otherwise specified.
007X2.................... Anesthesia for upper NEW 0.00 0.00 No.
gastrointestinal
endoscopic procedures,
endoscope introduced
proximal to duodenum;
endoscopic retrograde
cholangiopancreatography
(ERCP).
008X1.................... Anesthesia for lower NEW 0.00 0.00 No.
intestinal endoscopic
procedures, endoscope
introduced distal to
duodenum; not otherwise
specified.
008X2.................... Anesthesia for lower NEW 0.00 0.00 No.
intestinal endoscopic
procedures, endoscope
introduced distal to
duodenum; screening
colonoscopy.
008X3.................... Anesthesia for combined NEW 0.00 0.00 No.
upper and lower
gastrointestinal
endoscopic procedures,
endoscope introduced both
proximal to and distal to
the duodenum.
10040.................... Acne surgery (e.g., 1.21 0.91 0.91 No.
marsupialization, opening
or removal of multiple
milia, comedones, cysts,
pustules).
15734.................... Muscle, myocutaneous, or 19.86 23.00 23.00 No.
fasciocutaneous flap;
trunk.
15736.................... Muscle, myocutaneous, or 17.04 17.04 17.04 No.
fasciocutaneous flap;
upper extremity.
15738.................... Muscle, myocutaneous, or 19.04 19.04 19.04 No.
fasciocutaneous flap;
lower extremity.
157X1.................... Midface flap (i.e., NEW 13.50 13.50 No.
zygomaticofacial flap)
with preservation of
vascular pedicle(s).
157X2.................... Muscle, myocutaneous, or NEW 15.68 15.68 No.
fasciocutaneous flap;
head and neck with named
vascular pedicle (i.e.,
buccinators,
genioglossus, temporalis,
masseter,
sternocleidomastoid,
levator scapulae).
192X1.................... Preparation of tumor NEW 3.00 3.00 No.
cavity with placement of
a radiation therapy
applicator for
intraoperative radiation
therapy (IORT) concurrent
with partial mastectomy.
19303.................... Mastectomy, simple, 15.85 15.00 15.00 No.
complete.
2093X.................... Bone marrow aspiration for NEW 1.16 1.16 No.
bone grafting, spine
surgery only, through
separate skin or fascial
incision.
29445.................... Application of rigid total 1.78 1.78 1.78 No.
contact leg cast.
29580.................... Strapping; Unna boot...... 0.55 0.55 0.55 No.
29581.................... Application of multi-layer 0.25 0.60 0.60 No.
compression system; leg
(below knee), including
ankle and foot.
30140.................... Submucous resection 3.57 3.00 3.00 No.
inferior turbinate,
partial or complete, any
method.
30901.................... Control nasal hemorrhage, 1.10 1.10 1.10 No.
anterior, simple (limited
cautery and/or packing)
any method.
30903.................... Control nasal hemorrhage, 1.54 1.54 1.54 No.
anterior, complex
(extensive cautery and/or
packing) any method.
30905.................... Control nasal hemorrhage, 1.97 1.97 1.97 No.
posterior, with posterior
nasal packs and/or
cautery, any method;
initial.
[[Page 34015]]
30906.................... Control nasal hemorrhage, 2.45 2.45 2.45 No.
posterior, with posterior
nasal packs and/or
cautery, any method;
subsequent.
31XX1.................... Nasal/sinus endoscopy, NEW 8.00 8.00 No.
surgical; with ligation
of sphenopalatine artery.
31XX2.................... Nasal/sinus endoscopy, NEW 9.00 9.00 No.
surgical with
ethmoidectomy; total
(anterior and posterior),
including frontal sinus
exploration, with removal
of tissue from frontal
sinus, when performed.
31XX3.................... Nasal/sinus endoscopy, NEW 8.00 8.00 No.
surgical with
ethmoidectomy; total
(anterior and posterior),
including sphenoidotomy.
31XX4.................... Nasal/sinus endoscopy, NEW 8.48 8.48 No.
surgical with
ethmoidectomy; total
(anterior and posterior),
including sphenoidotomy,
with removal of tissue
from the sphenoid sinus.
31XX5.................... Nasal/sinus endoscopy, NEW 4.50 4.50 No.
surgical; with dilation
of frontal and sphenoid
sinus ostia (e.g.,
balloon dilation).
31254.................... Nasal/sinus endoscopy, 4.64 4.27 4.27 No.
surgical with
ethmoidectomy; partial
(anterior).
31255.................... Nasal/sinus endoscopy, 6.95 5.75 5.75 No.
surgical with
ethmoidectomy; total
(anterior and posterior).
31256.................... Nasal/sinus endoscopy, 3.29 3.11 3.11 No.
surgical, with maxillary
antrostomy.
31267.................... Nasal/sinus endoscopy, 5.45 4.68 4.68 No.
surgical, with maxillary
antrostomy; with removal
of tissue from maxillary
sinus.
31276.................... Nasal/sinus endoscopy, 8.84 6.75 6.75 No.
surgical, with frontal
sinus exploration,
including removal of
tissue from frontal
sinus, when performed.
31287.................... Nasal/sinus endoscopy, 3.91 3.50 3.50 No.
surgical, with
sphenoidotomy.
31288.................... Nasal/sinus endoscopy, 4.57 4.10 4.10 No.
surgical, with
sphenoidotomy; with
removal of tissue from
the sphenoid sinus.
31295.................... Nasal/sinus endoscopy, 2.70 2.70 2.70 No.
surgical; with dilation
of maxillary sinus ostium
(e.g., balloon dilation),
transnasal or canine
fossa.
31296.................... Nasal/sinus endoscopy, 3.29 3.10 3.10 No.
surgical; with dilation
of frontal sinus ostium
(e.g., balloon dilation).
31297.................... Nasal/sinus endoscopy, 2.64 2.44 2.44 No.
surgical; with dilation
of sphenoid sinus ostium
(e.g., balloon dilation).
31600.................... Tracheostomy, planned 7.17 5.56 5.56 No.
(separate procedure).
31601.................... Tracheostomy, planned 4.44 8.00 8.00 No.
(separate procedure);
younger than 2 years.
31603.................... Tracheostomy, emergency 4.14 6.00 6.00 No.
procedure; transtracheal.
31605.................... Tracheostomy, emergency 3.57 6.45 6.45 No.
procedure; cricothyroid
membrane.
31610.................... Tracheostomy, fenestration 9.38 12.00 12.00 No.
procedure with skin flaps.
31645.................... Bronchoscopy, rigid or 2.91 2.88 2.88 No.
flexible, including
fluoroscopic guidance,
when performed with
therapeutic aspiration of
tracheobronchial tree,
initial.
31646.................... Bronchoscopy, rigid or 2.47 2.78 2.78 No.
flexible, including
fluoroscopic guidance,
when performed with
therapeutic aspiration of
tracheobronchial tree,
subsequent, same hospital
stay.
32998.................... Ablation therapy for 5.68 9.03 9.03 No.
reduction or eradication
of 1 or more pulmonary
tumor(s) including pleura
or chest wall when
involved by tumor
extension, percutaneous,
including imaging
guidance when performed,
unilateral;
radiofrequency.
32X99.................... Ablation therapy for NEW 9.03 9.03 No.
reduction or eradication
of 1 or more pulmonary
tumor(s) including pleura
or chest wall when
involved by tumor
extension, percutaneous,
including imaging
guidance when performed,
unilateral; cryoablation.
339X1.................... Implantation of a total NEW 49.00 49.00 No.
replacement heart system
(artificial heart) with
recipient cardiectomy.
339X2.................... Removal and replacement of NEW C C No.
total replacement heart
system (artificial heart).
339X3.................... Removal of a total NEW C C No.
replacement heart system
(artificial heart) for
heart transplantation.
34812.................... Open femoral artery 6.74 4.13 4.13 No.
exposure for delivery of
endovascular prosthesis
by groin incision,
unilateral.
34820.................... Open iliac artery exposure 9.74 7.00 7.00 No.
for delivery of
endovascular prosthesis
or iliac occlusion by
abdominal or
retroperitoneal incision,
unilateral.
34833.................... Open iliac artery exposure 11.98 8.16 8.16 No.
with creation of conduit
for delivery of
endovascular prosthesis
or for establishment of
cardiopulmonary bypass,
by abdominal or
retroperitoneal incision,
unilateral.
34834.................... Open brachial artery 5.34 2.65 2.65 No.
exposure for delivery of
endovascular prosthesis
unilateral.
34X01.................... Endovascular repair of NEW 23.71 23.71 No.
infrarenal aorta by
deployment of an aorto-
aortic tube endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the aortic
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the aortic bifurcation;
for other than rupture
(e.g., for aneurysm,
pseudoaneurysm,
dissection, penetrating
ulcer).
34X02.................... Endovascular repair of NEW 36.00 36.00 No.
infrarenal aorta by
deployment of an aorto-
aortic tube endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the aortic
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the aortic bifurcation;
for rupture including
temporary aortic and/or
iliac balloon occlusion
when performed (e.g., for
aneurysm, pseudoaneurysm,
dissection, penetrating
ulcer, traumatic
disruption).
34X03.................... Endovascular repair of NEW 26.52 26.52 No.
infrarenal aorta and/or
iliac artery(ies) by
deployment of an aorto-
uniiliac endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the iliac
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the iliac bifurcation;
for other than rupture
(e.g., for aneurysm,
pseudoaneurysm,
dissection, penetrating
ulcer).
34X04.................... Endovascular repair of NEW 45.00 45.00 No.
infrarenal aorta and/or
iliac artery(ies) by
deployment of an aorto-
uniiliac endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the iliac
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the iliac bifurcation;
for rupture including
temporary aortic and/or
iliac balloon occlusion
when performed (e.g., for
aneurysm, pseudoaneurysm,
dissection, penetrating
ulcer, traumatic
disruption).
[[Page 34016]]
34X05.................... Endovascular repair of NEW 29.58 29.58 No.
infrarenal aorta and/or
iliac artery(ies) by
deployment of an aorto-
biiliac endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the iliac
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the iliac bifurcation;
for other than rupture
(e.g., for aneurysm,
pseudoaneurysm,
dissection, penetrating
ulcer).
34X06.................... Endovascular repair of NEW 45.00 45.00 No.
infrarenal aorta and/or
iliac artery(ies) by
deployment of an aorto-
biiliac endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, all
endograft extension(s)
placed in the aorta from
the level of the renal
arteries to the iliac
bifurcation, and all
angioplasty/stenting
performed from the level
of the renal arteries to
the iliac bifurcation;
for rupture including
temporary aortic and/or
iliac balloon occlusion
when performed (e.g., for
aneurysm, pseudoaneurysm,
dissection, penetrating
ulcer, traumatic
disruption).
34X07.................... Endovascular repair of NEW 22.28 22.28 No.
iliac artery by
deployment of an ilio-
iliac tube endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, and all
endograft extension(s)
proximally to the aortic
bifurcation and distally
to the iliac bifurcation,
and treatment zone
angioplasty/stenting when
performed, unilateral;
for other than rupture
(e.g., for aneurysm,
pseudoaneurysm,
dissection, arteriovenous
malformation).
34X08.................... Endovascular repair of NEW 36.50 36.50 No.
iliac artery by
deployment of an ilio-
iliac tube endograft
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, and all
endograft extension(s)
proximally to the aortic
bifurcation and distally
to the iliac bifurcation,
and treatment zone
angioplasty/stenting when
performed, unilateral;
for rupture including
temporary aortic and/or
iliac balloon occlusion
when performed (e.g., for
aneurysm, pseudoaneurysm,
dissection, arteriovenous
malformation, traumatic
disruption).
34X09.................... Placement of extension NEW 6.50 6.50 No.
prosthesis(es) distal to
the common iliac
artery(ies) or proximal
to the renal artery(ies)
for endovascular repair
of infrarenal abdominal
aortic or iliac aneurysm,
false aneurysm,
dissection, penetrating
ulcer, including pre-
procedure sizing and
device selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, and
treatment zone
angioplasty/stenting when
performed, per vessel
treated.
34X10.................... Delayed placement of NEW 15.00 15.00 No.
distal or proximal
extension prosthesis for
endovascular repair of
infrarenal abdominal
aortic or iliac aneurysm,
false aneurysm,
dissection, endoleak, or
endograft migration,
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, and
treatment zone
angioplasty/stenting when
performed; initial vessel
treated.
34X11.................... Delayed placement of NEW 6.00 6.00 No.
distal or proximal
extension prosthesis for
endovascular repair of
infrarenal abdominal
aortic or iliac aneurysm,
false aneurysm,
dissection, endoleak, or
endograft migration,
including pre-procedure
sizing and device
selection, all
nonselective
catheterization(s), all
associated radiological
supervision and
interpretation, and
treatment zone
angioplasty/stenting when
performed; each
additional vessel treated.
34X12.................... Transcatheter delivery of NEW 12.00 12.00 No.
enhanced fixation
device(s) to the
endograft (e.g., anchor,
screw, tack) and all
associated radiological
supervision and
interpretation.
34X13.................... Percutaneous access and NEW 2.50 2.50 No.
closure of femoral artery
for delivery of endograft
through a large sheath
(12 French or larger),
including ultrasound
guidance, when performed,
unilateral.
34X15.................... Open femoral artery NEW 5.25 5.25 No.
exposure with creation of
conduit for delivery of
endovascular prosthesis
or for establishment of
cardiopulmonary bypass,
by groin incision,
unilateral.
34X19.................... Open axillary/subclavian NEW 6.00 6.00 No.
artery exposure for
delivery of endovascular
prosthesis by
infraclavicular or
supraclavicular incision,
unilateral.
34X20.................... Open axillary/subclavian NEW 7.19 7.19 No.
artery exposure with
creation of conduit for
delivery of endovascular
prosthesis or for
establishment of
cardiopulmonary bypass,
by infraclavicular or
supraclavicular incision,
unilateral.
36215.................... Selective catheter 4.67 4.17 4.17 No.
placement, arterial
system; each first order
thoracic or
brachiocephalic branch,
within a vascular family.
36216.................... Selective catheter 5.27 5.27 5.27 No.
placement, arterial
system; initial second
order thoracic or
brachiocephalic branch,
within a vascular family.
36217.................... Selective catheter 6.29 6.29 6.29 No.
placement, arterial
system; initial third
order or more selective
thoracic or
brachiocephalic branch,
within a vascular family.
36218.................... Selective catheter 1.01 1.01 1.01 No.
placement, arterial
system; additional second
order, third order, and
beyond, thoracic or
brachiocephalic branch,
within a vascular family.
36470.................... Injection of sclerosant; 1.10 0.75 0.75 No.
single incompetent vein
(other than
telangiectasia).
36471.................... Injection of sclerosant; 1.65 1.50 1.50 No.
multiple incompetent
veins (other than
telangiectasia), same leg.
364X3.................... Endovenous ablation NEW 3.50 3.50 No.
therapy of incompetent
vein, extremity, by
transcatheter delivery of
a chemical adhesive
(e.g., cyanoacrylate)
remote from the access
site, inclusive of all
imaging guidance and
monitoring, percutaneous;
first vein treated.
364X4.................... Endovenous ablation NEW 1.75 1.75 No.
therapy of incompetent
vein, extremity, by
transcatheter delivery of
a chemical adhesive
(e.g., cyanoacrylate)
remote from the access
site, inclusive of all
imaging guidance and
monitoring, percutaneous;
subsequent vein(s)
treated in a single
extremity, each through
separate access sites.
364X5.................... Injection of non- NEW 2.35 2.35 No.
compounded foam
sclerosant with
ultrasound compression
maneuvers to guide
dispersion of the
injectate, inclusive of
all imaging guidance and
monitoring; single
incompetent extremity
truncal vein (e.g., great
saphenous vein, accessory
saphenous vein).
364X6.................... Injection of non- NEW 3.00 3.00 No.
compounded foam
sclerosant with
ultrasound compression
maneuvers to guide
dispersion of the
injectate, inclusive of
all imaging guidance and
monitoring; multiple
incompetent truncal veins
(e.g., great saphenous
vein, accessory saphenous
vein), same leg.
36511.................... Therapeutic apheresis; for 1.74 2.00 2.00 No.
white blood cells.
36512.................... Therapeutic apheresis; for 1.74 2.00 2.00 No.
red blood cells.
36513.................... Therapeutic apheresis; for 1.74 2.00 2.00 No.
platelets.
36514.................... Therapeutic apheresis; for 1.74 1.81 1.81 No.
plasma pheresis.
[[Page 34017]]
36516.................... Therapeutic apheresis; 1.22 1.56 1.56 No.
with extracorporeal
selective adsorption or
selective filtration and
plasma reinfusion.
36522.................... Photopheresis, 1.67 1.75 1.75 No.
extracorporeal.
36555.................... Insertion of non-tunneled 2.43 1.93 1.93 No.
centrally inserted
central venous catheter;
younger than 5 years of
age.
36556.................... Insertion of non-tunneled 2.50 1.75 1.75 No.
centrally inserted
central venous catheter;
age 5 years or older.
36569.................... Insertion of peripherally 1.82 1.70 1.70 No.
inserted central venous
catheter (PICC), without
subcutaneous port or
pump; age 5 years or
older.
36620.................... Arterial catheterization 1.15 1.00 1.00 No.
or cannulation for
sampling, monitoring or
transfusion (separate
procedure); percutaneous.
38220.................... Diagnostic bone marrow; 1.08 1.20 1.20 Yes.
aspiration(s).
38221.................... Diagnostic bone marrow; 1.37 1.28 1.28 Yes.
biopsy(ies).
382X3.................... Diagnostic bone marrow; NEW 1.44 1.44 Yes.
biopsy(ies) and
aspiration(s).
3857X.................... Laparoscopy, surgical; NEW 20.00 20.00 No.
with bilateral total
pelvic lymphadenectomy
and peri-aortic lymph
node sampling peritoneal
washings, peritoneal
biopsy(s), omentectomy,
and diaphragmatic
washings, including
biopsy(s) when performed.
43107.................... Total or near total 44.18 52.05 52.05 No.
esophagectomy, without
thoracotomy; with
pharyngogastrostomy or
cervical
esophagogastrostomy, with
or without pyloroplasty
(transhiatal).
43112.................... Total or near total 47.48 62.00 62.00 No.
esophagectomy, with
thoracotomy; with
pharyngogastrostomy or
cervical
esophagogastrostomy, with
or without pyloroplasty
(i.e., McKeown
esophagectomy, or tri-
incisional esophagectomy).
43117.................... Partial esophagectomy, 43.65 57.50 57.50 No.
distal two-thirds, with
thoracotomy and separate
abdominal incision, with
or without proximal
gastrectomy; with
thoracic
esophagogastrostomy, with
or without pyloroplasty
(Ivor Lewis).
432X5.................... Esophagectomy, total or NEW 55.00 55.00 No
near total, with
laparoscopic mobilization
of the abdominal and
mediastinal esophagus and
proximal gastrectomy,
with laparoscopic pyloric
drainage procedure if
performed, with open
cervical
pharyngogastrostomy or
esophagogastrostomy
(i.e., laparoscopic
transhiatal
esophagectomy).
432X6.................... Esophagectomy, distal two- NEW 63.00 63.00 No.
thirds, with laparoscopic
mobilization of the
abdominal and lower
mediastinal esophagus and
proximal gastrectomy,
with laparoscopic pyloric
drainage procedure if
performed, with separate
thoracoscopic
mobilization of the
middle and upper
mediastinal esophagus and
thoracic
esophagogastrostomy
(i.e., laparoscopic
thoracoscopic
esophagectomy, Ivor Lewis
esophagectomy).
432X7.................... Esophagectomy, total or NEW 66.42 66.42 No.
near total, with
thoracoscopic
mobilization of the
upper, middle, and lower
mediastinal esophagus,
with separate
laparoscopic proximal
gastrectomy, with
laparoscopic pyloric
drainage procedure if
performed, with open
cervical
pharyngogastrostomy or
esophagogastrostomy
(i.e., thoracoscopic,
laparoscopic and cervical
incision esophagectomy,
McKeown esophagectomy,
tri-incisional
esophagectomy).
51798.................... Measurement of post- 0.00 0.00 0.00 No.
voiding residual urine
and/or bladder capacity
by ultrasound, non-
imaging.
52601.................... Transurethral 15.26 13.16 13.16 No.
electrosurgical resection
of prostate, including
control of postoperative
bleeding, complete
(vasectomy, meatotomy,
cystourethroscopy,
urethral calibration and/
or dilation, and internal
urethrotomy are included).
55X87.................... Transperineal placement of NEW 3.03 3.03 No.
biodegradable material,
peri-prostatic, single or
multiple injection(s),
including image guidance,
when performed.
57240.................... Anterior colporrhaphy, 11.50 10.08 10.08 No.
repair of cystocele with
or without repair of
urethrocele, including
cystourethroscopy, when
performed.
57250.................... Posterior colporrhaphy, 11.50 10.08 10.08 No.
repair of rectocele with
or without perineorrhaphy.
57260.................... Combined anteroposterior 14.44 13.25 13.25 No.
colporrhaphy, including
cystourethroscopy, when
performed.
57265.................... Combined anteroposterior 15.94 15.00 15.00 No.
colporrhaphy, including
cystourethroscopy, when
performed; with
enterocele repair.
5857X.................... Laparoscopy, surgical, NEW 32.60 32.60 No.
total hysterectomy; with
or without salpingo-
oophorectomy, unilateral
or bilateral, with
resection of malignancy
(tumor debulking), with
omentectomy.
64418.................... Injection, anesthetic 1.32 1.10 1.10 No.
agent; suprascapular
nerve.
64553.................... Percutaneous implantation 2.36 6.13 6.13 No
of neurostimulator
electrode array; cranial
nerve.
64555.................... Percutaneous implantation 2.32 5.76 5.76 No.
of neurostimulator
electrode array;
peripheral nerve
(excludes sacral nerve).
64910.................... Nerve repair; with 11.39 10.52 10.52 No.
synthetic conduit or vein
allograft (e.g., nerve
tube), each nerve.
64911.................... Nerve repair; with 14.39 14.00 14.00 No
autogenous vein graft
(includes harvest of vein
graft), each nerve.
64X91.................... Nerve repair; with nerve NEW 12.00 12.00 No.
allograft, each nerve,
first strand (cable).
64X92.................... Nerve repair; with nerve NEW 3.00 3.00 No.
allograft, each
additional strand.
67820.................... Correction of trichiasis; 0.71 0.32 0.32 No.
epilation, by forceps
only.
70490.................... Computed tomography, soft 1.28 1.28 1.28 No.
tissue neck; without
contrast material.
70491.................... Computed tomography, soft 1.38 1.38 1.38 No.
tissue neck; with
contrast material(s).
70492.................... Computed tomography, soft 1.45 1.62 1.62 No.
tissue neck; without
contrast material
followed by contrast
material(s) and further
sections.
70544.................... Magnetic resonance 1.20 1.20 1.20 No.
angiography, head;
without contrast
material(s).
70545.................... Magnetic resonance 1.20 1.20 1.20 No.
angiography, head; with
contrast material(s).
70546.................... Magnetic resonance 1.80 1.48 1.48 No.
angiography, head;
without contrast
material(s), followed by
contrast material(s) and
further sequences.
70547.................... Magnetic resonance 1.20 1.20 1.20 No.
angiography, neck;
without contrast
material(s).
70548.................... Magnetic resonance 1.20 1.50 1.50 No.
angiography, neck; with
contrast material(s).
70549.................... Magnetic resonance 1.80 1.80 1.80 No.
angiography, neck;
without contrast
material(s), followed by
contrast material(s) and
further sequences.
710X1.................... Radiologic examination, NEW 0.18 0.18 No.
chest; single view.
710X2.................... Radiologic examination, NEW 0.22 0.22 No.
chest; 2 views.
710X3.................... Radiologic examination, NEW 0.27 0.27 No.
chest; 3 views.
710X4.................... Radiologic examination, NEW 0.31 0.31 No.
chest; 4 or more views.
71100.................... Radiologic examination, 0.22 0.22 0.22 No.
ribs, unilateral; 2 views.
71101.................... Radiologic examination, 0.27 0.27 0.27 No.
ribs, unilateral;
including posteroanterior
chest, minimum of 3 views.
71110.................... Radiologic examination, 0.27 0.29 0.29 No.
ribs, bilateral; 3 views.
71111.................... Radiologic examination, 0.32 0.32 0.32 No.
ribs, bilateral;
including posteroanterior
chest, minimum of 4 views.
[[Page 34018]]
71250.................... Computed tomography, 1.02 1.16 1.16 No.
thorax; without contrast
material.
71260.................... Computed tomography, 1.24 1.24 1.24 No.
thorax; with contrast
material(s).
71270.................... Computed tomography, 1.38 1.38 1.38 No.
thorax; without contrast
material, followed by
contrast material(s) and
further sections.
72195.................... Magnetic resonance (e.g., 1.46 1.46 1.46 No.
proton) imaging, pelvis;
without contrast
material(s).
72196.................... Magnetic resonance (e.g., 1.73 1.73 1.73 No.
proton) imaging, pelvis;
with contrast material(s).
72197.................... Magnetic resonance (e.g., 2.26 2.20 2.20 No.
proton) imaging, pelvis;
without contrast
material(s), followed by
contrast material(s) and
further sequences.
73100.................... Radiologic examination, 0.16 0.16 0.16 No.
wrist; 2 views.
73110.................... Radiologic examination, 0.17 0.17 0.17 No.
wrist; complete, minimum
of 3 views.
73120.................... Radiologic examination, 0.16 0.16 0.16 No.
hand; 2 views.
73130.................... Radiologic examination, 0.17 0.17 0.17 No.
hand; minimum of 3 views.
73140.................... Radiologic examination, 0.13 0.13 0.13 No.
finger(s), minimum of 2
views.
73718.................... Magnetic resonance (e.g., 1.35 1.35 1.35 No.
proton) imaging, lower
extremity other than
joint; without contrast
material(s).
73719.................... Magnetic resonance (e.g., 1.62 1.62 1.62 No.
proton) imaging, lower
extremity other than
joint; with contrast
material(s).
73720.................... Magnetic resonance (e.g., 2.15 2.15 2.15 No.
proton) imaging, lower
extremity other than
joint; without contrast
material(s), followed by
contrast material(s) and
further sequences.
74022.................... Radiologic examination, 0.32 0.32 0.32 No.
abdomen; complete acute
abdomen series, including
supine, erect, and/or
decubitus views, single
view chest.
740X1.................... Radiologic examination, NEW 0.18 0.18 No.
abdomen; 1 view.
740X2.................... Radiologic examination, NEW 0.23 0.23 No.
abdomen; 2 views.
740X3.................... Radiologic examination, NEW 0.27 0.27 No.
abdomen; 3 or more views.
74181.................... Magnetic resonance (e.g., 1.46 1.46 1.46 No.
proton) imaging, abdomen;
without contrast
material(s).
74182.................... Magnetic resonance (e.g., 1.73 1.73 1.73 No.
proton) imaging, abdomen;
with contrast material(s).
74183.................... Magnetic resonance (e.g., 2.26 2.20 2.20 No.
proton) imaging, abdomen;
without contrast
material(s), followed by
with contrast material(s)
and further sequences.
75635.................... Computed tomographic 2.40 2.40 2.40 No.
angiography, abdominal
aorta and bilateral
iliofemoral lower
extremity runoff, with
contrast material(s),
including noncontrast
images, if performed, and
image postprocessing.
75710.................... Angiography, extremity, 1.14 1.75 1.75 No.
unilateral, radiological
supervision and
interpretation.
75716.................... Angiography, extremity, 1.31 1.97 1.97 No.
bilateral, radiological
supervision and
interpretation.
76510.................... Ophthalmic ultrasound, 1.55 0.70 0.70 No.
diagnostic; B-scan and
quantitative A-scan
performed during the same
patient encounter.
76511.................... Ophthalmic ultrasound, 0.94 0.64 0.64 No.
diagnostic; quantitative
A-scan only.
76512.................... Ophthalmic ultrasound, 0.94 0.56 0.56 No.
diagnostic; B-scan (with
or without superimposed
non-quantitative A-scan).
76516.................... Ophthalmic biometry by 0.54 0.40 0.40 No.
ultrasound echography, A-
scan.
76519.................... Ophthalmic biometry by 0.54 0.54 0.54 No.
ultrasound echography, A-
scan; with intraocular
lens power calculation.
76881.................... Ultrasound, extremity, 0.63 0.63 0.63 No.
nonvascular, real-time
with image documentation;
complete.
76882.................... Ultrasound, extremity, 0.49 0.49 0.49 No.
nonvascular, real-time
with image documentation;
limited, anatomic
specific.
77261.................... Therapeutic radiology 1.39 1.30 1.30 No.
treatment planning;
simple.
77262.................... Therapeutic radiology 2.11 2.00 2.00 No.
treatment planning;
intermediate.
77263.................... Therapeutic radiology 3.14 3.14 3.14 No.
treatment planning;
complex.
78300.................... Bone and/or joint imaging; 0.62 0.62 0.62 No.
limited area.
78305.................... Bone and/or joint imaging; 0.83 0.83 0.83 No.
multiple areas.
78306.................... Bone and/or joint imaging; 0.86 0.86 0.86 No.
whole body.
88333.................... Pathology consultation 1.20 1.20 1.20 No.
during surgery; cytologic
examination (e.g., touch
prep, squash prep),
initial site.
88334.................... Pathology consultation 0.73 0.73 0.73 No.
during surgery; cytologic
examination (e.g., touch
prep, squash prep), each
additional site.
88360.................... Morphometric analysis, 1.10 0.85 0.85 No.
tumor
immunohistochemistry
(e.g., Her-2/neu,
estrogen receptor/
progesterone receptor),
quantitative or
semiquantitative, per
specimen, each single
antibody stain procedure;
manual.
88361.................... Morphometric analysis, 1.18 0.95 0.95 No.
tumor
immunohistochemistry
(e.g., Her-2/neu,
estrogen receptor/
progesterone receptor),
quantitative or
semiquantitative, per
specimen, each single
antibody stain procedure;
using computer-assisted
technology.
92136.................... Ophthalmic biometry by 0.54 0.54 0.54 No.
partial coherence
interferometry with
intraocular lens power
calculation.
93279.................... Programming device 0.65 0.65 0.65 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional; single
lead pacemaker system.
93280.................... Programming device 0.77 0.77 0.77 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional; dual
lead pacemaker system.
93281.................... Programming device 0.90 0.85 0.85 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional;
multiple lead pacemaker
system.
93282.................... Programming device 0.85 0.85 0.85 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional; single
lead transvenous
implantable defibrillator
system.
93283.................... Programming device 1.15 1.15 1.15 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional; dual
lead transvenous
implantable defibrillator
system.
[[Page 34019]]
93284.................... Programming device 1.25 1.25 1.25 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional;
multiple lead transvenous
implantable defibrillator
system.
93285.................... Programming device 0.52 0.52 0.52 No.
evaluation (in person)
with iterative adjustment
of the implantable device
to test the function of
the device and select
optimal permanent
programmed values with
analysis, review and
report by a physician or
other qualified health
care professional;
implantable loop recorder
system.
93286.................... Peri-procedural device 0.30 0.30 0.30 No.
evaluation (in person)
and programming of device
system parameters before
or after a surgery,
procedure, or test with
analysis, review and
report by a physician or
other qualified health
care professional;
single, dual, or multiple
lead pacemaker system.
93287.................... Peri-procedural device 0.45 0.45 0.45 No.
evaluation (in person)
and programming of device
system parameters before
or after a surgery,
procedure, or test with
analysis, review and
report by a physician or
other qualified health
care professional;
single, dual, or multiple
lead implantable
defibrillator system.
93288.................... Interrogation device 0.43 0.43 0.43 No.
evaluation (in person)
with analysis, review and
report by a physician or
other qualified health
care professional,
includes connection,
recording and
disconnection per patient
encounter; single, dual,
or multiple lead
pacemaker system.
93289.................... Interrogation device 0.92 0.75 0.75 No.
evaluation (in person)
with analysis, review and
report by a physician or
other qualified health
care professional,
includes connection,
recording and
disconnection per patient
encounter; single, dual,
or multiple lead
transvenous implantable
defibrillator system,
including analysis of
heart rhythm derived data
elements.
93290.................... Interrogation device 0.43 0.43 0.43 No.
evaluation (in person)
with analysis, review and
report by a physician or
other qualified health
care professional,
includes connection,
recording and
disconnection per patient
encounter; implantable
cardiovascular monitor
system, including
analysis of 1 or more
recorded physiologic
cardiovascular data
elements from all
internal and external
sensors.
93291.................... Interrogation device 0.43 0.37 0.37 No.
evaluation (in person)
with analysis, review and
report by a physician or
other qualified health
care professional,
includes connection,
recording and
disconnection per patient
encounter; implantable
loop recorder system,
including heart rhythm
derived data analysis.
93292.................... Interrogation device 0.43 0.43 0.43 No.
evaluation (in person)
with analysis, review and
report by a physician or
other qualified health
care professional,
includes connection,
recording and
disconnection per patient
encounter; wearable
defibrillator system.
93293.................... Transtelephonic rhythm 0.32 0.31 0.31 No.
strip pacemaker
evaluation(s) single,
dual, or multiple lead
pacemaker system,
includes recording with
and without magnet
application with
analysis, review and
report(s) by a physician
or other qualified health
care professional, up to
90 days.
93294.................... Interrogation device 0.65 0.60 0.60 No.
evaluation(s) (remote),
up to 90 days; single,
dual, or multiple lead
pacemaker system with
interim analysis,
review(s) and report(s)
by a physician or other
qualified health care
professional.
93295.................... Interrogation device 1.29 0.74 0.74 No.
evaluation(s) (remote),
up to 90 days; single,
dual, or multiple lead
implantable defibrillator
system with interim
analysis, review(s) and
report(s) by a physician
or other qualified health
care professional.
93296.................... Interrogation device 0.00 0.00 0.00 No.
evaluation(s) (remote),
up to 90 days; single,
dual, or multiple lead
pacemaker system or
implantable defibrillator
system, remote data
acquisition(s), receipt
of transmissions and
technician review,
technical support and
distribution of results.
93297.................... Interrogation device 0.52 0.52 0.52 No.
evaluation(s), (remote)
up to 30 days;
implantable
cardiovascular monitor
system, including
analysis of 1 or more
recorded physiologic
cardiovascular data
elements from all
internal and external
sensors, analysis,
review(s) and report(s)
by a physician or other
qualified health care
professional.
93298.................... Interrogation device 0.52 0.52 0.52 No.
evaluation(s), (remote)
up to 30 days;
implantable loop recorder
system, including
analysis of recorded
heart rhythm data,
analysis, review(s) and
report(s) by a physician
or other qualified health
care professional.
93299.................... Interrogation device 0.00 0.00 0.00 No.
evaluation(s), (remote)
up to 30 days;
implantable
cardiovascular monitor
system or implantable
loop recorder system,
remote data
acquisition(s), receipt
of transmissions and
technician review,
technical support and
distribution of results.
93306.................... Echocardiography, 1.30 1.50 1.50 No.
transthoracic, real-time
with image documentation
(2D), includes M-mode
recording, when
performed, complete, with
spectral Doppler
echocardiography, and
with color flow Doppler
echocardiography.
93307.................... Echocardiography, 0.92 0.92 0.92 No.
transthoracic, real-time
with image documentation
(2D), includes M-mode
recording, when
performed, complete,
without spectral or color
Doppler echocardiography.
93308.................... Echocardiography, 0.53 0.53 0.53 No.
transthoracic, real-time
with image documentation
(2D), includes M-mode
recording, when
performed, follow-up or
limited study.
93350.................... Echocardiography, 1.46 1.46 1.46 No.
transthoracic, real-time
with image documentation
(2D), includes M-mode
recording, when
performed, during rest
and cardiovascular stress
test using treadmill,
bicycle exercise and/or
pharmacologically induced
stress, with
interpretation and report.
93351.................... Echocardiography, 1.75 1.75 1.75 No.
transthoracic, real-time
with image documentation
(2D), includes M-mode
recording, when
performed, during rest
and cardiovascular stress
test using treadmill,
bicycle exercise and/or
pharmacologically induced
stress, with
interpretation and
report; including
performance of continuous
electrocardiographic
monitoring, with
supervision by a
physician or other
qualified health care
professional.
93503.................... Insertion and placement of 2.91 2.00 2.00 No.
flow directed catheter
(e.g., Swan-Ganz) for
monitoring purposes.
93613.................... Intracardiac 6.99 5.23 5.23 No.
electrophysiologic 3-
dimensional mapping.
93668.................... Peripheral arterial N 0.00 0.00 No.
disease (PAD)
rehabilitation, per
session.
94621.................... Cardiopulmonary exercise 1.42 1.42 1.42 No.
testing, including
measurements of minute
ventilation, CO2
production, O2 uptake,
and electrocardiographic
recordings.
946X2.................... Exercise test for NEW 0.70 0.70 No.
bronchospasm, including
pre- and post-spirometry
and pulse oximetry.
946X3.................... Pulmonary stress testing NEW 0.48 0.48 No.
(e.g., 6-minute walk
test), including
measurement of heart
rate, oximetry, and
oxygen titration, when
performed.
95004.................... Percutaneous tests 0.01 0.01 0.01 No.
(scratch, puncture,
prick) with allergenic
extracts, immediate type
reaction, including test
interpretation and
report, specify number of
tests.
[[Page 34020]]
95250.................... Ambulatory continuous 0.00 0.00 0.00 No.
glucose monitoring of
interstitial tissue fluid
via a subcutaneous sensor
for a minimum of 72
hours; sensor placement,
hook-up, calibration of
monitor, patient
training, removal of
sensor, and printout of
recording.
95251.................... Ambulatory continuous 0.85 0.70 0.70 No.
glucose monitoring of
interstitial tissue fluid
via a subcutaneous sensor
for a minimum of 72
hours; interpretation and
report.
95930.................... Visual evoked potential 0.35 0.35 0.35 No.
(VEP) testing central
nervous system except
glaucoma, checkerboard or
flash, with
interpretation and report.
96160.................... Administration of patient- 0.00 0.00 0.00 No.
focused health risk
assessment instrument
(e.g., health hazard
appraisal) with scoring
and documentation, per
standardized instrument.
96161.................... Administration of 0.00 0.00 0.00 No.
caregiver-focused health
risk assessment
instrument (e.g.,
depression inventory) for
the benefit of the
patient, with scoring and
documentation, per
standardized instrument.
96360.................... Intravenous infusion, 0.17 0.17 0.17 No.
hydration; initial, 31
minutes to 1 hour.
96361.................... Intravenous infusion, 0.09 0.09 0.09 No.
hydration; each
additional hour.
96372.................... Therapeutic, prophylactic, 0.17 0.17 0.17 No.
or diagnostic injection
(specify substance or
drug); subcutaneous or
intramuscular.
96374.................... Therapeutic, prophylactic, 0.18 0.18 0.18 No.
or diagnostic injection
(specify substance or
drug); intravenous push,
single or initial
substance/drug.
96375.................... Therapeutic, prophylactic, 0.10 0.10 0.10 No.
or diagnostic injection
(specify substance or
drug); each additional
sequential intravenous
push of a new substance/
drug.
96377.................... Application of on-body 0.00 0.17 0.17 No.
injector (includes
cannula insertion) for
timed subcutaneous
injection.
96401.................... Chemotherapy 0.21 0.21 0.21 No.
administration,
subcutaneous or
intramuscular; non-
hormonal anti-neoplastic.
96402.................... Chemotherapy 0.19 0.19 0.19 No.
administration,
subcutaneous or
intramuscular; hormonal
anti-neoplastic.
96409.................... Chemotherapy 0.24 0.24 0.24 No.
administration;
intravenous, push
technique, single or
initial substance/drug.
96411.................... Chemotherapy 0.20 0.20 0.20 No.
administration;
intravenous, push
technique, each
additional substance/drug.
96910.................... Photochemotherapy; tar and 0.00 0.00 0.00 No.
ultraviolet B (Goeckerman
treatment) or petrolatum
and ultraviolet B.
96X73.................... Photodynamic therapy by NEW 0.48 0.48 No.
external application of
light to destroy
premalignant lesions of
the skin and adjacent
mucosa with application
and illumination/
activation of
photosensitizing drug(s),
per day.
96X74.................... Debridement of NEW 1.01 1.01 No.
premalignant
hyperkeratotic lesion(s)
(i.e., targeted
curettage, abrasion)
followed with
photodynamic therapy by
external application of
light to destroy
premalignant lesions of
the skin and adjacent
mucosa with application
and illumination/
activation of
photosensitizing drug(s),
per day.
97012.................... Application of a modality 0.25 0.25 0.25 No.
to 1 or more areas;
traction, mechanical.
97014.................... Application of a modality 0.18 0.18 0.18 No.
to 1 or more areas;
electrical stimulation
(unattended).
97016.................... Application of a modality 0.18 0.18 0.18 No.
to 1 or more areas;
vasopneumatic devices.
97018.................... Application of a modality 0.06 0.06 0.06 No.
to 1 or more areas;
paraffin bath.
97022.................... Application of a modality 0.17 0.17 0.17 No.
to 1 or more areas;
whirlpool.
97032.................... Application of a modality 0.25 0.25 0.25 No.
to 1 or more areas;
electrical stimulation
(manual), each 15 minutes.
97033.................... Application of a modality 0.26 0.26 0.26 No.
to 1 or more areas;
iontophoresis, each 15
minutes.
97034.................... Application of a modality 0.21 0.21 0.21 No.
to 1 or more areas;
contrast baths, each 15
minutes.
97035.................... Application of a modality 0.21 0.21 0.21 No.
to 1 or more areas;
ultrasound, each 15
minutes.
97110.................... Therapeutic procedure, 1 0.45 0.45 0.45 No.
or more areas, each 15
minutes; therapeutic
exercises to develop
strength and endurance,
range of motion and
flexibility.
97112.................... Therapeutic procedure, 1 0.45 0.50 0.50 No.
or more areas, each 15
minutes; neuromuscular
reeducation of movement,
balance, coordination,
kinesthetic sense,
posture, and/or
proprioception for
sitting and/or standing
activities.
97113.................... Therapeutic procedure, 1 0.44 0.48 0.48 No.
or more areas, each 15
minutes; aquatic therapy
with therapeutic
exercises.
97116.................... Therapeutic procedure, 1 0.40 0.45 0.45 No.
or more areas, each 15
minutes; gait training
(includes stair climbing).
97140.................... Manual therapy techniques 0.43 0.43 0.43 No.
(e.g., mobilization/
manipulation, manual
lymphatic drainage,
manual traction), 1 or
more regions, each 15
minutes.
97530.................... Therapeutic activities, 0.44 0.44 0.44 No.
direct (one-on-one)
patient contact (use of
dynamic activities to
improve functional
performance), each 15
minutes.
97533.................... Sensory integrative 0.44 0.48 0.48 No.
techniques to enhance
sensory processing and
promote adaptive
responses to
environmental demands,
direct (one-on-one)
patient contact, each 15
minutes.
97535.................... Self-care/home management 0.45 0.45 0.45 No.
training (e.g.,
activities of daily
living (ADL) and
compensatory training,
meal preparation, safety
procedures, and
instructions in use of
assistive technology
devices/adaptive
equipment) direct one-on-
one contact, each 15
minutes.
97537.................... Community/work 0.45 0.48 0.48 No.
reintegration training
(e.g., shopping,
transportation, money
management, avocational
activities and/or work
environment/modification
analysis, work task
analysis, use of
assistive technology
device/adaptive
equipment), direct one-on-
one contact, each 15
minutes.
97542.................... Wheelchair management 0.45 0.48 0.48 No.
(e.g., assessment,
fitting, training), each
15 minutes.
97760.................... Orthotic(s) management and 0.45 0.50 0.50 No.
training (including
assessment and fitting
when not otherwise
reported), upper
extremity(ies), lower
extremity(ies) and/or
trunk, initial
orthotic(s) encounter,
each 15 minutes.
97761.................... Prosthetic(s) training, 0.45 0.50 0.50 No.
upper and/or lower
extremity(ies), initial
prosthetic(s) encounter,
each 15 minutes.
977X1.................... Orthotic(s)/prosthetic(s) NEW 0.48 0.48 No.
management and/or
training, upper
extremity(ies), lower
extremity(ies), and/or
trunk, subsequent
orthotic(s)/prosthetic(s)
encounter, each 15
minutes.
97X11.................... Therapeutic interventions NEW 1.50 I Yes.
that focus on cognitive
function (e.g.,
attention, memory,
reasoning, executive
function, problem
solving, and/or pragmatic
functioning) and
compensatory strategies
to manage the performance
of an activity (e.g.,
managing time or
schedules, initiating,
organizing and sequencing
tasks, direct (one-on-
one) patient contact (do
not report 97X11 in
conjunction with 0364T,
0365T, 0368T, 0369T)
(report 97X11 only once
per day).
993X1.................... Patient/caregiver training NEW 0.00 0.00 No.
for initiation of home
INR monitoring under the
direction of a physician
or other qualified health
care professional,
including face-to-face,
use and care of the INR
monitor, obtaining blood
sample, instructions for
reporting home INR test
results, and
documentation of
patient's/caregiver's
ability to perform
testing and report
results.
[[Page 34021]]
993X2.................... Anticoagulant management NEW 0.18 0.18 No.
for a patient taking
warfarin, must include
review and interpretation
of a new home, office, or
lab International
No.rmalized Ratio (INR)
test result, patient
instructions, dosage
adjustment (as needed),
and scheduling of
additional test(s) when
performed.
994X1.................... Initial psychiatric NEW 1.70 1.70 No.
collaborative care
management, first 70
minutes in the first
calendar month of
behavioral health care
manager activities, in
consultation with a
psychiatric consultant,
and directed by the
treating physician or
other qualified health
care professional, with
the following required
elements: Outreach to and
engagement in treatment
of a patient directed by
the treating physician or
other qualified health
care professional;
initial assessment of the
patient, including
administration of
validated rating scales,
with the development of
an individualized
treatment plan; review by
the psychiatric
consultant with
modifications of the plan
if recommended; entering
patient in a registry and
tracking patient follow-
up and progress using the
registry, with
appropriate
documentation, and
participation in weekly
caseload consultation
with the psychiatric
consultant; and provision
of brief interventions
using evidence-based
techniques such as
behavioral activation,
motivational
interviewing, and other
focused treatment
strategies.
994X2.................... Subsequent psychiatric NEW 1.53 1.53 No.
collaborative care
management, first 60
minutes in a subsequent
month of behavioral
health care manager
activities, in
consultation with a
psychiatric consultant,
and directed by the
treating physician or
other qualified health
care professional, with
the following required
elements: Tracking
patient follow-up and
progress using the
registry, with
appropriate
documentation;
participation in weekly
caseload consultation
with the psychiatric
consultant; ongoing
collaboration with and
coordination of the
patient's mental health
care with the treating
physician or other
qualified health care
professional and any
other treating mental
health providers;
additional review of
progress and
recommendations for
changes in treatment, as
indicated, including
medications, based on
recommendations provided
by the psychiatric
consultant; provision of
brief interventions using
evidence-based techniques
such as behavioral
activation, motivational
interviewing, and other
focused treatment
strategies; monitoring of
patient outcomes using
validated rating scales;
and relapse prevention
planning with patients as
they achieve remission of
symptoms and/or other
treatment goals and are
prepared for discharge
from active treatment.
994X3.................... Initial or subsequent NEW 0.82 0.82 No.
psychiatric collaborative
care management, each
additional 30 minutes in
a calendar month of
behavioral health care
manager activities, in
consultation with a
psychiatric consultant,
and directed by the
treating physician or
other qualified health
care professional.
99XX3.................... Assessment of and care NEW 3.44 3.44 No.
planning for a patient
with cognitive
impairment, requiring an
independent historian, in
the office or other
outpatient, home or
domiciliary or rest home,
with all of the following
required elements:
Cognition-focused
evaluation including a
pertinent history and
examination; Medical
decision making of
moderate or high
complexity; Functional
assessment (e.g., Basic
and Instrumental
Activities of Daily
Living), including
decision-making capacity;
Use of standardized
instruments for staging
of dementia (e.g.,
Functional Assessment
Staging Test [FAST],
Clinical Dementia Rating
[CDR]); Medication
reconciliation and review
for high-risk
medications; Evaluation
for neuropsychiatric and
behavioral symptoms,
including depression,
including use of
standardized screening
instrument(s); Evaluation
of safety (e.g., home),
including motor vehicle
operation; Identification
of caregiver(s),
caregiver knowledge,
caregiver needs, social
supports, and the
willingness of caregiver
to take on caregiving
tasks; Development,
updating or revision, or
review of an Advance Care
Plan; Creation of a
written care plan,
including initial plans
to address any
neuropsychiatric
symptoms, neuro-cognitive
symptoms, functional
limitations, and referral
to community resources as
needed (e.g.,
rehabilitation services,
adult day programs,
support groups) shared
with the patient and/or
caregiver with initial
education and support.
Typically, 50 minutes are
spent face-to-face with
the patient and/or family
or caregiver.
99XX5.................... Care management services NEW 0.61 0.61 No.
for behavioral health
conditions, at least 20
minutes of clinical staff
time, directed by a
physician or other
qualified health care
professional, per
calendar month, with the
following required
elements: Initial
assessment or follow-up
monitoring, including the
use of applicable
validated rating scales;
Behavioral health care
planning in relation to
behavioral/psychiatric
health problems,
including revision for
patients who are not
progressing or whose
status changes;
Facilitating and
coordinating treatment
such as psychotherapy,
pharmacotherapy,
counseling and/or
psychiatric consultation;
and Continuity of care
with a designated member
of the care team.
G0283.................... Electrical stimulation 0.18 0.18 0.18 No.
(unattended), to one or
more areas for
indication(s) other than
wound care, as part of a
therapy plan of care.
GDDD1.................... Insertion, non- NEW ......... 1.82 No.
biodegradable drug
delivery implants, 4 or
more.
GDDD2.................... Removal, non-biodegradable NEW ......... 2.10 No.
drug deliver implants, 4
or more.
GDDD3.................... Removal with reinsertion, NEW ......... 3.55 No.
non-biodegradable drug
delivery implants, 4 or
more.
GRRR1.................... Superficial radiation NEW ......... 7.93 No.
treatment planning and
management related
services, including but
not limited to, when
performed, clinical
treatment planning (e.g.,
77261, 77262, 77263),
therapeutic radiology
simulation-aided field
setting (e.g., 77280,
77285, 77290, 77293),
basic radiation dosimetry
calculation (e.g.,
77300), treatment devices
(e.g., 77332, 77333,
77334), isodose planning
(e.g., 77306, 77307,
77316, 77317, 77318),
radiation treatment
management (e.g., 77427,
77431, 77432, 77435,
77469, 77470, 77499), and
associated evaluation and
management per course of
treatment.
GXXX1.................... Therapeutic interventions NEW ......... 0.44 No.
that focus on cognitive
function (e.g.,
attention, memory,
reasoning, executive
function, problem
solving, and/or pragmatic
functioning) and
compensatory strategies
to manage the performance
of an activity (e.g.,
managing time or
schedules, initiating,
organizing and sequencing
tasks, direct (one-on-
one) patient contact.
GYYY1.................... Prolonged preventive NEW ......... 1.17 No.
service(s), initial 30
minutes.
GYYY2.................... Prolonged preventive NEW ......... 1.17 No.
service(s), first 30
minutes.
----------------------------------------------------------------------------------------------------------------
[[Page 34022]]
Table 11--CY 2018 Proposed Codes With Direct PE Input Recommendations With Refinements
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RUC CMS Direct
HCPCS code Input code Nonfacility (NF)/ Labor activity recommendation or refinement costs
HCPCS code description Input code description Facility (F) (where applicable) current value (min or Comment change (in
(min or qty) qty) dollars)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
157X1............. Mdfc flap w/prsrv ED050 Technologist PACS NF .................... 115 117 E15: Refined $0.04
vasc pedcl. workstation. equipment time to
conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv EF014 light, surgical...... NF .................... 115 117 E15: Refined 0.02
vasc pedcl. equipment time to
conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv EF031 table, power......... NF .................... 115 117 E15: Refined 0.03
vasc pedcl. equipment time to
conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv EQ011 ECG, 3-channel (with NF .................... 115 117 E15: Refined 0.03
vasc pedcl. SpO2, NIBP, temp, equipment time to
resp). conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv EQ110 electrocautery- NF .................... 115 117 E15: Refined 0.01
vasc pedcl. hyfrecator, up to 45 equipment time to
watts. conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv EQ138 instrument pack, NF .................... 127 129 E15: Refined 0.01
vasc pedcl. medium ($1500 and equipment time to
up). conform to changes
in clinical labor
time.
157X1............. Mdfc flap w/prsrv L038A COMT/COT/RN/CST...... NF Obtain vital signs.. 3 5 L1: Refined time to 0.76
vasc pedcl. standard for this
clinical labor task.
29445............. Apply rigid leg cast. EF031 table, power......... NF .................... 69 67 E15: Refined -0.03
equipment time to
conform to changes
in clinical labor
time.
29445............. Apply rigid leg cast. EQ080 cast cart............ NF .................... 69 67 E15: Refined -0.02
equipment time to
conform to changes
in clinical labor
time.
29445............. Apply rigid leg cast. EQ168 light, exam.......... NF .................... 69 67 E15: Refined -0.01
equipment time to
conform to changes
in clinical labor
time.
29445............. Apply rigid leg cast. L037D RN/LPN/MTA........... NF Check dressings & 5 3 L1: Refined time to -0.74
wound/home care standard for this
instructions/ clinical labor task.
coordinate office
visits/
prescriptions.
[[Page 34023]]
29580............. Application of paste EF023 table, exam.......... NF .................... 35 34 E15: Refined 0.00
boot. equipment time to
conform to changes
in clinical labor
time.
29580............. Application of paste EQ168 light, exam.......... NF .................... 35 34 E15: Refined 0.00
boot. equipment time to
conform to changes
in clinical labor
time.
29580............. Application of paste L037D RN/LPN/MTA........... NF Provide pre-service 3 2 L1: Refined time to -0.37
boot. education/obtain standard for this
consent. clinical labor task.
29581............. Apply multlay comprs EF023 table, exam.......... NF .................... 37 36 E15: Refined 0.00
lwr leg. equipment time to
conform to changes
in clinical labor
time.
29581............. Apply multlay comprs EQ168 light, exam.......... NF .................... 37 36 E15: Refined 0.00
lwr leg. equipment time to
conform to changes
in clinical labor
time.
29581............. Apply multlay comprs L037D RN/LPN/MTA........... NF Provide pre-service 3 2 L1: Refined time to -0.37
lwr leg. education/obtain standard for this
consent. clinical labor task.
30140............. Resect inferior EF008 chair with headrest, NF .................... 98 100 E15: Refined 0.02
turbinate. exam, reclining. equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior EQ137 instrument pack, NF .................... 102 104 E15: Refined 0.00
turbinate. basic ($500-$1499). equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior EQ170 light, fiberoptic NF .................... 98 100 E15: Refined 0.02
turbinate. headlight w-source. equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior EQ234 suction and pressure NF .................... 98 100 E15: Refined 0.02
turbinate. cabinet, ENT (SMR). equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior EQ383 reusable shaver NF .................... 102 104 E15: Refined 0.01
turbinate. blade, 2mm. equipment time to
conform to changes
in clinical labor
time.
[[Page 34024]]
30140............. Resect inferior EQ384 Microdebrider NF .................... 98 100 E15: Refined 0.03
turbinate. handpiece. equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior EQ385 Microdebrider console NF .................... 98 100 E15: Refined 0.06
turbinate. equipment time to
conform to changes
in clinical labor
time.
30140............. Resect inferior L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
turbinate. standard for this
clinical labor task.
30901............. Control of nosebleed. EF008 chair with headrest, NF .................... 22 26 E1: Refined 0.04
exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30901............. Control of nosebleed. EQ137 instrument pack, NF .................... 29 33 E5: Refined 0.01
basic ($500-$1499). equipment time to
conform to
established
policies for
surgical instrument
packs.
30901............. Control of nosebleed. EQ170 light, fiberoptic NF .................... 22 26 E1: Refined 0.03
headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30901............. Control of nosebleed. EQ234 suction and pressure NF .................... 22 26 E1: Refined 0.04
cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
30903............. Control of nosebleed. EF008 chair with headrest, NF .................... 27 31 E1: Refined 0.04
exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30903............. Control of nosebleed. EQ110 electrocautery- NF .................... 27 31 E1: Refined 0.01
hyfrecator, up to 45 equipment time to
watts. conform to
established
policies for non-
highly technical
equipment.
30903............. Control of nosebleed. EQ137 instrument pack, NF .................... 34 38 E5: Refined 0.01
basic ($500-$1499). equipment time to
conform to
established
policies for
surgical instrument
packs.
[[Page 34025]]
30903............. Control of nosebleed. EQ170 light, fiberoptic NF .................... 27 31 E1: Refined 0.03
headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30903............. Control of nosebleed. EQ234 suction and pressure NF .................... 27 31 E1: Refined 0.04
cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
30905............. Control of nosebleed. EF008 chair with headrest, NF .................... 32 62 E1: Refined 0.32
exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30905............. Control of nosebleed. EQ110 electrocautery- NF .................... 32 62 E1: Refined 0.08
hyfrecator, up to 45 equipment time to
watts. conform to
established
policies for non-
highly technical
equipment.
30905............. Control of nosebleed. EQ137 instrument pack, NF .................... 39 69 E5: Refined 0.07
basic ($500-1499). equipment time to
conform to
established
policies for
surgical instrument
packs.
30905............. Control of nosebleed. EQ170 light, fiberoptic NF .................... 32 62 E1: Refined 0.24
headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30905............. Control of nosebleed. EQ234 suction and pressure NF .................... 32 62 E1: Refined 0.28
cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
30906............. Repeat control of EF008 chair with headrest, NF .................... 42 72 E1: Refined 0.32
nosebleed. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30906............. Repeat control of EQ110 electrocautery- NF .................... 42 72 E1: Refined 0.08
nosebleed. hyfrecator, up to 45 equipment time to
watts. conform to
established
policies for non-
highly technical
equipment.
[[Page 34026]]
30906............. Repeat control of EQ137 instrument pack, NF .................... 49 79 E5: Refined 0.07
nosebleed. basic ($500-$1499). equipment time to
conform to
established
policies for
surgical instrument
packs.
30906............. Repeat control of EQ170 light, fiberoptic NF .................... 42 72 E1: Refined 0.24
nosebleed. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
30906............. Repeat control of EQ234 suction and pressure NF .................... 42 72 E1: Refined 0.28
nosebleed. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EF008 chair with headrest, NF .................... 47 52 E1: Refined 0.05
ethmdct. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EF015 mayo stand........... NF .................... 47 52 E1: Refined 0.01
ethmdct. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EQ138 instrument pack, NF .................... 59 64 E5: Refined 0.03
ethmdct. medium ($1500 and equipment time to
up). conform to
established
policies for
surgical instrument
packs.
31254............. Nsl/sins ndsc w/prtl EQ167 light source, xenon.. NF .................... 47 52 E1: Refined 0.14
ethmdct. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EQ170 light, fiberoptic NF .................... 47 52 E1: Refined 0.04
ethmdct. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EQ234 suction and pressure NF .................... 47 52 E1: Refined 0.05
ethmdct. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34027]]
31254............. Nsl/sins ndsc w/prtl EQ383 reusable shaver NF .................... 47 52 E1: Refined 0.02
ethmdct. blade, 2mm. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EQ384 Microdebrider NF .................... 47 52 E1: Refined 0.06
ethmdct. handpiece. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl EQ385 Microdebrider console NF .................... 47 52 E1: Refined 0.15
ethmdct. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31254............. Nsl/sins ndsc w/prtl ES005 endoscope NF .................... 37 51 E4: Refined 0.85
ethmdct. disinfector, rigid equipment time to
or fiberoptic, w- conform to
cart. established
policies for scopes.
31254............. Nsl/sins ndsc w/prtl ES031 video system, NF .................... 47 44 E19: Refined -0.39
ethmdct. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31254............. Nsl/sins ndsc w/prtl ES040 PROXY endoscope, NF .................... 37 51 E4: Refined 0.11
ethmdct. rigid, sinoscopy (0 equipment time to
degrees). conform to
established
policies for scopes.
31254............. Nsl/sins ndsc w/prtl L037D RN/LPN/MTA........... NF Complete pre-service 3 0 L1: Refined time to -1.11
ethmdct. diagnostic and standard for this
referral forms. clinical labor task.
31254............. Nsl/sins ndsc w/prtl L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
ethmdct. standard for this
clinical labor task.
31254............. Nsl/sins ndsc w/prtl L037D RN/LPN/MTA........... NF Provide pre-service 3 0 L1: Refined time to -1.11
ethmdct. education/obtain standard for this
consent. clinical labor task.
31254............. Nsl/sins ndsc w/prtl L037D RN/LPN/MTA........... NF Complete pre- 3 0 L1: Refined time to -1.11
ethmdct. procedure phone standard for this
calls and clinical labor task.
prescription.
31295............. Sinus endo w/balloon EF008 chair with headrest, NF .................... 37 42 E1: Refined 0.05
dil. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EF015 mayo stand........... NF .................... 37 42 E1: Refined 0.01
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34028]]
31295............. Sinus endo w/balloon EQ138 instrument pack, NF .................... 49 54 E5: Refined 0.03
dil. medium ($1500 and equipment time to
up). conform to
established
policies for
surgical instrument
packs.
31295............. Sinus endo w/balloon EQ167 light source, xenon.. NF .................... 37 42 E1: Refined 0.14
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EQ170 light, fiberoptic NF .................... 37 42 E1: Refined 0.04
dil. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EQ234 suction and pressure NF .................... 37 42 E1: Refined 0.05
dil. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EQ383 reusable shaver NF .................... 37 42 E1: Refined 0.02
dil. blade, 2mm. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EQ384 Microdebrider NF .................... 37 42 E1: Refined 0.06
dil. handpiece. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon EQ385 Microdebrider console NF .................... 37 42 E1: Refined 0.15
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31295............. Sinus endo w/balloon ES005 endoscope NF .................... 27 41 E4: Refined 0.85
dil. disinfector, rigid equipment time to
or fiberoptic, w- conform to
cart. established
policies for scopes.
31295............. Sinus endo w/balloon ES031 video system, NF .................... 37 34 E19: Refined -0.39
dil. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31295............. Sinus endo w/balloon ES040 PROXY endoscope, NF .................... 27 41 E4: Refined 0.11
dil. rigid, sinoscopy (0 equipment time to
degrees). conform to
established
policies for scopes.
[[Page 34029]]
31295............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Provide pre-service 3 0 L1: Refined time to -1.11
dil. education/obtain standard for this
consent. clinical labor task.
31295............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre- 3 0 L1: Refined time to -1.11
dil. procedure phone standard for this
calls and clinical labor task.
prescription.
31295............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
dil. standard for this
clinical labor task.
31295............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre-service 3 0 L1: Refined time to -1.11
dil. diagnostic and standard for this
referral forms. clinical labor task.
31296............. Sinus endo w/balloon EF008 chair with headrest, NF .................... 40 45 E1: Refined 0.05
dil. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EF015 mayo stand........... NF .................... 40 45 E1: Refined 0.01
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EQ138 instrument pack, NF .................... 52 57 E5: Refined 0.03
dil. medium ($1500 and equipment time to
up). conform to
established
policies for
surgical instrument
packs.
31296............. Sinus endo w/balloon EQ167 light source, xenon.. NF .................... 40 45 E1: Refined 0.14
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EQ170 light, fiberoptic NF .................... 40 45 E1: Refined 0.04
dil. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EQ234 suction and pressure NF .................... 40 45 E1: Refined 0.05
dil. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EQ383 reusable shaver NF .................... 40 45 E1: Refined 0.02
dil. blade, 2mm. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34030]]
31296............. Sinus endo w/balloon EQ384 Microdebrider NF .................... 40 45 E1: Refined 0.06
dil. handpiece. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon EQ385 Microdebrider console NF .................... 40 45 E1: Refined 0.15
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31296............. Sinus endo w/balloon ES005 endoscope NF .................... 32 44 E4: Refined 0.73
dil. disinfector, rigid equipment time to
or fiberoptic, w- conform to
cart. established
policies for scopes.
31296............. Sinus endo w/balloon ES031 video system, NF .................... 40 37 E19: Refined -0.39
dil. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31296............. Sinus endo w/balloon ES040 PROXY endoscope, NF .................... 32 44 E4: Refined 0.09
dil. rigid, sinoscopy (0 equipment time to
degrees). conform to
established
policies for scopes.
31296............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre-service 3 0 L1: Refined time to -1.11
dil. diagnostic and standard for this
referral forms. clinical labor task.
31296............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Provide pre-service 3 0 L1: Refined time to -1.11
dil. education/obtain standard for this
consent. clinical labor task.
31296............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
dil. standard for this
clinical labor task.
31296............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre- 3 0 L1: Refined time to -1.11
dil. procedure phone standard for this
calls and clinical labor task.
prescription.
31297............. Sinus endo w/balloon EF008 chair with headrest, NF .................... 37 42 E1: Refined 0.05
dil. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EF015 mayo stand........... NF .................... 37 42 E1: Refined 0.01
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ138 instrument pack, NF .................... 49 54 E5: Refined 0.03
dil. medium ($1500 and equipment time to
up). conform to
established
policies for
surgical instrument
packs.
[[Page 34031]]
31297............. Sinus endo w/balloon EQ167 light source, xenon.. NF .................... 37 42 E1: Refined 0.14
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ170 light, fiberoptic NF .................... 37 42 E1: Refined 0.04
dil. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ234 suction and pressure NF .................... 37 42 E1: Refined 0.05
dil. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ383 reusable shaver NF .................... 37 42 E1: Refined 0.02
dil. blade, 2mm. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ384 Microdebrider NF .................... 37 42 E1: Refined 0.06
dil. handpiece. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon EQ385 Microdebrider console NF .................... 37 42 E1: Refined 0.15
dil. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31297............. Sinus endo w/balloon ES005 endoscope NF .................... 27 41 E4: Refined 0.85
dil. disinfector, rigid equipment time to
or fiberoptic, w- conform to
cart. established
policies for scopes.
31297............. Sinus endo w/balloon ES031 video system, NF .................... 37 34 E19: Refined -0.39
dil. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31297............. Sinus endo w/balloon ES040 PROXY endoscope, NF .................... 27 41 E4: Refined 0.11
dil. rigid, sinoscopy (0 equipment time to
degrees). conform to
established
policies for scopes.
31297............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
dil. standard for this
clinical labor task.
31297............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre- 3 0 L1: Refined time to -1.11
dil. procedure phone standard for this
calls and clinical labor task.
prescription.
[[Page 34032]]
31297............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Complete pre-service 3 0 L1: Refined time to -1.11
dil. diagnostic and standard for this
referral forms. clinical labor task.
31297............. Sinus endo w/balloon L037D RN/LPN/MTA........... NF Provide pre-service 3 0 L1: Refined time to -1.11
dil. education/obtain standard for this
consent. clinical labor task.
31645............. Brnchsc w/ther aspir EF027 table, instrument, NF .................... 57 0 G1: See preamble -0.08
1st. mobile. text.
31645............. Brnchsc w/ther aspir EF031 table, power......... NF .................... 57 58 E1: Refined 0.02
1st. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31645............. Brnchsc w/ther aspir EQ004 CO2 respiratory NF .................... 57 0 G1: See preamble -1.47
1st. profile monitor. text.
31645............. Brnchsc w/ther aspir EQ032 IV infusion pump..... NF .................... 57 0 G1: See preamble -0.36
1st. text.
31645............. Brnchsc w/ther aspir EQ235 suction machine NF .................... 57 58 E1: Refined 0.00
1st. (Gomco). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31645............. Brnchsc w/ther aspir ES017 fiberscope, flexible, NF .................... 72 82 E4: Refined 0.82
1st. bronchoscopy. equipment time to
conform to
established
policies for scopes.
31645............. Brnchsc w/ther aspir ES031 video system, NF .................... 42 55 E19: Refined 1.68
1st. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31645............. Brnchsc w/ther aspir SD084 gas, oxygen.......... NF .................... 175 0 G1: See preamble -0.53
1st. text.
31XX5............. Nsl/sins ndsc w/sins EF008 chair with headrest, NF .................... 59 64 E1: Refined 0.05
dilat. exam, reclining. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EF015 mayo stand........... NF .................... 59 64 E1: Refined 0.01
dilat. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EQ138 instrument pack, NF .................... 71 76 E5: Refined 0.03
dilat. medium ($1500 and equipment time to
up). conform to
established
policies for
surgical instrument
packs.
31XX5............. Nsl/sins ndsc w/sins EQ167 light source, xenon.. NF .................... 59 64 E1: Refined 0.14
dilat. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34033]]
31XX5............. Nsl/sins ndsc w/sins EQ170 light, fiberoptic NF .................... 59 64 E1: Refined 0.04
dilat. headlight w-source. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EQ234 suction and pressure NF .................... 59 64 E1: Refined 0.05
dilat. cabinet, ENT (SMR). equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EQ383 reusable shaver NF .................... 59 64 E1: Refined 0.02
dilat. blade, 2mm. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EQ384 Microdebrider NF .................... 59 64 E1: Refined 0.06
dilat. handpiece. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins EQ385 Microdebrider console NF .................... 59 64 E1: Refined 0.15
dilat. equipment time to
conform to
established
policies for non-
highly technical
equipment.
31XX5............. Nsl/sins ndsc w/sins ES005 endoscope NF .................... 57 73 E4: Refined 0.97
dilat. disinfector, rigid equipment time to
or fiberoptic, w- conform to
cart. established
policies for scopes.
31XX5............. Nsl/sins ndsc w/sins ES031 video system, NF .................... 59 56 E19: Refined -0.39
dilat. endoscopy equipment time to
(processor, digital conform to
capture, monitor, established
printer, cart). policies for scope
accessories.
31XX5............. Nsl/sins ndsc w/sins ES040 PROXY endoscope, NF .................... 57 73 E4: Refined 0.12
dilat. rigid, sinoscopy (0 equipment time to
degrees). conform to
established
policies for scopes.
31XX5............. Nsl/sins ndsc w/sins L037D RN/LPN/MTA........... NF Complete pre-service 3 0 L1: Refined time to -1.11
dilat. diagnostic and standard for this
referral forms. clinical labor task.
31XX5............. Nsl/sins ndsc w/sins L037D RN/LPN/MTA........... NF Provide pre-service 3 0 L1: Refined time to -1.11
dilat. education/obtain standard for this
consent. clinical labor task.
31XX5............. Nsl/sins ndsc w/sins L037D RN/LPN/MTA........... NF Complete pre- 3 0 L1: Refined time to -1.11
dilat. procedure phone standard for this
calls and clinical labor task.
prescription.
31XX5............. Nsl/sins ndsc w/sins L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
dilat. standard for this
clinical labor task.
[[Page 34034]]
32998............. Ablate pulm tumor ED050 Technologist PACS NF .................... 133 112 E18: Refined -0.46
perq rf. workstation. equipment time to
conform to
established
policies for PACS
Workstations.
32998............. Ablate pulm tumor EL007 room, CT............. NF .................... 98 96 E2: Refined -9.73
perq rf. equipment time to
conform to
established
policies for highly
technical equipment.
32998............. Ablate pulm tumor EQ168 light, exam.......... NF .................... 98 107 E1: Refined 0.04
perq rf. equipment time to
conform to
established
policies for non-
highly technical
equipment.
32998............. Ablate pulm tumor EQ214 radiofrequency NF .................... 98 96 E2: Refined -0.25
perq rf. generator (NEURO). equipment time to
conform to
established
policies for highly
technical equipment.
32X99............. Ablate pulm tumor ED050 Technologist PACS NF .................... 138 117 E18: Refined -0.46
perq crybl. workstation. equipment time to
conform to
established
policies for PACS
Workstations.
32X99............. Ablate pulm tumor EL007 room, CT............. NF .................... 103 101 E2: Refined -9.73
perq crybl. equipment time to
conform to
established
policies for highly
technical equipment.
32X99............. Ablate pulm tumor EQ168 light, exam.......... NF .................... 103 112 E1: Refined 0.04
perq crybl. equipment time to
conform to
established
policies for non-
highly technical
equipment.
32X99............. Ablate pulm tumor EQ302 cryosurgery system NF .................... 103 101 E2: Refined -0.19
perq crybl. (for tumor ablation). equipment time to
conform to
established
policies for highly
technical equipment.
36215............. Place catheter in ED050 Technologist PACS NF .................... 61 59 E15: Refined -0.04
artery. workstation. equipment time to
conform to changes
in clinical labor
time.
36215............. Place catheter in EF027 table, instrument, NF .................... 180 0 G1: See preamble -0.25
artery. mobile. text.
[[Page 34035]]
36215............. Place catheter in L037D RN/LPN/MTA........... NF Other Clinical 3 1 G1: See preamble -0.74
artery. Activity--specify: text.
Post-procedure
doppler evaluation
(extremity).
36216............. Place catheter in ED050 Technologist PACS NF .................... 76 74 E15: Refined -0.04
artery. workstation. equipment time to
conform to changes
in clinical labor
time.
36216............. Place catheter in EF027 table, instrument, NF .................... 180 0 G1: See preamble -0.25
artery. mobile. text.
36216............. Place catheter in L037D RN/LPN/MTA........... NF Other Clinical 3 1 G1: See preamble -0.74
artery. Activity--specify: text.
Post-procedure
doppler evaluation
(extremity).
36217............. Place catheter in ED050 Technologist PACS NF .................... 91 89 E15: Refined -0.04
artery. workstation. equipment time to
conform to changes
in clinical labor
time.
36217............. Place catheter in EF027 table, instrument, NF .................... 180 0 G1: See preamble -0.25
artery. mobile. text.
36217............. Place catheter in L037D RN/LPN/MTA........... NF Other Clinical 3 1 G1: See preamble -0.74
artery. Activity--specify: text.
Post-procedure
doppler evaluation
(extremity).
36217............. Place catheter in L037D RN/LPN/MTA........... NF Circulator (25%).... 12 15 G1: See preamble 1.11
artery. text.
36470............. Njx sclrsnt 1 L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
incmptnt vein. standard for this
clinical labor task.
36470............. Njx sclrsnt 1 L037D RN/LPN/MTA........... NF Check dressings, 5 3 L1: Refined time to -0.74
incmptnt vein. catheters, wounds. standard for this
clinical labor task.
36470............. Njx sclrsnt 1 SG055 gauze, sterile 4in x NF .................... 6 0 S7: Supply item -0.95
incmptnt vein. 4in. replaced by another
item; see preamble
SG056.
36470............. Njx sclrsnt 1 SG056 gauze, sterile 4in x NF .................... 0 1 S8: Supply item 0.80
incmptnt vein. 4in (10 pack uou). replaces another
item; see preamble
SG055.
36471............. Njx sclrsnt mlt L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
incmptnt vn. standard for this
clinical labor task.
36471............. Njx sclrsnt mlt L037D RN/LPN/MTA........... NF Check dressings, 5 3 L1: Refined time to -0.74
incmptnt vn. catheters, wounds. standard for this
clinical labor task.
36471............. Njx sclrsnt mlt SG055 gauze, sterile 4in x NF .................... 6 0 S7: Supply item -0.95
incmptnt vn. 4in. replaced by another
item; see preamble
SG056.
36471............. Njx sclrsnt mlt SG056 gauze, sterile 4in x NF .................... 0 1 S8: Supply item 0.80
incmptnt vn. 4in (10 pack uou). replaces another
item; see preamble
SG055.
[[Page 34036]]
364X3............. Endoven ther chem EF014 light, surgical...... NF .................... 58 53 E1: Refined -0.05
adhes 1st. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X3............. Endoven ther chem EF031 table, power......... NF .................... 58 53 E1: Refined -0.08
adhes 1st. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X3............. Endoven ther chem EQ250 ultrasound unit, NF .................... 58 53 E1: Refined -0.58
adhes 1st. portable. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X3............. Endoven ther chem L037D RN/LPN/MTA........... NF Check dressings, 5 3 L1: Refined time to -0.74
adhes 1st. catheters, wounds. standard for this
clinical labor task.
364X3............. Endoven ther chem L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
adhes 1st. standard for this
clinical labor task.
364X3............. Endoven ther chem L054A Vascular Technologist NF Prepare room, 0 2 G1: See preamble 1.08
adhes 1st. equipment and text.
supplies.
364X3............. Endoven ther chem L054A Vascular Technologist NF Setup scope 2 0 G1: See preamble -1.08
adhes 1st. (nonfacility text.
setting only).
364X3............. Endoven ther chem SG055 gauze, sterile 4in x NF .................... 6 0 S7: Supply item -0.95
adhes 1st. 4in. replaced by another
item; see preamble
SG056.
364X3............. Endoven ther chem SG056 gauze, sterile 4in x NF .................... 0 1 S8: Supply item 0.80
adhes 1st. 4in (10 pack uou). replaces another
item; see preamble
SG055.
364X5............. Njx noncmpnd sclrsnt EF014 light, surgical...... NF .................... 48 43 E1: Refined -0.05
1 vein. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X5............. Njx noncmpnd sclrsnt EF031 table, power......... NF .................... 48 43 E1: Refined -0.08
1 vein. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X5............. Njx noncmpnd sclrsnt EQ250 ultrasound unit, NF .................... 48 43 E1: Refined -0.58
1 vein. portable. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X5............. Njx noncmpnd sclrsnt L037D RN/LPN/MTA........... NF Check dressings, 5 3 L1: Refined time to -0.74
1 vein. catheters, wounds. standard for this
clinical labor task.
[[Page 34037]]
364X5............. Njx noncmpnd sclrsnt L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
1 vein. standard for this
clinical labor task.
364X5............. Njx noncmpnd sclrsnt L054A Vascular Technologist NF Setup scope 2 0 G1: See preamble -1.08
1 vein. (nonfacility text.
setting only).
364X5............. Njx noncmpnd sclrsnt L054A Vascular Technologist NF Prepare room, 0 2 G1: See preamble 1.08
1 vein. equipment and text.
supplies.
364X5............. Njx noncmpnd sclrsnt SG055 gauze, sterile 4in x NF .................... 6 0 S7: Supply item -0.95
1 vein. 4in. replaced by another
item; see preamble
SG056.
364X5............. Njx noncmpnd sclrsnt SG056 gauze, sterile 4in x NF .................... 0 1 S8: Supply item 0.80
1 vein. 4in (10 pack uou). replaces another
item; see preamble
SG055.
364X6............. Njx noncmpnd sclrsnt EF014 light, surgical...... NF .................... 58 53 E1: Refined -0.05
mlt vn. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X6............. Njx noncmpnd sclrsnt EF031 table, power......... NF .................... 58 53 E1: Refined -0.08
mlt vn. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X6............. Njx noncmpnd sclrsnt EQ250 ultrasound unit, NF .................... 58 53 E1: Refined -0.58
mlt vn. portable. equipment time to
conform to
established
policies for non-
highly technical
equipment.
364X6............. Njx noncmpnd sclrsnt L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
mlt vn. standard for this
clinical labor task.
364X6............. Njx noncmpnd sclrsnt L037D RN/LPN/MTA........... NF Check dressings, 5 3 L1: Refined time to -0.74
mlt vn. catheters, wounds. standard for this
clinical labor task.
364X6............. Njx noncmpnd sclrsnt L054A Vascular Technologist NF Setup scope 2 0 G1: See preamble -1.08
mlt vn. (nonfacility text.
setting only).
364X6............. Njx noncmpnd sclrsnt L054A Vascular Technologist NF Prepare room, 0 2 G1: See preamble 1.08
mlt vn. equipment and text.
supplies.
364X6............. Njx noncmpnd sclrsnt SG055 gauze, sterile 4in x NF .................... 6 0 S7: Supply item -0.95
mlt vn. 4in. replaced by another
item; see preamble
SG056.
364X6............. Njx noncmpnd sclrsnt SG056 gauze, sterile 4in x NF .................... 0 1 S8: Supply item 0.80
mlt vn. 4in (10 pack uou). replaces another
item; see preamble
SG055.
36555............. Insert non-tunnel cv EF023 table, exam.......... NF .................... 68 38 E1: Refined -0.09
cath. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34038]]
36555............. Insert non-tunnel cv EQ011 ECG, 3-channel (with NF .................... 68 0 G1: See preamble -0.95
cath. SpO2, NIBP, temp, text.
resp).
36555............. Insert non-tunnel cv EQ168 light, exam.......... NF .................... 68 38 E1: Refined -0.13
cath. equipment time to
conform to
established
policies for non-
highly technical
equipment.
36555............. Insert non-tunnel cv L037D RN/LPN/MTA........... NF Monitor pt. 7.5 0 L11: Removed -2.78
cath. following procedure/ clinical labor
check tubes, associated with
monitors, drains, moderate sedation;
multitasking 1:4. moderate sedation
not typical for
this procedure.
36569............. Insert picc cath..... EF023 table, exam.......... NF .................... 30 0 G1: See preamble -0.09
text.
36569............. Insert picc cath..... EQ168 light, exam.......... NF .................... 30 32 E15: Refined 0.01
equipment time to
conform to changes
in clinical labor
time.
36569............. Insert picc cath..... L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
standard for this
clinical labor task.
38220............. Dx bone marrow EF023 table, exam.......... NF .................... 84 82 E1: Refined -0.01
aspirations. equipment time to
conform to
established
policies for non-
highly technical
equipment.
38220............. Dx bone marrow L033A Lab Technician....... NF Other Clinical 12 9 G1: See preamble -0.99
aspirations. Activity--specify:L text.
ab Tech activities.
38221............. Dx bone marrow EF023 table, exam.......... NF .................... 83 82 E1: Refined 0.00
biopsies. equipment time to
conform to
established
policies for non-
highly technical
equipment.
38221............. Dx bone marrow L033A Lab Technician....... NF Other Clinical 7.5 7 G1: See preamble -0.17
biopsies. Activity--specify:L text.
ab Tech activities.
382X3............. Dx bone marrow bx & EF023 table, exam.......... NF .................... 95 92 E1: Refined -0.01
aspir. equipment time to
conform to
established
policies for non-
highly technical
equipment.
382X3............. Dx bone marrow bx & L033A Lab Technician....... NF Other Clinical 12.5 10 G1: See preamble -0.83
aspir. Activity--specify:L text.
ab Tech activities.
55X87............. Tprnl plmt EF031 table, power......... NF .................... 63 65 E15: Refined 0.03
biodegrdabl matrl. equipment time to
conform to changes
in clinical labor
time.
[[Page 34039]]
55X87............. Tprnl plmt EQ250 ultrasound unit, NF .................... 48 50 E15: Refined 0.23
biodegrdabl matrl. portable. equipment time to
conform to changes
in clinical labor
time.
55X87............. Tprnl plmt EQ386 Endocavitary US probe NF .................... 48 50 E15: Refined 0.13
biodegrdabl matrl. equipment time to
conform to changes
in clinical labor
time.
55X87............. Tprnl plmt ER061 stepper, stabilizer, NF .................... 48 50 E15: Refined 0.12
biodegrdabl matrl. template (for equipment time to
brachytherapy conform to changes
treatment). in clinical labor
time.
55X87............. Tprnl plmt ER062 stirrups (for NF .................... 48 50 E15: Refined 0.02
biodegrdabl matrl. brachytherapy table). equipment time to
conform to changes
in clinical labor
time.
55X87............. Tprnl plmt L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
biodegrdabl matrl. standard for this
clinical labor task.
5857X............. Laps tot hyst resj EQ168 light, exam.......... F .................... 142 125 E7: Refined -0.07
mal. equipment time to
conform to office
visit duration.
5857X............. Laps tot hyst resj SA051 pack, pelvic exam.... F .................... 4 3 G1: See preamble -1.17
mal. text.
67820............. Revise eyelashes..... EL006 lane, screening (oph) NF .................... 11 5 G1: See preamble -0.54
text.
67820............. Revise eyelashes..... L038A COMT/COT/RN/CST...... F Coordinate pre- 3 0 L1: Refined time to -1.14
surgery services. standard for this
clinical labor task.
67820............. Revise eyelashes..... L038A COMT/COT/RN/CST...... F Provide pre-service 3 0 L1: Refined time to -1.14
education/obtain standard for this
consent. clinical labor task.
67820............. Revise eyelashes..... L038A COMT/COT/RN/CST...... F Schedule space and 3 0 L1: Refined time to -1.14
equipment in standard for this
facility. clinical labor task.
67820............. Revise eyelashes..... L038A COMT/COT/RN/CST...... F Complete pre-service 3 0 L1: Refined time to -1.14
diagnostic and standard for this
referral forms. clinical labor task.
67820............. Revise eyelashes..... L038A COMT/COT/RN/CST...... F Follow-up phone 3 0 L1: Refined time to -1.14
calls and standard for this
prescriptions. clinical labor task.
70544............. Mr angiography head w/ ED050 Technologist PACS NF .................... 72 69 E15: Refined -0.07
o dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70544............. Mr angiography head w/ ED053 Professional PACS NF .................... 17 15 E18: Refined -0.12
o dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
[[Page 34040]]
70544............. Mr angiography head w/ EL008 room, MR............. NF .................... 39 38 E15: Refined -3.38
o dye. equipment time to
conform to changes
in clinical labor
time.
70544............. Mr angiography head w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
o dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
70544............. Mr angiography head w/ L047A MRI Technologist..... NF Provide pre-service 7 5 G1: See preamble -0.94
o dye. education/obtain text.
consent.
70545............. Mr angiography head w/ ED050 Technologist PACS NF .................... 75 74 E15: Refined -0.02
dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70545............. Mr angiography head w/ ED053 Professional PACS NF .................... 17 15 E18: Refined -0.12
dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
70545............. Mr angiography head w/ EL008 room, MR............. NF .................... 37 36 E15: Refined -3.38
dye. equipment time to
conform to changes
in clinical labor
time.
70545............. Mr angiography head w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
70545............. Mr angiography head w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
dye. standard for this
clinical labor task.
70545............. Mr angiography head w/ L047A MRI Technologist..... NF Provide pre-service 9 7 G1: See preamble -0.94
dye. education/obtain text.
consent.
70546............. Mr angiograph head w/ ED050 Technologist PACS NF .................... 116 115 E15: Refined -0.02
o&w/dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70546............. Mr angiograph head w/ ED053 Professional PACS NF .................... 20 18 E18: Refined -0.12
o&w/dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
70546............. Mr angiograph head w/ EL008 room, MR............. NF .................... 58 57 E15: Refined -3.38
o&w/dye. equipment time to
conform to changes
in clinical labor
time.
[[Page 34041]]
70546............. Mr angiograph head w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
o&w/dye. standard for this
clinical labor task.
70546............. Mr angiograph head w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
o&w/dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
70546............. Mr angiograph head w/ L047A MRI Technologist..... NF Provide pre-service 9 7 G1: See preamble -0.94
o&w/dye. education/obtain text.
consent.
70547............. Mr angiography neck w/ ED050 Technologist PACS NF .................... 72 69 E15: Refined -0.07
o dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70547............. Mr angiography neck w/ ED053 Professional PACS NF .................... 17 15 E18: Refined -0.12
o dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
70547............. Mr angiography neck w/ EL008 room, MR............. NF .................... 39 38 E15: Refined -3.38
o dye. equipment time to
conform to changes
in clinical labor
time.
70547............. Mr angiography neck w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
o dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
70547............. Mr angiography neck w/ L047A MRI Technologist..... NF Provide pre-service 7 5 G1: See preamble -0.94
o dye. education/obtain text.
consent.
70548............. Mr angiography neck w/ ED050 Technologist PACS NF .................... 75 74 E15: Refined -0.02
dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70548............. Mr angiography neck w/ ED053 Professional PACS NF .................... 20 18 E18: Refined -0.12
dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
70548............. Mr angiography neck w/ EL008 room, MR............. NF .................... 37 36 E15: Refined -3.38
dye. equipment time to
conform to changes
in clinical labor
time.
70548............. Mr angiography neck w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
[[Page 34042]]
70548............. Mr angiography neck w/ L047A MRI Technologist..... NF Provide pre-service 9 7 G1: See preamble -0.94
dye. education/obtain text.
consent.
70548............. Mr angiography neck w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
dye. standard for this
clinical labor task.
70549............. Mr angiograph neck w/ ED050 Technologist PACS NF .................... 116 115 E15: Refined -0.02
o&w/dye. workstation. equipment time to
conform to changes
in clinical labor
time.
70549............. Mr angiograph neck w/ ED053 Professional PACS NF .................... 25 23 E18: Refined -0.12
o&w/dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
70549............. Mr angiograph neck w/ EL008 room, MR............. NF .................... 58 57 E15: Refined -3.38
o&w/dye. equipment time to
conform to changes
in clinical labor
time.
70549............. Mr angiograph neck w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
o&w/dye. standard for this
clinical labor task.
70549............. Mr angiograph neck w/ L047A MRI Technologist..... NF Provide pre-service 9 7 G1: See preamble -0.94
o&w/dye. education/obtain text.
consent.
70549............. Mr angiograph neck w/ L047A MRI Technologist..... NF Technologist QCs 4 3 L1: Refined time to -0.47
o&w/dye. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
71250............. Ct thorax w/o dye.... ED053 Professional PACS NF .................... 20 18 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
71260............. Ct thorax w/dye...... ED053 Professional PACS NF .................... 21 19 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
71270............. Ct thorax w/o & w/dye ED053 Professional PACS NF .................... 25 23 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
72195............. Mri pelvis w/o dye... ED053 Professional PACS NF .................... 25 23 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
[[Page 34043]]
72196............. Mri pelvis w/dye..... ED050 Technologist PACS NF .................... 64 66 E15: Refined 0.04
workstation. equipment time to
conform to changes
in clinical labor
time.
72196............. Mri pelvis w/dye..... ED053 Professional PACS NF .................... 30 28 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
72196............. Mri pelvis w/dye..... L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
standard for this
clinical labor task.
72197............. Mri pelvis w/o & w/ ED050 Technologist PACS NF .................... 79 81 E15: Refined 0.04
dye. workstation. equipment time to
conform to changes
in clinical labor
time.
72197............. Mri pelvis w/o & w/ ED053 Professional PACS NF .................... 32 30 E18: Refined -0.12
dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
72197............. Mri pelvis w/o & w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
dye. standard for this
clinical labor task.
73718............. Mri lower extremity w/ ED050 Technologist PACS NF .................... 55 53 E15: Refined -0.04
o dye. workstation. equipment time to
conform to changes
in clinical labor
time.
73718............. Mri lower extremity w/ ED053 Professional PACS NF .................... 20 18 E18: Refined -0.12
o dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
73718............. Mri lower extremity w/ EL008 room, MR............. NF .................... 44 42 E15: Refined -6.76
o dye. equipment time to
conform to changes
in clinical labor
time.
73718............. Mri lower extremity w/ L047A MRI Technologist..... NF Prepare room, 5 3 G1: See preamble -0.94
o dye. equipment, supplies. text.
73719............. Mri lower extremity w/ ED050 Technologist PACS NF .................... 62 64 E15: Refined 0.04
dye. workstation. equipment time to
conform to changes
in clinical labor
time.
73719............. Mri lower extremity w/ ED053 Professional PACS NF .................... 25 23 E18: Refined -0.12
dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
[[Page 34044]]
73719............. Mri lower extremity w/ EL008 room, MR............. NF .................... 48 46 E15: Refined -6.76
dye. equipment time to
conform to changes
in clinical labor
time.
73719............. Mri lower extremity w/ L047A MRI Technologist..... NF Provide pre-service 5 7 G1: See preamble 0.94
dye. education/obtain text.
consent.
73719............. Mri lower extremity w/ L047A MRI Technologist..... NF Prepare room, 7 5 G1: See preamble -0.94
dye. equipment, supplies. text.
73719............. Mri lower extremity w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
dye. standard for this
clinical labor task.
73720............. Mri lwr extremity w/ ED050 Technologist PACS NF .................... 77 79 E15: Refined 0.04
o&w/dye. workstation. equipment time to
conform to changes
in clinical labor
time.
73720............. Mri lwr extremity w/ ED053 Professional PACS NF .................... 29 27 E18: Refined -0.12
o&w/dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
73720............. Mri lwr extremity w/ EL008 room, MR............. NF .................... 63 61 E15: Refined -6.76
o&w/dye. equipment time to
conform to changes
in clinical labor
time.
73720............. Mri lwr extremity w/ L047A MRI Technologist..... NF Prepare room, 7 5 G1: See preamble -0.94
o&w/dye. equipment, supplies. text.
73720............. Mri lwr extremity w/ L047A MRI Technologist..... NF Provide pre-service 5 7 G1: See preamble 0.94
o&w/dye. education/obtain text.
consent.
73720............. Mri lwr extremity w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
o&w/dye. standard for this
clinical labor task.
74181............. Mri abdomen w/o dye.. ED053 Professional PACS NF .................... 25 23 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
74182............. Mri abdomen w/dye.... ED050 Technologist PACS NF .................... 74 76 E15: Refined 0.04
workstation. equipment time to
conform to changes
in clinical labor
time.
74182............. Mri abdomen w/dye.... ED053 Professional PACS NF .................... 30 28 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
74182............. Mri abdomen w/dye.... L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
standard for this
clinical labor task.
[[Page 34045]]
74183............. Mri abdomen w/o & w/ ED050 Technologist PACS NF .................... 79 81 E15: Refined 0.04
dye. workstation. equipment time to
conform to changes
in clinical labor
time.
74183............. Mri abdomen w/o & w/ ED053 Professional PACS NF .................... 35 33 E18: Refined -0.12
dye. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
74183............. Mri abdomen w/o & w/ L047A MRI Technologist..... NF Obtain vital signs.. 3 5 L1: Refined time to 0.94
dye. standard for this
clinical labor task.
75635............. Ct angio abdominal ED050 Technologist PACS NF .................... 119 124 E18: Refined 0.11
arteries. workstation. equipment time to
conform to
established
policies for PACS
Workstations.
75635............. Ct angio abdominal ED053 Professional PACS NF .................... 49 44 E18: Refined -0.29
arteries. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
75635............. Ct angio abdominal EL007 room, CT............. NF .................... 71 70 E15: Refined -2.70
arteries. equipment time to
conform to changes
in clinical labor
time.
75635............. Ct angio abdominal L046A CT Technologist...... NF Technologist QCs 4 3 L1: Refined time to -0.46
arteries. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
75710............. Artery x-rays arm/leg ED050 Technologist PACS NF .................... 52 49 E15: Refined -0.07
workstation. equipment time to
conform to changes
in clinical labor
time.
75710............. Artery x-rays arm/leg ED053 Professional PACS NF .................... 55 48 E18: Refined -0.41
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
75710............. Artery x-rays arm/leg L041B Radiologic NF Technologist QCs 4 3 L1: Refined time to -0.41
Technologist. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
75710............. Artery x-rays arm/leg L041B Radiologic NF Prepare room, 2 0 G1: See preamble -0.82
Technologist. equipment, supplies. text.
75716............. Artery x-rays arms/ ED050 Technologist PACS NF .................... 62 59 E15: Refined -0.07
legs. workstation. equipment time to
conform to changes
in clinical labor
time.
[[Page 34046]]
75716............. Artery x-rays arms/ ED053 Professional PACS NF .................... 65 58 E18: Refined -0.41
legs. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
75716............. Artery x-rays arms/ L041B Radiologic NF Prepare room, 2 0 G1: See preamble -0.82
legs. Technologist. equipment, supplies. text.
75716............. Artery x-rays arms/ L041B Radiologic NF Technologist QCs 4 3 L1: Refined time to -0.41
legs. Technologist. images in PACS, standard for this
checking all clinical labor task.
images, reformats,
and dose page.
76881............. Us xtr non-vasc EF031 table, power......... NF .................... 8 7 E1: Refined -0.02
complete. equipment time to
conform to
established
policies for non-
highly technical
equipment.
76881............. Us xtr non-vasc EQ250 ultrasound unit, NF .................... 8 7 E1: Refined -0.12
complete. portable. equipment time to
conform to
established
policies for non-
highly technical
equipment.
76881............. Us xtr non-vasc L026A Medical/Technical NF Exam document 1 0 G1: See preamble -0.26
complete. Assistant. scanned into PACS. text.
Exam completed in
RIS system to
generate billing
process and to
populate images
into Radiologist
work queue.
78300............. Bone imaging limited ED053 Professional PACS NF .................... 15 13 E18: Refined -0.12
area. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
78305............. Bone imaging multiple ED053 Professional PACS NF .................... 15 13 E18: Refined -0.12
areas. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
78306............. Bone imaging whole ED053 Professional PACS NF .................... 78 13 E18: Refined -3.76
body. Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
88333............. Intraop cyto path L033A Lab Technician....... NF Prepare room. Filter 10 0 G6: Indirect -3.30
consult 1. and replenish Practice Expense
stains and input and/or not
supplies. individually
(including OCT allocable to a
blocks, set up particular patient
grossing station for a particular
with colored service.
stains).
[[Page 34047]]
88333............. Intraop cyto path L037B Histotechnologist.... NF Clean room/equipment 5 1 L1: Refined time to -1.48
consult 1. following procedure standard for this
(including any clinical labor task.
equipment
maintenance that
must be done after
the procedure).
88360............. Tumor immunohistochem/ EP112 Benchmark ULTRA NF .................... 18 16 G1: See preamble -1.14
manual. automated slide text.
preparation system.
88360............. Tumor immunohistochem/ L033A Lab Technician....... NF Recycle xylene from 1 0 G6: Indirect -0.33
manual. tissue processor Practice Expense
and stainer. input and/or not
individually
allocable to a
particular patient
for a particular
service.
88360............. Tumor immunohistochem/ L037B Histotechnologist.... NF Clean room/equipment 1 0 L2: Clinical labor -0.37
manual. following procedure task redundant with
(including any clinical labor task
equipment Clean equipment and
maintenance that work station in
must be done after histology lab.
the procedure).
88360............. Tumor immunohistochem/ L037B Histotechnologist.... NF Verify results and 1 0 G6: Indirect -0.37
manual. complete work load Practice Expense
recording logs. input and/or not
individually
allocable to a
particular patient
for a particular
service.
88360............. Tumor immunohistochem/ L037B Histotechnologist.... NF Enter patient data, 5 1 L1: Refined time to -1.48
manual. computational prep standard for this
for antibody clinical labor task.
testing, generate
and apply bar codes
to slides, and
enter data for
automated slide
stainer.
88361............. Tumor immunohistochem/ EP112 Benchmark ULTRA NF .................... 18 16 G1: See preamble -1.14
comput. automated slide text.
preparation system.
88361............. Tumor immunohistochem/ L033A Lab Technician....... NF Recycle xylene from 1 0 G6: Indirect -0.33
comput. tissue processor Practice Expense
and stainer. input and/or not
individually
allocable to a
particular patient
for a particular
service.
[[Page 34048]]
88361............. Tumor immunohistochem/ L037B Histotechnologist.... NF Verify results and 1 0 G6: Indirect -0.37
comput. complete work load Practice Expense
recording logs. input and/or not
individually
allocable to a
particular patient
for a particular
service.
88361............. Tumor immunohistochem/ L037B Histotechnologist.... NF Performing 1 0 G1: See preamble -0.37
comput. instrument text.
calibration,
instrument qc and
start up and
shutdown..
88361............. Tumor immunohistochem/ L037B Histotechnologist.... NF Gate areas to be 1 0 G1: See preamble -0.37
comput. counted by the text.
machine.
88361............. Tumor immunohistochem/ L037B Histotechnologist.... NF Enter patient data, 5 1 L1: Refined time to -1.48
comput. computational prep standard for this
for antibody clinical labor task.
testing, generate
and apply bar codes
to slides, and
enter data for
automated slide
stainer.
88361............. Tumor immunohistochem/ L037B Histotechnologist.... NF Clean room/equipment 1 0 L2: Clinical labor -0.37
comput. following procedure task redundant with
(including any clinical labor task
equipment Clean equipment and
maintenance that work station in
must be done after histology lab.
the procedure).
93279............. Pm device progr eval EF023 table, exam.......... NF .................... 33 26 E1: Refined -0.02
sngl. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93279............. Pm device progr eval EQ198 pacemaker follow-up NF .................... 33 26 E1: Refined -0.53
sngl. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93279............. Pm device progr eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
sngl. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93279............. Pm device progr eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
sngl. Activity--specify: standard for this
Review charts. clinical labor task.
93280............. Pm device progr eval EF023 table, exam.......... NF .................... 38 31 E1: Refined -0.02
dual. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34049]]
93280............. Pm device progr eval EQ198 pacemaker follow-up NF .................... 38 31 E1: Refined -0.53
dual. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93280............. Pm device progr eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
dual. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93280............. Pm device progr eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
dual. Activity--specify: standard for this
Review charts. clinical labor task.
93281............. Pm device progr eval EF023 table, exam.......... NF .................... 39 31 E1: Refined -0.02
multi. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93281............. Pm device progr eval EQ198 pacemaker follow-up NF .................... 39 31 E1: Refined -0.61
multi. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93281............. Pm device progr eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
multi. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93281............. Pm device progr eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
multi. Activity--specify: standard for this
Review charts. clinical labor task.
93281............. Pm device progr eval L037D RN/LPN/MTA........... NF Assist physician in 16 15 L15: Refined -0.37
multi. performing clinical labor time
procedure. to match
intraservice work
time.
93282............. Prgrmg eval EF023 table, exam.......... NF .................... 35 28 E1: Refined -0.02
implantable dfb. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93282............. Prgrmg eval EQ198 pacemaker follow-up NF .................... 35 28 E1: Refined -0.53
implantable dfb. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93282............. Prgrmg eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
implantable dfb. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93282............. Prgrmg eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
implantable dfb. Activity--specify: standard for this
Review charts. clinical labor task.
[[Page 34050]]
93283............. Prgrmg eval EF023 table, exam.......... NF .................... 38 31 E1: Refined -0.02
implantable dfb. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93283............. Prgrmg eval EQ198 pacemaker follow-up NF .................... 38 31 E1: Refined -0.53
implantable dfb. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93283............. Prgrmg eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
implantable dfb. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93283............. Prgrmg eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
implantable dfb. Activity--specify: standard for this
Review charts. clinical labor task.
93284............. Prgrmg eval EF023 table, exam.......... NF .................... 40.5 33.5 E1: Refined -0.02
implantable dfb. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93284............. Prgrmg eval EQ198 pacemaker follow-up NF .................... 40.5 33.5 E1: Refined -0.53
implantable dfb. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93284............. Prgrmg eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
implantable dfb. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93284............. Prgrmg eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
implantable dfb. Activity--specify: standard for this
Review charts. clinical labor task.
93285............. Ilr device eval progr EF023 table, exam.......... NF .................... 30 25 E1: Refined -0.01
equipment time to
conform to
established
policies for non-
highly technical
equipment.
93285............. Ilr device eval progr EQ198 pacemaker follow-up NF .................... 30 25 E1: Refined -0.38
system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93285............. Ilr device eval progr L026A Medical/Technical NF Complete diagnostic 1 0 L2: Clinical labor -0.26
Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93285............. Ilr device eval progr L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
Activity--specify: standard for this
Review charts. clinical labor task.
[[Page 34051]]
93286............. Peri-px pacemaker EF023 table, exam.......... NF .................... 27 20 E1: Refined -0.02
device evl. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93286............. Peri-px pacemaker EQ198 pacemaker follow-up NF .................... 27 20 E1: Refined -0.53
device evl. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93286............. Peri-px pacemaker L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
device evl. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93286............. Peri-px pacemaker L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
device evl. Activity--specify: standard for this
Review charts. clinical labor task.
93287............. Peri-px device eval & EF023 table, exam.......... NF .................... 27 20 E1: Refined -0.02
prgr. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93287............. Peri-px device eval & EQ198 pacemaker follow-up NF .................... 27 20 E1: Refined -0.53
prgr. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93287............. Peri-px device eval & L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
prgr. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93287............. Peri-px device eval & L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
prgr. Activity--specify: standard for this
Review charts. clinical labor task.
93288............. Pm device eval in EF023 table, exam.......... NF .................... 33 26 E1: Refined -0.02
person. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93288............. Pm device eval in EQ198 pacemaker follow-up NF .................... 33 26 E1: Refined -0.53
person. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93288............. Pm device eval in L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
person. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93288............. Pm device eval in L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
person. Activity--specify: standard for this
Review charts. clinical labor task.
[[Page 34052]]
93289............. Interrog device eval EF023 table, exam.......... NF .................... 33 26 E1: Refined -0.02
heart. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93289............. Interrog device eval EQ198 pacemaker follow-up NF .................... 33 26 E1: Refined -0.53
heart. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93289............. Interrog device eval L026A Medical/Technical NF Complete diagnostic 2 0 L2: Clinical labor -0.52
heart. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93289............. Interrog device eval L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
heart. Activity--specify: standard for this
Review charts. clinical labor task.
93290............. Icm device eval...... EF023 table, exam.......... NF .................... 28 24 E1: Refined -0.01
equipment time to
conform to
established
policies for non-
highly technical
equipment.
93290............. Icm device eval...... EQ198 pacemaker follow-up NF .................... 28 24 E1: Refined -0.30
system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93290............. Icm device eval...... L026A Medical/Technical NF Complete diagnostic 1 0 L2: Clinical labor -0.26
Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93290............. Icm device eval...... L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
Activity--specify: standard for this
Review charts. clinical labor task.
93291............. Ilr device EF023 table, exam.......... NF .................... 27 22 E1: Refined -0.01
interrogate. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93291............. Ilr device EQ198 pacemaker follow-up NF .................... 27 22 E1: Refined -0.38
interrogate. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93291............. Ilr device L026A Medical/Technical NF Complete diagnostic 1 0 L2: Clinical labor -0.26
interrogate. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93291............. Ilr device L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
interrogate. Activity--specify: standard for this
Review charts. clinical labor task.
[[Page 34053]]
93292............. Wcd device EF023 table, exam.......... NF .................... 30 25 E1: Refined -0.01
interrogate. equipment time to
conform to
established
policies for non-
highly technical
equipment.
93292............. Wcd device EQ198 pacemaker follow-up NF .................... 30 25 E1: Refined -0.38
interrogate. system (incl equipment time to
software and conform to
hardware) (Paceart). established
policies for non-
highly technical
equipment.
93292............. Wcd device L026A Medical/Technical NF Complete diagnostic 1 0 L2: Clinical labor -0.26
interrogate. Assistant. forms, lab, X-ray task redundant with
requisitions. clinical labor task
L037D.
93292............. Wcd device L037D RN/LPN/MTA........... NF Other Clinical 2 0 L1: Refined time to -0.74
interrogate. Activity--specify: standard for this
Review charts. clinical labor task.
93350............. Stress tte only...... ED053 Professional PACS NF .................... 20 18 E18: Refined -0.12
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
93351............. Stress tte complete.. ED050 Technologist PACS NF .................... 104 114 E18: Refined 0.22
workstation. equipment time to
conform to
established
policies for PACS
Workstations.
93351............. Stress tte complete.. ED053 Professional PACS NF .................... 30 25 E18: Refined -0.29
Workstation. equipment time to
conform to
established
policies for PACS
Workstations.
93351............. Stress tte complete.. EQ078 cardiac monitor w- NF .................... 104 91 E1: Refined -0.49
treadmill (12-lead equipment time to
PC-based ECG). conform to
established
policies for non-
highly technical
equipment.
93351............. Stress tte complete.. L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
standard for this
clinical labor task.
93351............. Stress tte complete.. L037D RN/LPN/MTA........... NF Provide pre-service 3 2 L1: Refined time to -0.37
education/obtain standard for this
consent. clinical labor task.
93351............. Stress tte complete.. L051A RN................... NF Setup scope (non 5 0 G1: See preamble -2.55
facility setting text.
only).
94621............. Cardiopulm exercise EQ042 Vmax 29c (cardio-pulm NF .................... 127 115 E6: Refined -1.98
testing. stress test equip, equipment time to
treadmill, computer conform to
system). established
policies for
equipment with 4x
monitoring time.
[[Page 34054]]
94621............. Cardiopulm exercise EQ211 pulse oximeter w- NF .................... 127 115 E6: Refined -0.05
testing. printer. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
94621............. Cardiopulm exercise L047C RN/Respiratory NF Prepare and position 5 3 G1: See preamble -0.94
testing. Therapist. pt/monitor pt/set text.
up IV.
94621............. Cardiopulm exercise L047C RN/Respiratory NF Provide pre-service 10 5 G1: See preamble -2.35
testing. Therapist. education/obtain text.
consent.
94621............. Cardiopulm exercise L047C RN/Respiratory NF Complete diagnostic 5 3 L1: Refined time to -0.94
testing. Therapist. forms, lab, X-ray standard for this
requisitions. clinical labor task.
946X2............. Exercise tst brncspsm EQ043 Vmax 29s (spirometry NF .................... 87 83 E6: Refined -0.31
testing equip, equipment time to
computer system). conform to
established
policies for
equipment with 4x
monitoring time.
946X2............. Exercise tst brncspsm EQ078 cardiac monitor w- NF .................... 87 83 E6: Refined -0.15
treadmill (12-lead equipment time to
PC-based ECG). conform to
established
policies for
equipment with 4x
monitoring time.
946X2............. Exercise tst brncspsm EQ211 pulse oximeter w- NF .................... 87 83 E6: Refined -0.02
printer. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
946X2............. Exercise tst brncspsm L047C RN/Respiratory NF Complete diagnostic 4 3 L1: Refined time to -0.47
Therapist. forms, lab, X-ray standard for this
requisitions. clinical labor task.
946X3............. Pulmonary stress EQ211 pulse oximeter w- NF .................... 17 15 E1: Refined -0.01
testing. printer. equipment time to
conform to
established
policies for non-
highly technical
equipment.
946X3............. Pulmonary stress L047C RN/Respiratory NF Complete diagnostic 2 3 L1: Refined time to 0.47
testing. Therapist. forms, lab, X-ray standard for this
requisitions. clinical labor task.
95004............. Percut allergy skin EF015 mayo stand........... NF .................... 1.28 1.58 E6: Refined 0.00
tests. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
95004............. Percut allergy skin EF023 table, exam.......... NF .................... 1.28 1.58 E6: Refined 0.00
tests. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
[[Page 34055]]
96160............. Pt-focused hlth risk L026A Medical/Technical NF Explain purpose of 2 0 G1: See preamble -0.52
assmt. Assistant. assessment to text.
patient/caregiver
and answer
questions.
96160............. Pt-focused hlth risk L026A Medical/Technical NF Remain in exam room 2 0 G1: See preamble -0.52
assmt. Assistant. with patient/ text.
caregiver exclusive
to completion of
assessment.
96160............. Pt-focused hlth risk L026A Medical/Technical NF Collate and score 1 0 G1: See preamble -0.26
assmt. Assistant. data elements on text.
assessment in
advance of
physician exam.
96160............. Pt-focused hlth risk L026A Medical/Technical NF Scan assessment or 2 0 G1: See preamble -0.52
assmt. Assistant. enter data elements text.
and total score
into electronic
health record.
96160............. Pt-focused hlth risk L026A Medical/Technical NF Administration, 0 7 G1: See preamble 1.82
assmt. Assistant. scoring, and text.
documenting results
of completed
standardized
instrument.
96161............. Caregiver health risk L026A Medical/Technical NF Explain purpose of 2 0 G1: See preamble -0.52
assmt. Assistant. assessment to text.
patient/caregiver
and answer
questions.
96161............. Caregiver health risk L026A Medical/Technical NF Remain in exam room 2 0 G1: See preamble -0.52
assmt. Assistant. with patient/ text.
caregiver exclusive
to completion of
assessment.
96161............. Caregiver health risk L026A Medical/Technical NF Collate and score 1 0 G1: See preamble -0.26
assmt. Assistant. data elements on text.
assessment in
advance of
physician exam.
96161............. Caregiver health risk L026A Medical/Technical NF Scan assessment or 2 0 G1: See preamble -0.52
assmt. Assistant. enter data elements text.
and total score
into electronic
health record.
96161............. Caregiver health risk L026A Medical/Technical NF Administration, 0 7 G1: See preamble 1.82
assmt. Assistant. scoring, and text.
documenting results
of completed
standardized
instrument.
96360............. Hydration iv infusion EF023 table, exam.......... NF .................... 16 24 E6: Refined 0.02
init. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
[[Page 34056]]
96360............. Hydration iv infusion EQ032 IV infusion pump..... NF .................... 16 24 E6: Refined 0.05
init. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
96360............. Hydration iv infusion L056A RN/OCN............... NF Obtain vital signs.. 3 5 L1: Refined time to 1.58
init. standard for this
clinical labor task.
96361............. Hydrate iv infusion EF023 table, exam.......... NF .................... 7 9 E15: Refined 0.01
add-on. equipment time to
conform to changes
in clinical labor
time.
96361............. Hydrate iv infusion EQ032 IV infusion pump..... NF .................... 7 9 E15: Refined 0.01
add-on. equipment time to
conform to changes
in clinical labor
time.
96361............. Hydrate iv infusion L056A RN/OCN............... NF Obtain vital signs.. 3 5 L1: Refined time to 1.58
add-on. standard for this
clinical labor task.
96372............. Ther/proph/diag inj EF023 table, exam.......... NF .................... 12 9 E15: Refined -0.01
sc/im. equipment time to
conform to changes
in clinical labor
time.
96372............. Ther/proph/diag inj EQ189 otoscope- NF .................... 12 9 E15: Refined -0.01
sc/im. ophthalmoscope (wall equipment time to
unit). conform to changes
in clinical labor
time.
96372............. Ther/proph/diag inj L037D RN/LPN/MTA........... NF Complete medical 1 0 G6: Indirect -0.37
sc/im. record Practice Expense
documentation. input and/or not
individually
allocable to a
particular patient
for a particular
service.
96372............. Ther/proph/diag inj L037D RN/LPN/MTA........... NF Document lot number 1 0 L3: Refined clinical -0.37
sc/im. and expiration date. labor time to
conform with
identical labor
activity in other
codes in the family.
96372............. Ther/proph/diag inj L037D RN/LPN/MTA........... NF Clean room/equipment 1 0 G8: Input removed; -0.37
sc/im. by physician staff. code is typically
billed with an E/M
or other evaluation
service.
96374............. Ther/proph/diag inj EF023 table, exam.......... NF .................... 23 31 E6: Refined 0.02
iv push. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
[[Page 34057]]
96374............. Ther/proph/diag inj EQ189 otoscope- NF .................... 23 31 E6: Refined 0.01
iv push. ophthalmoscope (wall equipment time to
unit). conform to
established
policies for
equipment with 4x
monitoring time.
96374............. Ther/proph/diag inj L056A RN/OCN............... NF Complete medical 1 0 G6: Indirect -0.79
iv push. record Practice Expense
documentation. input and/or not
individually
allocable to a
particular patient
for a particular
service.
96375............. Tx/pro/dx inj new EF023 table, exam.......... NF .................... 12 17 E6: Refined 0.01
drug addon. equipment time to
conform to
established
policies for
equipment with 4x
monitoring time.
96375............. Tx/pro/dx inj new EQ189 otoscope- NF .................... 12 17 E6: Refined 0.01
drug addon. ophthalmoscope (wall equipment time to
unit). conform to
established
policies for
equipment with 4x
monitoring time.
96375............. Tx/pro/dx inj new L056A RN/OCN............... NF Complete medical 1 0 G6: Indirect -0.79
drug addon. record Practice Expense
documentation. input and/or not
individually
allocable to a
particular patient
for a particular
service.
96377............. Applicaton on-body EF023 table, exam.......... NF .................... 12 11 E15: Refined 0.00
injector. equipment time to
conform to changes
in clinical labor
time.
96377............. Applicaton on-body EQ189 otoscope- NF .................... 12 11 E15: Refined 0.00
injector. ophthalmoscope (wall equipment time to
unit). conform to changes
in clinical labor
time.
96377............. Applicaton on-body L056A RN/OCN............... NF Complete medical 1 0 G6: Indirect -0.79
injector. record Practice Expense
documentation. input and/or not
individually
allocable to a
particular patient
for a particular
service.
96910............. Photochemotherapy EF023 table, exam.......... NF .................... 67 65 E15: Refined -0.01
with uv-b. equipment time to
conform to changes
in clinical labor
time.
[[Page 34058]]
96910............. Photochemotherapy EQ168 light, exam.......... NF .................... 67 65 E15: Refined -0.01
with uv-b. equipment time to
conform to changes
in clinical labor
time.
96910............. Photochemotherapy EQ204 phototherapy unit, NF .................... 67 65 E15: Refined -0.01
with uv-b. hand-foot, UVA-UVB. equipment time to
conform to changes
in clinical labor
time.
96910............. Photochemotherapy EQ205 phototherapy unit, NF .................... 67 65 E15: Refined -0.07
with uv-b. whole body, UVA-UVB. equipment time to
conform to changes
in clinical labor
time.
96910............. Photochemotherapy L037D RN/LPN/MTA........... NF Complete diagnostic 2 0 G6: Indirect -0.74
with uv-b. forms, lab & X-ray Practice Expense
requisitions, and input and/or not
documentation. individually
allocable to a
particular patient
for a particular
service.
96910............. Photochemotherapy L037D RN/LPN/MTA........... NF Provide pre-service 3 1 G1: See preamble -0.74
with uv-b. education/obtain text.
consent.
96910............. Photochemotherapy L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
with uv-b. standard for this
clinical labor task.
96X73............. Pdt dstr prmlg les EF031 table, power......... NF .................... 230 52 E1: Refined -2.91
phys/qhp. equipment time to
conform to
established
policies for non-
highly technical
equipment.
96X73............. Pdt dstr prmlg les EQ169 light, external PDT, NF .................... 20 52 E1: Refined 1.12
phys/qhp. w-probe set equipment time to
(LumaCare). conform to
established
policies for non-
highly technical
equipment.
96X73............. Pdt dstr prmlg les L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
phys/qhp. standard for this
clinical labor task.
96X73............. Pdt dstr prmlg les SJ027 goggles, uv-blocking. NF .................... 0 3 S8: Supply item 12.30
phys/qhp. replaces another
item; see preamble.
96X74............. Dbrdmt prmlg les w/ EF031 table, power......... NF .................... 232 54 E1: Refined -2.91
pdt. equipment time to
conform to
established
policies for non-
highly technical
equipment.
[[Page 34059]]
96X74............. Dbrdmt prmlg les w/ EQ168 light, exam.......... NF .................... 52 54 E1: Refined 0.01
pdt. equipment time to
conform to
established
policies for non-
highly technical
equipment.
96X74............. Dbrdmt prmlg les w/ EQ169 light, external PDT, NF .................... 20 54 E1: Refined 1.19
pdt. w-probe set equipment time to
(LumaCare). conform to
established
policies for non-
highly technical
equipment.
96X74............. Dbrdmt prmlg les w/ L037D RN/LPN/MTA........... NF Obtain vital signs.. 3 5 L1: Refined time to 0.74
pdt. standard for this
clinical labor task.
96X74............. Dbrdmt prmlg les w/ SJ027 goggles, uv-blocking. NF .................... 0 3 S8: Supply item 12.30
pdt. replaces another
item; see preamble.
97012............. Mechanical traction EQ241 traction system (hi- NF .................... 13 15 G1: See preamble 0.03
therapy. low table, digital text.
unit, accessories).
97012............. Mechanical traction L023A Physical Therapy Aide NF Clean room/equipment 1 2 G1: See preamble 0.23
therapy. by physician staff. text.
97012............. Mechanical traction L023A Physical Therapy Aide NF Assist therapist.... 2 0 G1: See preamble -0.46
therapy. text.
97012............. Mechanical traction L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
therapy. Activity--specify: text.
post-treatment
assistance.
97012............. Mechanical traction L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
therapy. equipment, supplies. text.
97012............. Mechanical traction L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
therapy. patient. text.
97012............. Mechanical traction L039B Physical Therapy NF Check dressings & 0 1 G1: See preamble 0.39
therapy. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97012............. Mechanical traction L039B Physical Therapy NF Assist therapist.... 0 5 G1: See preamble 1.95
therapy. Assistant. text.
97012............. Mechanical traction SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
therapy. text.
97012............. Mechanical traction SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
therapy. text.
97012............. Mechanical traction SG039 dressing, 5in x 9in NF .................... 0 1 G1: See preamble 0.27
therapy. (ABD-Combine). text.
97012............. Mechanical traction SK082 towel, paper (Bounty) NF .................... 2 0 G1: See preamble -0.01
therapy. (per sheet). text.
97012............. Mechanical traction SM012 disinfectant spray NF .................... 2 0 G1: See preamble -0.06
therapy. (Transeptic). text.
97014............. Electric stimulation EF028 table, mat, hi-lo, 6 NF .................... 10 15 G1: See preamble 0.05
therapy. x 8 platform. text.
97014............. Electric stimulation EQ116 electrotherapy NF .................... 10 15 G1: See preamble 0.03
therapy. stimulator, high text.
volt, 2 channel.
97014............. Electric stimulation L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
therapy. equipment, supplies. text.
97014............. Electric stimulation L023A Physical Therapy Aide NF Assist therapist.... 2 0 G1: See preamble -0.46
therapy. text.
[[Page 34060]]
97014............. Electric stimulation L023A Physical Therapy Aide NF Clean room/equipment 1 2 G1: See preamble 0.23
therapy. by physician staff. text.
97014............. Electric stimulation L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
therapy. Activity--specify: text.
post-treatment
assistance.
97014............. Electric stimulation L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
therapy. patient. text.
97014............. Electric stimulation L039B Physical Therapy NF Assist therapist.... 0 3 G1: See preamble 1.17
therapy. Assistant. text.
97014............. Electric stimulation L039B Physical Therapy NF Check dressings & 0 1 G1: See preamble 0.39
therapy. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97014............. Electric stimulation SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
therapy. text.
97014............. Electric stimulation SJ024 electrolyte coupling NF .................... 0 1 G1: See preamble 0.02
therapy. gel. text.
97014............. Electric stimulation SK068 razor................ NF .................... 0 1 G1: See preamble 0.39
therapy. text.
97014............. Electric stimulation SK082 towel, paper (Bounty) NF .................... 1 0 G1: See preamble -0.01
therapy. (per sheet). text.
97014............. Electric stimulation SM012 disinfectant spray NF .................... 1 0 G1: See preamble -0.03
therapy. (Transeptic). text.
97016............. Vasopneumatic device EF028 table, mat, hi-lo, 6 NF .................... 11 20 G1: See preamble 0.09
therapy. x 8 platform. text.
97016............. Vasopneumatic device EQ263 vasopneumatic NF .................... 11 20 G1: See preamble 0.02
therapy. compression system. text.
97016............. Vasopneumatic device L023A Physical Therapy Aide NF Other clinical 0 2 G1: See preamble 0.46
therapy. Activity--specify: text.
post-treatment
assistance.
97016............. Vasopneumatic device L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
therapy. equipment, supplies. text.
97016............. Vasopneumatic device L023A Physical Therapy Aide NF Clean room/equipment 1 2 G1: See preamble 0.23
therapy. by physician staff. text.
97016............. Vasopneumatic device L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
therapy. patient. text.
97016............. Vasopneumatic device L023A Physical Therapy Aide NF Assist therapist.... 2 0 G1: See preamble -0.46
therapy. text.
97016............. Vasopneumatic device L039B Physical Therapy NF Assist therapist.... 0 10 G1: See preamble 3.90
therapy. Assistant. text.
97016............. Vasopneumatic device L039B Physical Therapy NF Check dressings & 0 5 G1: See preamble 1.95
therapy. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97016............. Vasopneumatic device L039B Physical Therapy NF Obtain vital signs.. 0 2 G1: See preamble 0.78
therapy. Assistant. text.
97016............. Vasopneumatic device SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
therapy. text.
97018............. Paraffin bath therapy EQ200 paraffin bath, hand- NF .................... 11 15 G1: See preamble 0.03
foot (institutional). text.
[[Page 34061]]
97018............. Paraffin bath therapy L023A Physical Therapy Aide NF Prepare room, 1 3 G1: See preamble 0.46
equipment, supplies. text.
97018............. Paraffin bath therapy L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
Activity--specify: text.
post-treatment
assistance.
97018............. Paraffin bath therapy L023A Physical Therapy Aide NF Clean room/equipment 1 2 G1: See preamble 0.23
by physician staff. text.
97018............. Paraffin bath therapy L023A Physical Therapy Aide NF Assist therapist.... 2 0 G1: See preamble -0.46
text.
97018............. Paraffin bath therapy L023A Physical Therapy Aide NF Prepare and position 1 3 G1: See preamble 0.46
patient. text.
97018............. Paraffin bath therapy L039B Physical Therapy NF Check dressings & 0 1 G1: See preamble 0.39
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97018............. Paraffin bath therapy L039B Physical Therapy NF Assist therapist.... 0 5 G1: See preamble 1.95
Assistant. text.
97018............. Paraffin bath therapy SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
specialty visit. text.
97022............. Whirlpool therapy.... EF012 lift, hydraulic, NF .................... 26 4 G1: See preamble -0.28
chair. text.
97022............. Whirlpool therapy.... EF036 whirlpool, lo-boy NF .................... 26 24 G1: See preamble -0.02
tank (whole body). text.
97022............. Whirlpool therapy.... L023A Physical Therapy Aide NF Prepare and position 2 3 G1: See preamble 0.23
patient. text.
97022............. Whirlpool therapy.... L023A Physical Therapy Aide NF Assist therapist.... 2 0 G1: See preamble -0.46
text.
97022............. Whirlpool therapy.... L023A Physical Therapy Aide NF Other clinical 0 3 G1: See preamble 0.69
Activity--specify: text.
post-treatment
assistance.
97022............. Whirlpool therapy.... L039B Physical Therapy NF Assist therapist.... 0 5 G1: See preamble 1.95
Assistant. text.
97022............. Whirlpool therapy.... L039B Physical Therapy NF Check dressings & 0 1 G1: See preamble 0.39
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97022............. Whirlpool therapy.... SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
text.
97022............. Whirlpool therapy.... SB024 gloves, sterile...... NF .................... 0 1 G1: See preamble 0.84
text.
97022............. Whirlpool therapy.... SB033 mask, surgical....... NF .................... 0 1 G1: See preamble 0.20
text.
97022............. Whirlpool therapy.... SG017 bandage, Kling, non- NF .................... 0 1 G1: See preamble 0.36
sterile 2in. text.
97022............. Whirlpool therapy.... SG027 cast, stockinette 4in NF .................... 0 1 G1: See preamble 0.46
text.
97022............. Whirlpool therapy.... SG055 gauze, sterile 4in x NF .................... 0 5 G1: See preamble 0.80
4in. text.
97022............. Whirlpool therapy.... SG079 tape, surgical paper NF .................... 0 12 G1: See preamble 0.02
1in (Micropore). text.
97022............. Whirlpool therapy.... SJ046 silver nitrate NF .................... 0 1 G1: See preamble 0.07
applicator. text.
97032............. Electrical EF028 table, mat, hi-lo, 6 NF .................... 18 15 G1: See preamble -0.03
stimulation. x 8 platform. text.
97032............. Electrical EQ116 electrotherapy NF .................... 18 15 G1: See preamble -0.02
stimulation. stimulator, high text.
volt, 2 channel.
[[Page 34062]]
97032............. Electrical L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
stimulation. equipment, supplies. text.
97032............. Electrical L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
stimulation. patient. text.
97032............. Electrical L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
stimulation. Activity--specify: text.
post-treatment
assistance.
97032............. Electrical L023A Physical Therapy Aide NF Clean room/equipment 1 2 G1: See preamble 0.23
stimulation. by physician staff. text.
97032............. Electrical L039B Physical Therapy NF Assist therapist.... 0 3 G1: See preamble 1.17
stimulation. Assistant. text.
97032............. Electrical L039B Physical Therapy NF Check dressings & 0 1 G1: See preamble 0.39
stimulation. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97032............. Electrical SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
stimulation. text.
97032............. Electrical SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
stimulation. text.
97032............. Electrical SD055 electrode, electrical NF .................... 0 2 G1: See preamble 2.62
stimulation. stimulation. text.
97032............. Electrical SG079 tape, surgical paper NF .................... 0 6 G1: See preamble 0.01
stimulation. 1in (Micropore). text.
97032............. Electrical SJ020 electrode conductive NF .................... 0 5 G1: See preamble 0.08
stimulation. gel. text.
97032............. Electrical SJ053 swab-pad, alcohol.... NF .................... 1 2 G1: See preamble 0.01
stimulation. text.
97032............. Electrical SK068 razor................ NF .................... 0 1 G1: See preamble 0.39
stimulation. text.
97032............. Electrical SK082 towel, paper (Bounty) NF .................... 1 0 G1: See preamble -0.01
stimulation. (per sheet). text.
97032............. Electrical SM012 disinfectant spray NF .................... 1 0 G1: See preamble -0.03
stimulation. (Transeptic). text.
97033............. Electric current EF028 table, mat, hi-lo, 6 NF .................... 20 15 G1: See preamble -0.05
therapy. x 8 platform. text.
97033............. Electric current EQ141 iontophoresis machine NF .................... 20 15 G1: See preamble -0.01
therapy. text.
97033............. Electric current L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
therapy. Activity--specify: text.
post-treatment
assistance.
97033............. Electric current L023A Physical Therapy Aide NF Prepare room, 2 3 G1: See preamble 0.23
therapy. equipment, supplies. text.
97033............. Electric current L023A Physical Therapy Aide NF Clean room/equipment 1 3 G1: See preamble 0.46
therapy. by physician staff. text.
97033............. Electric current L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
therapy. Assistant. Activity--specify: text.
Obtain measurements.
97033............. Electric current SG055 gauze, sterile 4in x NF .................... 0 1 G1: See preamble 0.16
therapy. 4in. text.
97033............. Electric current SK068 razor................ NF .................... 0 1 G1: See preamble 0.39
therapy. text.
97034............. Contrast bath therapy L023A Physical Therapy Aide NF Clean room/equipment 2 5 G1: See preamble 0.69
by physician staff. text.
97034............. Contrast bath therapy L023A Physical Therapy Aide NF Prepare room, 2 3 G1: See preamble 0.23
equipment, supplies. text.
97034............. Contrast bath therapy L023A Physical Therapy Aide NF Prepare and position 1 2 G1: See preamble 0.23
patient. text.
[[Page 34063]]
97034............. Contrast bath therapy L039B Physical Therapy NF Assist therapist.... 0 3 G1: See preamble 1.17
Assistant. text.
97034............. Contrast bath therapy L039B Physical Therapy NF Check dressings & 0 3 G1: See preamble 1.17
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97034............. Contrast bath therapy SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
text.
97034............. Contrast bath therapy SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
text.
97035............. Ultrasound therapy... EF028 table, mat, hi-lo, 6 NF .................... 16 15 G1: See preamble -0.01
x 8 platform. text.
97035............. Ultrasound therapy... EQ251 ultrasound unit, NF .................... 16 8 G1: See preamble -0.03
therapeutic. text.
97035............. Ultrasound therapy... L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
patient. text.
97035............. Ultrasound therapy... L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
equipment, supplies. text.
97035............. Ultrasound therapy... L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
Activity--specify: text.
post-treatment
assistance.
97035............. Ultrasound therapy... L039B Physical Therapy NF Assist therapist.... 0 3 G1: See preamble 1.17
Assistant. text.
97035............. Ultrasound therapy... SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
text.
97035............. Ultrasound therapy... SB026 gown, patient........ NF .................... 1 0 G1: See preamble -0.53
text.
97035............. Ultrasound therapy... SJ024 electrolyte coupling NF .................... 0 1 G1: See preamble 0.02
gel. text.
97035............. Ultrasound therapy... SJ062 ultrasound NF .................... 30 0 G1: See preamble -0.39
transmission gel. text.
97035............. Ultrasound therapy... SK082 towel, paper (Bounty) NF .................... 1 0 G1: See preamble -0.01
(per sheet). text.
97035............. Ultrasound therapy... SM012 disinfectant spray NF .................... 1 0 G1: See preamble -0.03
(Transeptic). text.
97110............. Therapeutic exercises EF028 table, mat, hi-lo, 6 NF .................... 22 10 G1: See preamble -0.12
x 8 platform. text.
97110............. Therapeutic exercises EQ118 exercise equipment NF .................... 22 8 G1: See preamble -0.40
(treadmill, bike, text.
stepper, UBE,
pulleys, balance
board).
97110............. Therapeutic exercises EQ129 hydrocollator, cold.. NF .................... 0 4 G1: See preamble 0.02
text.
97110............. Therapeutic exercises EQ130 hydrocollator, hot... NF .................... 0 4 G1: See preamble 0.01
text.
97110............. Therapeutic exercises L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
Activity--specify: text.
post-treatment
assistance.
97110............. Therapeutic exercises L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
equipment, supplies. text.
97110............. Therapeutic exercises L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
patient. text.
97110............. Therapeutic exercises L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
text.
97110............. Therapeutic exercises L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
[[Page 34064]]
97110............. Therapeutic exercises L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97110............. Therapeutic exercises L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
Assistant. Activity--specify: text.
Obtain measurements.
97110............. Therapeutic exercises L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
Assistant. text.
97110............. Therapeutic exercises L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97110............. Therapeutic exercises L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97110............. Therapeutic exercises SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
specialty visit. text.
97110............. Therapeutic exercises SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
text.
97110............. Therapeutic exercises SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
(per sheet). text.
97110............. Therapeutic exercises SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
(Transeptic). text.
97112............. Neuromuscular EF028 table, mat, hi-lo, 6 NF .................... 22 10 G1: See preamble -0.12
reeducation. x 8 platform. text.
97112............. Neuromuscular EQ068 balance assessment- NF .................... 22 15 G1: See preamble -0.37
reeducation. retraining system text.
(Balance Master).
97112............. Neuromuscular EQ118 exercise equipment NF .................... 22 15 G1: See preamble -0.20
reeducation. (treadmill, bike, text.
stepper, UBE,
pulleys, balance
board).
97112............. Neuromuscular EQ201 parallel bars, NF .................... 22 5 G1: See preamble -0.06
reeducation. platform mounted. text.
97112............. Neuromuscular L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
reeducation. equipment, supplies. text.
97112............. Neuromuscular L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
reeducation. patient. text.
97112............. Neuromuscular L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
reeducation. text.
97112............. Neuromuscular L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
reeducation. Activity--specify: text.
post-treatment
assistance.
97112............. Neuromuscular L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
reeducation. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
[[Page 34065]]
97112............. Neuromuscular L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
reeducation. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97112............. Neuromuscular L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
reeducation. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97112............. Neuromuscular L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
reeducation. Assistant. text.
97112............. Neuromuscular L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
reeducation. Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97112............. Neuromuscular L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
reeducation. Assistant. Activity--specify: text.
Obtain measurements.
97112............. Neuromuscular SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
reeducation. specialty visit. text.
97112............. Neuromuscular SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
reeducation. text.
97112............. Neuromuscular SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
reeducation. (per sheet). text.
97112............. Neuromuscular SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
reeducation. (Transeptic). text.
97113............. Aquatic therapy/ EF012 lift, hydraulic, NF .................... 0 4 G1: See preamble 0.05
exercises. chair. text.
97113............. Aquatic therapy/ EQ050 aquatic therapy pool. NF .................... 30 15 G1: See preamble -1.15
exercises. text.
97113............. Aquatic therapy/ EQ145 kit, aquatic exercise NF .................... 30 10 G1: See preamble -0.03
exercises. text.
97113............. Aquatic therapy/ EQ207 pool cleaner......... NF .................... 0 15 G1: See preamble 0.05
exercises. text.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Prepare room, 2 0 G1: See preamble -0.46
exercises. equipment, supplies. text.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
exercises. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Other clinical 2 3 G1: See preamble 0.23
exercises. Activity--specify: text.
post-treatment
assistance.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Greet patient, 2 1.5 G1: See preamble -0.12
exercises. provide gowning, text.
ensure appropriate
medical records are
available.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Prepare and position 3 1.5 G1: See preamble -0.35
exercises. patient. text.
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Clean room/equipment 2 1 G1: See preamble -0.23
exercises. by physician staff. text.
[[Page 34066]]
97113............. Aquatic therapy/ L023A Physical Therapy Aide NF Assist therapist.... 15 0 G1: See preamble -3.45
exercises. text.
97113............. Aquatic therapy/ L039B Physical Therapy NF Check dressings & 2 2.5 G1: See preamble 0.20
exercises. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97113............. Aquatic therapy/ L039B Physical Therapy NF Obtain vital signs.. 2 1 G1: See preamble -0.39
exercises. Assistant. text.
97113............. Aquatic therapy/ L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
exercises. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97113............. Aquatic therapy/ L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
exercises. Assistant. Activity--specify: text.
Obtain measurements.
97113............. Aquatic therapy/ L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
exercises. Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97113............. Aquatic therapy/ L039B Physical Therapy NF Assist therapist.... 2 7.5 G1: See preamble 2.15
exercises. Assistant. text.
97113............. Aquatic therapy/ SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
exercises. specialty visit. text.
97113............. Aquatic therapy/ SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
exercises. text.
97113............. Aquatic therapy/ SB041 swimsuit, female for NF .................... 0 1 G1: See preamble 6.87
exercises. hydrotherapy. text.
97113............. Aquatic therapy/ SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
exercises. (per sheet). text.
97113............. Aquatic therapy/ SL032 culture media........ NF .................... 0 10 G1: See preamble 0.13
exercises. text.
97113............. Aquatic therapy/ SL033 culture swab system NF .................... 0 1 G1: See preamble 0.87
exercises. (Culturette). text.
97113............. Aquatic therapy/ SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
exercises. (Transeptic). text.
97116............. Gait training therapy EF028 table, mat, hi-lo, 6 NF .................... 22 0 G1: See preamble -0.22
x 8 platform. text.
97116............. Gait training therapy EQ144 kit, ambulation...... NF .................... 0 15 G1: See preamble 0.03
text.
97116............. Gait training therapy EQ201 parallel bars, NF .................... 22 10 G1: See preamble -0.04
platform mounted. text.
97116............. Gait training therapy EQ231 stairs, ambulation NF .................... 22 5 G1: See preamble -0.03
training. text.
97116............. Gait training therapy EQ243 treadmill............ NF .................... 22 0 G1: See preamble -0.29
text.
97116............. Gait training therapy L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
Activity--specify: text.
post-treatment
assistance.
97116............. Gait training therapy L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
equipment, supplies. text.
97116............. Gait training therapy L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
patient. text.
97116............. Gait training therapy L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
text.
[[Page 34067]]
97116............. Gait training therapy L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97116............. Gait training therapy L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
Assistant. text.
97116............. Gait training therapy L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97116............. Gait training therapy L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97116............. Gait training therapy L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97116............. Gait training therapy L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
Assistant. Activity--specify: text.
Obtain measurements.
97116............. Gait training therapy SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
specialty visit. text.
97116............. Gait training therapy SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
text.
97116............. Gait training therapy SJ056 Thera-bands (6in NF .................... 1.5 0 G1: See preamble -0.90
width). text.
97116............. Gait training therapy SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
(per sheet). text.
97116............. Gait training therapy SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
(Transeptic). text.
97116............. Gait training therapy SM021 sanitizing cloth-wipe NF .................... 0 1 G1: See preamble 0.04
(patient). text.
97140............. Manual therapy 1/> EF029 table, mobolization- NF .................... 22 15 G1: See preamble -0.13
regions. manipulation text.
(Lloyd's).
97140............. Manual therapy 1/> L023A Physical Therapy Aide NF Prepare room, 1 0 G1: See preamble -0.23
regions. equipment, supplies. text.
97140............. Manual therapy 1/> L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
regions. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97140............. Manual therapy 1/> L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
regions. patient. text.
97140............. Manual therapy 1/> L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
regions. Activity--specify: text.
post-treatment
assistance.
97140............. Manual therapy 1/> L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
regions. text.
[[Page 34068]]
97140............. Manual therapy 1/> L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
regions. Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97140............. Manual therapy 1/> L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
regions. Assistant. Activity--specify: text.
Obtain measurements.
97140............. Manual therapy 1/> L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
regions. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97140............. Manual therapy 1/> L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
regions. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97140............. Manual therapy 1/> L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
regions. Assistant. text.
97140............. Manual therapy 1/> SA048 pack, minimum multi- NF .................... 0 0.5 G1: See preamble 0.57
regions. specialty visit. text.
97140............. Manual therapy 1/> SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
regions. text.
97140............. Manual therapy 1/> SK046 lotion, massage, NF .................... 2 0.5 G1: See preamble -0.24
regions. unscented. text.
97140............. Manual therapy 1/> SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
regions. (per sheet). text.
97140............. Manual therapy 1/> SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
regions. (Transeptic). text.
97530............. Therapeutic EL003 environmental module-- NF .................... 22 12 G1: See preamble -0.50
activities. the workshop. text.
97530............. Therapeutic EQ219 rehab and testing NF .................... 22 4 G1: See preamble -3.20
activities. system (BTE primus). text.
97530............. Therapeutic EQ267 work samples, small NF .................... 22 12 G1: See preamble -0.06
activities. tools (Valpar 1). text.
97530............. Therapeutic L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
activities. patient. text.
97530............. Therapeutic L023A Physical Therapy Aide NF Assist therapist.... 3.75 0 G1: See preamble -0.86
activities. text.
97530............. Therapeutic L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
activities. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97530............. Therapeutic L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
activities. Activity--specify: text.
post-treatment
assistance.
97530............. Therapeutic L023A Physical Therapy Aide NF Prepare room, 1 1.5 G1: See preamble 0.12
activities. equipment, supplies. text.
97530............. Therapeutic L039B Physical Therapy NF Assist therapist.... 3.75 7.5 G1: See preamble 1.46
activities. Assistant. text.
[[Page 34069]]
97530............. Therapeutic L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
activities. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97530............. Therapeutic L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
activities. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97530............. Therapeutic SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
activities. text.
97530............. Therapeutic SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
activities. (per sheet). text.
97530............. Therapeutic SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
activities. (Transeptic). text.
97533............. Sensory integration.. EQ224 sensory integration NF .................... 22 15 G1: See preamble -0.06
equip (eg, ball pit, text.
glider, trampoline,
ramp).
97533............. Sensory integration.. EQ225 sensory integration NF .................... 22 15 G1: See preamble -0.05
equipment, text.
suspension system.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Obtain vital signs.. 0 1 G1: See preamble 0.23
text.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Assist therapist.... 0 7.5 G1: See preamble 1.73
text.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Prepare room, 1 1.5 G1: See preamble 0.12
equipment, supplies. text.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
patient. text.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
Activity--specify: text.
post-treatment
assistance.
97533............. Sensory integration.. L023A Physical Therapy Aide NF Check dressings & 0 2.5 G1: See preamble 0.58
wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97533............. Sensory integration.. L039B Physical Therapy NF Obtain vital signs.. 1 0 G1: See preamble -0.39
Assistant. text.
97533............. Sensory integration.. L039B Physical Therapy NF Assist therapist.... 7.5 0 G1: See preamble -2.93
Assistant. text.
97533............. Sensory integration.. L039B Physical Therapy NF Check dressings & 1.5 0 G1: See preamble -0.59
Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
[[Page 34070]]
97533............. Sensory integration.. L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97533............. Sensory integration.. SJ053 swab-pad, alcohol.... NF .................... 0 3 G1: See preamble 0.04
text.
97533............. Sensory integration.. SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
(per sheet). text.
97533............. Sensory integration.. SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
(Transeptic). text.
97535............. Self care mngment EL002 environmental module-- NF .................... 22 12 G1: See preamble -1.15
training. kitchen. text.
97535............. Self care mngment EQ143 kit, ADL............. NF .................... 22 16 G1: See preamble -0.01
training. text.
97535............. Self care mngment L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
training. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97535............. Self care mngment L023A Physical Therapy Aide NF Prepare room, 1 1.5 G1: See preamble 0.12
training. equipment, supplies. text.
97535............. Self care mngment L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
training. patient. text.
97535............. Self care mngment L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
training. Activity--specify: text.
post-treatment
assistance.
97535............. Self care mngment L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
training. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97535............. Self care mngment L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
training. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97535............. Self care mngment SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
training. text.
97535............. Self care mngment SK009 bath soap (one bar NF .................... 0 0.5 G1: See preamble 0.34
training. uou). text.
97535............. Self care mngment SK080 toothbrush........... NF .................... 0 1 G1: See preamble 0.81
training. text.
97535............. Self care mngment SK081 toothpaste........... NF .................... 0 0.25 G1: See preamble 0.12
training. text.
97535............. Self care mngment SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
training. (per sheet). text.
97535............. Self care mngment SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
training. (Transeptic). text.
[[Page 34071]]
97535............. Self care mngment SM013 disinfectant, surface NF .................... 0 2 G1: See preamble 0.33
training. (Envirocide, text.
Sanizide).
97537............. Community/work EL001 environmental module-- NF .................... 22 8 G1: See preamble -1.01
reintegration. car. text.
97537............. Community/work EQ147 kit, ergonomic NF .................... 22 8 G1: See preamble -0.08
reintegration. (office). text.
97537............. Community/work L023A Physical Therapy Aide NF Prepare room, 1 1.5 G1: See preamble 0.12
reintegration. equipment, supplies. text.
97537............. Community/work L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
reintegration. Activity--specify: text.
post-treatment
assistance.
97537............. Community/work L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
reintegration. patient. text.
97537............. Community/work L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
reintegration. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97537............. Community/work L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
reintegration. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97537............. Community/work L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
reintegration. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97537............. Community/work SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
reintegration. text.
97537............. Community/work SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
reintegration. (per sheet). text.
97537............. Community/work SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
reintegration. (Transeptic). text.
97542............. Wheelchair mngment EL002 environmental module-- NF .................... 22 8 G1: See preamble -1.61
training. kitchen. text.
97542............. Wheelchair mngment L023A Physical Therapy Aide NF Prepare room, 1 1.5 G1: See preamble 0.12
training. equipment, supplies. text.
97542............. Wheelchair mngment L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
training. Activity--specify: text.
post-treatment
assistance.
97542............. Wheelchair mngment L023A Physical Therapy Aide NF Prepare and position 1 0 G1: See preamble -0.23
training. patient. text.
97542............. Wheelchair mngment L023A Physical Therapy Aide NF Assist therapist.... 3.75 0 G1: See preamble -0.86
training. text.
[[Page 34072]]
97542............. Wheelchair mngment L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
training. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97542............. Wheelchair mngment L039B Physical Therapy NF Check dressings & 1.5 2.5 G1: See preamble 0.39
training. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97542............. Wheelchair mngment L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
training. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97542............. Wheelchair mngment L039B Physical Therapy NF Assist therapist.... 3.75 7.5 G1: See preamble 1.46
training. Assistant. text.
97542............. Wheelchair mngment SB022 gloves, non-sterile.. NF .................... 1 0 G1: See preamble -0.08
training. text.
97542............. Wheelchair mngment SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
training. (per sheet). text.
97542............. Wheelchair mngment SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
training. (Transeptic). text.
97760............. Orthotic mgmt&trainj EF005 cart-workbench, NF .................... 27 10 G1: See preamble -0.03
1st enc. orthotic, mobile. text.
97760............. Orthotic mgmt&trainj EF033 table, treatment, hi- NF .................... 27 10 G1: See preamble -0.09
1st enc. lo. text.
97760............. Orthotic mgmt&trainj EQ219 rehab and testing NF .................... 27 5 G1: See preamble -3.91
1st enc. system (BTE primus). text.
97760............. Orthotic mgmt&trainj ER064 water bath, NF .................... 27 10 G1: See preamble -0.04
1st enc. thermoplastic text.
softener (20in x
12in).
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
1st enc. text.
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
1st enc. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
1st enc. Activity--specify: text.
post-treatment
assistance.
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Greet patient, 2 1.5 G1: See preamble -0.12
1st enc. provide gowning, text.
ensure appropriate
medical records are
available.
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Clean room/equipment 2 1 G1: See preamble -0.23
1st enc. by physician staff. text.
[[Page 34073]]
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Prepare room, 2 1.5 G1: See preamble -0.12
1st enc. equipment, supplies. text.
97760............. Orthotic mgmt&trainj L023A Physical Therapy Aide NF Prepare and position 2 0 G1: See preamble -0.46
1st enc. patient. text.
97760............. Orthotic mgmt&trainj L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
1st enc. Assistant. text.
97760............. Orthotic mgmt&trainj L039B Physical Therapy NF Obtain vital signs.. 2 1 G1: See preamble -0.39
1st enc. Assistant. text.
97760............. Orthotic mgmt&trainj L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
1st enc. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97760............. Orthotic mgmt&trainj L039B Physical Therapy NF Check dressings & 2 2.5 G1: See preamble 0.20
1st enc. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97760............. Orthotic mgmt&trainj L039B Physical Therapy NF Conduct phone calls/ 2 0 G1: See preamble -0.78
1st enc. Assistant. call in text.
prescriptions.
97760............. Orthotic mgmt&trainj SH035 fluori-methane (cold NF .................... 5 7.5 G1: See preamble 1.06
1st enc. spray). text.
97760............. Orthotic mgmt&trainj SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
1st enc. (per sheet). text.
97760............. Orthotic mgmt&trainj SK087 water, distilled..... NF .................... 85 128 G1: See preamble 0.56
1st enc. text.
97760............. Orthotic mgmt&trainj SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
1st enc. (Transeptic). text.
97761............. Prosthetic trainj 1st EF028 table, mat, hi-lo, 6 NF .................... 27 5 G1: See preamble -0.22
enc. x 8 platform. text.
97761............. Prosthetic trainj 1st EQ069 balance board........ NF .................... 27 4 G1: See preamble -0.03
enc. text.
97761............. Prosthetic trainj 1st EQ201 parallel bars, NF .................... 27 4 G1: See preamble -0.09
enc. platform mounted. text.
97761............. Prosthetic trainj 1st EQ231 stairs, ambulation NF .................... 27 3 G1: See preamble -0.04
enc. training. text.
97761............. Prosthetic trainj 1st EQ243 treadmill............ NF .................... 27 3 G1: See preamble -0.32
enc. text.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Greet patient, 2 1.5 G1: See preamble -0.12
enc. provide gowning, text.
ensure appropriate
medical records are
available.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Prepare room, 2 0 G1: See preamble -0.46
enc. equipment, supplies. text.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Prepare and position 2 0 G1: See preamble -0.46
enc. patient. text.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
enc. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
[[Page 34074]]
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
enc. Activity--specify: text.
post-treatment
assistance.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Assist therapist.... 10 0 G1: See preamble -2.30
enc. text.
97761............. Prosthetic trainj 1st L023A Physical Therapy Aide NF Clean room/equipment 2 1 G1: See preamble -0.23
enc. by physician staff. text.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
enc. Assistant. Activity--specify: text.
Obtain measurements.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Obtain vital signs.. 2 1 G1: See preamble -0.39
enc. Assistant. text.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Assist therapist.... 5 7.5 G1: See preamble 0.98
enc. Assistant. text.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
enc. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Other Clinical 0 1 G1: See preamble 0.39
enc. Assistant. Activity--specify: text.
Conduct phone calls/
call in
prescriptions.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Conduct phone calls/ 2 0 G1: See preamble -0.78
enc. Assistant. call in text.
prescriptions.
97761............. Prosthetic trainj 1st L039B Physical Therapy NF Check dressings & 2 2.5 G1: See preamble 0.20
enc. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
97761............. Prosthetic trainj 1st SB026 gown, patient........ NF .................... 0.75 0 G1: See preamble -0.40
enc. text.
97761............. Prosthetic trainj 1st SG027 cast, stockinette 4in NF .................... 0.3 1 G1: See preamble 0.32
enc. text.
97761............. Prosthetic trainj 1st SG058 moleskin 9in width... NF .................... 0.2 0.33 G1: See preamble 0.45
enc. text.
97761............. Prosthetic trainj 1st SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
enc. (per sheet). text.
97761............. Prosthetic trainj 1st SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
enc. (Transeptic). text.
977X1............. Orthc/prostc mgmt EF005 cart-workbench, NF .................... 27 10 G1: See preamble -0.03
sbsq enc. orthotic, mobile. text.
977X1............. Orthc/prostc mgmt EF033 table, treatment, hi- NF .................... 27 16 G1: See preamble -0.06
sbsq enc. lo. text.
977X1............. Orthc/prostc mgmt ER064 water bath, NF .................... 27 10 G1: See preamble -0.04
sbsq enc. thermoplastic text.
softener (20in x
12in).
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Other clinical 0 1 G1: See preamble 0.23
sbsq enc. Activity--specify: text.
post-treatment
assistance.
[[Page 34075]]
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Greet patient, 2 1.5 G1: See preamble -0.12
sbsq enc. provide gowning, text.
ensure appropriate
medical records are
available.
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Clean room/equipment 2 1 G1: See preamble -0.23
sbsq enc. by physician staff. text.
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Other Clinical 0 1.5 G1: See preamble 0.35
sbsq enc. Activity--specify: text.
Verify/Coordinate
availability of
resources/equipment.
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Assist therapist.... 5 0 G1: See preamble -1.15
sbsq enc. text.
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Prepare room, 2 1.5 G1: See preamble -0.12
sbsq enc. equipment, supplies. text.
977X1............. Orthc/prostc mgmt L023A Physical Therapy Aide NF Prepare and position 2 0 G1: See preamble -0.46
sbsq enc. patient. text.
977X1............. Orthc/prostc mgmt L039B Physical Therapy NF Other Clinical 0 1.5 G1: See preamble 0.59
sbsq enc. Assistant. Activity--specify: text.
Review/read
documentation, plan
of care, treatment
goals.
977X1............. Orthc/prostc mgmt L039B Physical Therapy NF Obtain vital signs.. 2 1 G1: See preamble -0.39
sbsq enc. Assistant. text.
977X1............. Orthc/prostc mgmt L039B Physical Therapy NF Check dressings & 2 2.5 G1: See preamble 0.20
sbsq enc. Assistant. wound/home care text.
instructions/
coordinate office
visits/
prescriptions.
977X1............. Orthc/prostc mgmt L039B Physical Therapy NF Assist therapist.... 2.5 7.5 G1: See preamble 1.95
sbsq enc. Assistant. text.
977X1............. Orthc/prostc mgmt SA048 pack, minimum multi- NF .................... 0.5 1 G1: See preamble 0.57
sbsq enc. specialty visit. text.
977X1............. Orthc/prostc mgmt SG027 cast, stockinette 4in NF .................... 0.4 0.5 G1: See preamble 0.05
sbsq enc. text.
977X1............. Orthc/prostc mgmt SG058 moleskin 9in width... NF .................... 0.7 1 G1: See preamble 1.04
sbsq enc. text.
977X1............. Orthc/prostc mgmt SG060 outrigger line....... NF .................... 7 50 G1: See preamble 3.91
sbsq enc. text.
977X1............. Orthc/prostc mgmt SG061 outrigger post....... NF .................... 3 4 G1: See preamble 0.40
sbsq enc. text.
977X1............. Orthc/prostc mgmt SH035 fluori-methane (cold NF .................... 5 7.5 G1: See preamble 1.06
sbsq enc. spray). text.
977X1............. Orthc/prostc mgmt SJ047 splint straps 1in.... NF .................... 0.7 1 G1: See preamble 0.39
sbsq enc. text.
977X1............. Orthc/prostc mgmt SJ048 splint straps 2in.... NF .................... 1.3 2 G1: See preamble 1.07
sbsq enc. text.
977X1............. Orthc/prostc mgmt SK071 rubber bands, non- NF .................... 4 6 G1: See preamble 0.04
sbsq enc. sterile. text.
[[Page 34076]]
977X1............. Orthc/prostc mgmt SK082 towel, paper (Bounty) NF .................... 4 0 G1: See preamble -0.03
sbsq enc. (per sheet). text.
977X1............. Orthc/prostc mgmt SK087 water, distilled..... NF .................... 85 128 G1: See preamble 0.56
sbsq enc. text.
977X1............. Orthc/prostc mgmt SM012 disinfectant spray NF .................... 5 0 G1: See preamble -0.14
sbsq enc. (Transeptic). text.
97X11............. Ther ivntj w/focus ED038 notebook (Dell NF .................... 60 0 G1: See preamble -0.52
cog funcj. Latitute D600). text.
97X11............. Ther ivntj w/focus EF027 table, instrument, NF .................... 60 5 G1: See preamble -0.08
cog funcj. mobile. text.
97X11............. Ther ivntj w/focus L023A Physical Therapy Aide NF Assist physician in 0 12 G1: See preamble 2.76
cog funcj. performing text.
procedure.
97X11............. Ther ivntj w/focus SK057 paper, laser printing NF .................... 10 0 G1: See preamble -0.05
cog funcj. (each sheet). text.
994X1............. 1st psyc collab care EF042 One Couch and Two F .................... 38 0 G1: See preamble -0.15
mgmt. Chairs. text.
994X1............. 1st psyc collab care L057B Behavioral Health F Other clinical 85 0 G1: See preamble -48.45
mgmt. Care Manager. Activity--specify: text.
994X1 and 994X3.
994X2............. Sbsq psyc collab care EF042 One Couch and Two F .................... 27 0 G1: See preamble -0.11
mgmt. Chairs. text.
994X2............. Sbsq psyc collab care L057B Behavioral Health F Other clinical 60 0 G1: See preamble -34.20
mgmt. Care Manager. Activity--specify: text.
994X2.
994X3............. 1st/sbsq psyc collab EF042 One Couch and Two F .................... 13.5 0 G1: See preamble -0.05
care. Chairs. text.
994X3............. 1st/sbsq psyc collab L057B Behavioral Health F Other clinical 30 0 G1: See preamble -17.10
care. Care Manager. Activity--specify: text.
994X1 and 994X3.
99XX5............. Care mgmt svc bhvl L057B Behavioral Health F Other clinical 20 0 G1: See preamble -11.40
hlth cond. Care Manager. Activity--specify: text.
G0507.
G0507............. Care manage serv L057B Behavioral Health F Other clinical 20 0 G1: See preamble -11.40
minimum 20. Care Manager. Activity--specify: text.
G0507.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Table 12--CY 2018 Proposed Codes With Direct PE Input Recommendations
Without Refinement
------------------------------------------------------------------------
HCPCS code Description
------------------------------------------------------------------------
007X1............................. Anes upr gi ndsc px nos.
007X2............................. Anes upr gi ndsc px ercp.
008X1............................. Anes lwr intst ndsc nos.
008X2............................. Anes lwr intst scr colsc.
008X3............................. Anes upr lwr gi hdsc px.
10040............................. Acne surgery.
15734............................. Muscle-skin graft trunk.
15736............................. Muscle-skin graft arm.
15738............................. Muscle-skin graft leg.
157X2............................. Musc myoq/fscq flp h&n pedcl.
19303............................. Mast simple complete.
31255............................. Nsl/sins ndsc w/tot ethmdct.
31256............................. Exploration maxillary sinus.
31267............................. Endoscopy maxillary sinus.
31276............................. Nsl/sins ndsc frnt tiss rmvl.
31287............................. Nasal/sinus endoscopy surg.
31288............................. Nasal/sinus endoscopy surg.
31600............................. Incision of windpipe.
31601............................. Incision of windpipe.
31603............................. Incision of windpipe.
31610............................. Incision of windpipe.
31646............................. Brnchsc w/ther aspir sbsq.
31XX1............................. Nsl/sins ndsc w/artery lig.
31XX2............................. Nsl/sins ndsc total.
31XX3............................. Nsl/sins ndsc tot w/sphendt.
31XX4............................. Nsl/sins ndsc sphn tiss rmvl.
34812............................. Opn fem art expos.
34820............................. Opn ilac art expos.
34833............................. Opn ilac art expos cndt crtj.
34834............................. Opn brach art expos.
34X01............................. Evasc rpr a-ao ndgft.
34X02............................. Evasc rpr a-ao ndgft rpt.
34X03............................. Evasc rpr a-unilac ndgft.
34X04............................. Evasc rpr a-unilac ndgft rpt.
34X05............................. Evac rpr a-biiliac ndgft.
34X06............................. Evasc rpr a-biiliac rpt.
34X07............................. Evasc rpr ilio-iliac ndgft.
34X08............................. Evasc rpr ilio-iliac rpt.
34X09............................. Plmt xtn prosth evasc rpr.
34X10............................. Dlyd plmt xtn prosth 1st vsl.
34X11............................. Dlyd plmt xtn prosth ea addl.
34X12............................. Tcat dlvr enhncd fixj dev.
[[Page 34077]]
34X13............................. Perq access & clsr fem art.
34X15............................. Opn fem art expos cndt crtj.
34X19............................. Opn ax/subcla art expos.
34X20............................. Opn ax/subcla art expos cndt.
36218............................. Place catheter in artery.
364X4............................. Endoven ther chem adhes sbsq.
36514............................. Apheresis plasma.
36516............................. Apheresis immunoads slctv.
36522............................. Photopheresis.
36556............................. Insert non-tunnel cv cath.
3857X............................. Laps pelvic lymphadec.
43107............................. Removal of esophagus.
43112............................. Esphg tot w/thrcm.
43117............................. Partial removal of esophagus.
432X5............................. Esphg tot w/laps moblj.
432X6............................. Esphg dstl \2/3\ w/laps moblj.
432X7............................. Esphg tot thrsc moblj.
51798............................. Us urine capacity measure.
52601............................. Prostatectomy (turp).
57240............................. Anterior colporrhaphy.
57250............................. Repair rectum & vagina.
57260............................. Cmbn ant pst colprhy.
57265............................. Cmbn ap colprhy w/ntrcl rpr.
64418............................. N block inj suprascapular.
64553............................. Implant neuroelectrodes.
64555............................. Implant neuroelectrodes.
64910............................. Nerve repair w/allograft.
64911............................. Neurorraphy w/vein autograft.
64X91............................. Nrv rpr w/nrv algrft 1st.
70490............................. Ct soft tissue neck w/o dye.
70491............................. Ct soft tissue neck w/dye.
70492............................. Ct sft tsue nck w/o & w/dye.
710X1............................. X-ray exam chest 1 view.
710X2............................. X-ray exam chest 2 views.
710X3............................. X-ray exam chest 3 views.
710X4............................. X-ray exam chest 4+ views.
71100............................. X-ray exam ribs uni 2 views.
71101............................. X-ray exam unilat ribs/chest.
71110............................. X-ray exam ribs bil 3 views.
71111............................. X-ray exam ribs/chest4/> vws.
73100............................. X-ray exam of wrist.
73110............................. X-ray exam of wrist.
73120............................. X-ray exam of hand.
73130............................. X-ray exam of hand.
73140............................. X-ray exam of finger(s).
74022............................. X-ray exam series abdomen.
740X1............................. X-ray exam abdomen 1 view.
740X2............................. X-ray exam abdomen 2 views.
740X3............................. X-ray exam abdomen 3+ views.
76510............................. Ophth us b & quant a.
76511............................. Ophth us quant a only.
76512............................. Ophth us b w/non-quant a.
76516............................. Echo exam of eye.
76519............................. Echo exam of eye.
76882............................. Us xtr non-vasc lmtd.
88334............................. Intraop cyto path consult 2.
92136............................. Ophthalmic biometry.
93293............................. Pm phone r-strip device eval.
93296............................. Pm/icd remote tech serv.
93299............................. Icm/ilr remote tech serv.
93306............................. Tte w/doppler complete.
93307............................. Tte w/o doppler complete.
93308............................. Tte f-up or lmtd.
95250............................. Glucose monitoring cont.
95930............................. Visual ep test cns w/i&r.
96401............................. Chemo anti-neopl sq/im.
96402............................. Chemo hormon antineopl sq/im.
96409............................. Chemo iv push sngl drug.
96411............................. Chemo iv push addl drug.
96567............................. Pdt dstr prmlg les skn.
993X1............................. Pt/caregiver trainj home inr.
993X2............................. Anticoag mgmt pt warfarin.
99XX3............................. Assmt & care pln pt cog imp.
GXXX1............................. Cognitive skills development.
------------------------------------------------------------------------
Table 13--CY 2018 Proposed Rule--Invoices Received for New Direct PE Inputs
----------------------------------------------------------------------------------------------------------------
Estimated non-
facility
allowed
CMS code Average price Number of services for
invoices HCPCS codes
using this
item
----------------------------------------------------------------------------------------------------------------
EQ383........................................................... 790.00 1 39,006
SD322........................................................... 25.00 1 3,435
EQ384........................................................... 4,760.00 1 39,006
EQ385........................................................... 9,034.00 1 39,006
SD323........................................................... 1,495.00 1 387
SD324........................................................... 3,195.00 2 1550
SA125........................................................... 40.00 2 1550
SD328........................................................... 353.64 1 41
SD325........................................................... 39.90 1 4
SA126........................................................... 2,850.00 3 4
EQ386........................................................... 16,146.00 1 4
SA124........................................................... 2.35 2 421,539
SJ092........................................................... 8.44 209 9,931,981
SJ093........................................................... 0.19 5 9,931,981
SB054........................................................... 9.99 1 387,359
----------------------------------------------------------------------------------------------------------------
Table 14--CY 2018 Proposed Rule--Invoices Received for Existing Direct PE Inputs
--------------------------------------------------------------------------------------------------------------------------------------------------------
Estimated non-
facility
allowed
CPT/HCPCS codes Item name CMS code Current price Updated price Percent change Number of services for
invoices HCPCS codes
using this
item
--------------------------------------------------------------------------------------------------------------------------------------------------------
17000, 17003, 17004, 46607, LMX 4% anesthetic SH092 1.60 0.78 -51 1 23,584,412
96567, 96X73, 96X74. cream.
20982, 32998, 50592.............. probe, SD109 353.64 2233.00 531 1 2,972
radiofrequency, 3
array
(StarBurstSDE).
[[Page 34078]]
30140, 30901, 30903, 30905, Atomizer tips SL464 0.00 2.66 .............. 1 625,876
30906, 31231, 31237, 31238, (disposable).
43197, 43198.
36514............................ tubing set, plasma SC085 173.33 273.66 58 1 1,237
exchange.
36514, 36516..................... ACD-A anticoagulant SJ071 6.58 7.10 8 1 2,517
none (formerly in deleted code kit, apheresis SA072 140.00 243.33 74 1 22
36515). treatment.
36522............................ kit, photopheresis SA024 858.00 1598.00 86 1 25
procedure.
36522, 96567, 96910, 96912, goggles, uv- SJ027 2.30 4.1 78 1 697,047
96913, 96920, 96921, 96922, blocking.
96X73, 96X74.
88360, 88361..................... Antibody Estrogen SL493 14.00 14.47 3 3 209,384
Receptor
monoclonal.
95004, 95017, 95018.............. negative control, SH101 5.08 5.17 2 2 10,036,050
allergy test.
95004, 95017, 95018.............. positive control, SH102 17.28 26.12 51 6 10,036,050
allergy test.
95250............................ sensor, glucose SD114 29.50 53.08 80 19 26,205
monitoring
(interstitial).
95250............................ glucose continuous EQ125 2465.00 1170.54 -53 5 26,205
monitoring system.
993X1, G0249..................... test strip, INR.... SJ055 21.88 5.66 -74 2 1,265,540
--------------------------------------------------------------------------------------------------------------------------------------------------------
I. Evaluation & Management (E/M) Guidelines and Care Management
Services
In recent years, we have sought to recognize significant changes in
health care practice, especially innovations in the active management
and ongoing care of chronically ill patients. We have been engaged in
an ongoing incremental effort to identify gaps in appropriate coding
and payment for care management/coordination, cognitive services and
primary care within the PFS. This has included working with the CPT
Editorial Panel (CPT) to develop and value (or revalue) the following
service codes:
Transitional care management (TCM) services (2013).
Chronic care management services (CCM) (2015, 2017).
Behavioral health integration (BHI) services (2017).
Assessment/care planning services for cognitive impairment
(2017).
Prolonged E/M services without direct patient contact
(2017).
In response to public feedback regarding the initial implementation
of TCM and CCM, in the CY 2017 PFS final rule (81 FR 80225 through
80256), we finalized significant administrative burden reduction for
CCM and focused on limiting as much as possible the ways in which
Medicare's rules differed from the CPT guidance that generally applies
for all payers. We also worked with the CPT Editorial Panel and other
stakeholders to develop coding and improve payment accuracy for BHI,
cognitive impairment assessment/management, and prolonged services. In
the CY 2017 PFS final rule (81 FR 80255), we also reiterated our
commitment to addressing disparities for individuals with disabilities
and advancing health equity, and noted that we will continue to explore
improvements in payment accuracy for services furnished to individuals
with disabilities. We look forward to continued work with stakeholders
to ensure that the coding and valuation of these services accurately
reflects the resource costs involved in furnishing these services. We
are soliciting public comments on ways we might further reduce
administrative burden for these and similar services under the PFS.
1. E/M Guidelines
a. Background
Most physicians and other billing practitioners bill patient visits
to the PFS under a relatively generic set of codes that distinguish
level of complexity, site of care, and in some cases between new or
established patients. These codes are called Evaluation and Management
(E/M) visit codes. For example, there are generally three levels of
hospital and nursing facility inpatient E/M visit codes, and five
levels of office or hospital outpatient E/M visit codes, that vary
based on complexity. The latter also distinguish whether or not the
patient is new to the billing practitioner.
Billing practitioners must maintain information in the medical
record to document that they have reported the appropriate level of E/M
visit code. CMS maintains guidelines that specify the kind of
information that is required to support Medicare payment for each
level. According to these documentation guidelines, there are three key
components to selecting the appropriate level:
History of Present Illness (HPI or History);
Physical Examination (Exam); and
Medical Decision Making (MDM).
There are two versions of the documentation guidelines, commonly
referenced based on the year of their
[[Page 34079]]
release (the ``1995'' and ``1997'' guidelines), available under
downloads on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html. The most
substantial differences between the two sets of guidelines pertain to
requirements for the physical exam. The two versions have a slight
difference in requirements for documenting the history, and no
difference in requirements for MDM. In documenting a given E/M service,
practitioners must use one version of the guidelines or the other, with
one exception related to extended histories (see the Evaluation and
Management Services guide available on the CMS Web site at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf). These
guidelines are very similar to guidelines within the CPT codebook for
E/M visits. We provide an example of how the guidelines distinguish
between level 2 and level 3 visits in Table 15.
Stakeholders have long maintained that both the 1995 and 1997
guidelines are administratively burdensome and outdated with respect to
the practice of medicine, stating that they are too complex, ambiguous,
and that they fail to distinguish meaningful differences among code
levels. In general, we agree that there may be unnecessary burden with
these guidelines and that they are potentially outdated, and believe
this is especially true for the requirements for the history and the
physical exam. The guidelines have not been updated to account for
significant changes in technology, especially electronic health record
(EHR) use, which presents challenges for data and program integrity and
potential upcoding given the frequently automated selection of code
level.
While CMS conducts few audits on E/M visits relative to the volume
of PFS services they comprise, we have repeatedly heard from
practitioners that compliance with the guidelines is a source of
significant audit vulnerability and administrative burden. Our prior
attempts to revise the guidelines met with a lack of stakeholder
consensus and support, which contributed to the current policy that
allows practitioners to use either the 1995 guidelines or 1997
guidelines, resulting in further complexity in determining or selecting
the applicable requirements.
b. E/M Guidelines Public Comment Solicitation
We continue to agree with stakeholders that the E/M documentation
guidelines should be substantially revised. We believe that a
comprehensive reform of E/M documentation guidelines would require a
multi-year, collaborative effort among stakeholders. We believe that
revised guidelines could both reduce clinical burden and improve
documentation in a way that would be more effective in clinical
workflows and care coordination. We also think updated E/M guidelines
coupled with technological advancements in voice recognition, natural
language processing and user-centered design of EHRs could improve
documentation for patient care while also meeting requirements for
billing and population health management. We recognize that achieving
the goal of reduced clinician burden and improved, meaningful
documentation for patient care will require both updated E/M
guidelines, as well as changes in technology, clinician documentation
practices and workflow. We are seeking input from a broad array of
stakeholders, including patient advocates, on the specific changes we
should undertake to reform the guidelines, reduce the associated
burden, and better align E/M coding and documentation with the current
practice of medicine. We are specifically seeking comment on how we
might focus on initial changes to the guidelines for the history and
physical exam because we believe documentation for these elements may
be more significantly outdated, and that differences in MDM are likely
the most important factors in distinctions between visits of different
levels. We are also specifically seeking comment on whether it would be
appropriate to remove our documentation requirements for the history
and physical exam for all E/M visits at all levels. We believe medical
decision-making and time are the more significant factors in
distinguishing visit levels, and that the need for extended histories
and exams is being replaced by population-based screening and
intervention, at least for some specialties. In addition, an increase
in the utilization of EHRs, and to some extent, shared health
information via EHRs, may have changed the character of extended
patient histories since the guidelines were established. As long as a
history and physical exam are documented and generally consistent with
complexity of MDM, there may no longer be a need for us to maintain
such detailed specifications for what must be performed and documented
for the history and physical exam (for example, which and how many body
systems are involved). We are seeking comment on whether clinicians and
other stakeholders believe removing the documentation requirements for
the history and physical exam would be a good approach.
While we believe MDM guidelines may also need to be updated, we
believe in the nearer term it may be possible to eliminate the current
focus on details of history and physical exam, and allow MDM and/or
time to serve as the key determinant of E/M visit level. We are seeking
public comment on this approach. We are also seeking comment on how
such reforms may differentially affect physicians and practitioners of
different specialties, including primary care clinicians, and how we
could or should account for such effects as we examine this issue. We
note, however, that there may still be clinical or legal reasons for
individual practitioners to document an extended history or physical
exam (for example, where there are negative findings for certain body
systems in support of differential diagnosis). We are additionally
seeking comment on whether CMS should leave it largely to the
discretion of individual practitioners to what degree they should
perform and document the history and physical exam. We also welcome
comments on specific ideas that stakeholders may have on how to update
MDM guidelines to foster appropriate documentation for patient care
commensurate with the level of patient complexity, while avoiding
burdensome documentation requirements and/or inappropriate upcoding.
We note that through letters, meetings, public comment letters in
past rulemaking cycles, and other avenues, we have heard from many
stakeholders that the E/M code set itself is outdated and needs to be
revised. For example, some stakeholders recommend an extensive research
effort to revise and revalue E/M services, especially physician work
inputs (see 81 FR 46200). In prior rulemaking cycles, we acknowledged
the limitations of the current E/M code set and agree that the
structure of the underlying code set and its valuation relative to
other PFS services are also important issues that we expect to continue
to explore, though we are immediately focused on revision of the
current E/M guidelines in order to reduce unnecessary administrative
burden.
2. Care Management Public Comment Solicitation
We continue to be interested in the ongoing work of the medical
community and other stakeholders to refine the set of codes used to
describe care
[[Page 34080]]
management services. In section II.H., we are proposing to adopt CPT
codes for CY 2018 to replace the G-codes we established for several of
the care management services finalized last year. We are committed to
continued work with stakeholders on necessary refinements to the code
set, especially describing the professional work involved in caring for
complex patients in other clinical contexts. We are seeking comment on
ways we might further reduce burden on reporting practitioners for care
management services, including through stronger alignment between CMS
requirements and CPT guidance for existing and potential new codes.
Table 15--Key Component Documentation Requirements for Level 2 vs 3 Evaluation & Management (E/M) Visit
----------------------------------------------------------------------------------------------------------------
Key component [dagger] Level 2 (1995) Level 3 (1995) Level 2 (1997) Level 3 (1997)
----------------------------------------------------------------------------------------------------------------
History (History of Present Review of Systems Problem Pertinent No change from No change from
Illness or HPI). (ROS) n/a. ROS: inquires 1995. 1995.
about the system
directly related
to the problem(s)
identified in the
HPI.
Physical Examination (Exam)..... A limited A limited General multi- General multi-
examination of examination of system exam: system exam:
the affected body the affected body Performance and Performance and
area or organ area or organ documentation of documentation of
system. system and other one to five at least six
symptomatic or elements in one elements in one
related organ or more organ or more organ
system(s). system(s) or body system(s) or body
area(s). area(s).
Single organ Single organ
system exam: system exam:
Performance and Performance and
documentation of documentation of
one to five at least six
elements. elements.
---------------------------------------
Medical Decision Making (MDM) Straightforward: Low complexity: No change from 1995.
1. Minimal........ 1. Limited........
2. Minimal or no 2. Limited data
data review. review.
3. Minimal risk... 3. Low risk.......
---------------------------------------
Measured by: *
1. Problem--Number of diagnoses/
treatment options
2. Data--Amount and/or
complexity of data to be
reviewed
3. Risk--Risk of complications
and/or morbidity or mortality
----------------------------------------------------------------------------------------------------------------
* Two of three met or exceeded.
[dagger] For certain settings and patient types, each of these three key components must be met or exceeded (for
example, new patients; initial hospital visits). For others, only two of the three key components must be met
or exceeded (for example, established patients, subsequent hospital or other visits).
III. Other Provisions of the Proposed Rule
A. New Care Coordination Services and Payment for Rural Health Clinics
(RHCs) and Federally-Qualified Health Centers (FQHCs)
1. Overview
We have been engaged in a multi-year examination of coordinated and
collaborative care services in professional settings, and as a result
established codes and separate payment in the Physician Fee Schedule
(PFS) to separately recognize and pay for these important services. As
part of this initiative, the CY 2016 PFS proposed rule (80 FR 41708)
solicited public comments on (1) improving payment for the professional
work of care management services; (2) establishing separate payment for
collaborative care, particularly inter-professional consultation
between primary care physicians, psychiatrists, and other
practitioners; and (3) assessing whether current PFS payment for
Chronic Care Management (CCM) services is adequate and whether the
administrative burden associated with furnishing and billing these
services should be reduced.
As a result of the comments we received in response to our request,
we established in the PFS separate payment for complex CCM services,
and temporary codes to make separate payment for general behavioral
health integration (BHI) services and a psychiatric collaborative care
model (CoCM). We established four G codes to describe BHI and
psychiatric CoCM services and stated that we would consider whether to
adopt and establish values for any associated new CPT codes being
developed under our standard process once those codes are active. The
separate payment for complex CCM services, general BHI, and psychiatric
CoCM services were finalized in the CY 2017 PFS final rule (81 FR
80225) beginning January 1, 2017, for practitioners billing under the
PFS. Based on these payments and codes, we are proposing revisions to
the CCM payment for RHCs and FQHCs, and proposing requirements and
payment for general BHI and psychiatric CoCM services furnished in RHCs
and FQHCs, beginning on January 1, 2018.
[[Page 34081]]
2. Background
a. RHC and FQHC Payment Methodologies
RHC and FQHC visits are face-to-face encounters between a patient
and one or more RHC or FQHC practitioners during which time one or more
RHC or FQHC qualifying services are furnished. RHC and FQHC
practitioners are physicians, nurse practitioners (NPs), physician
assistants (PA), certified nurse midwives (CNMs), clinical
psychologists, and clinical social workers, and under certain
conditions, a registered nurse or licensed practical nurse furnishing
care to a homebound RHC or FQHC patient. A Transitional Care Management
(TCM) service can also be an RHC or FQHC visit, and a Diabetes Self-
Management Training (DSMT) service or a Medical Nutrition Therapy (MNT)
service furnished by a certified DSMT or MNT provider may also be an
FQHC visit. Only medically-necessary medical, mental health, or
qualified preventive health services that require the skill level of an
RHC or FQHC practitioner are RHC or FQHC billable visits. Services
furnished by auxiliary personnel (for example, nurses, medical
assistants, or other clinical personnel acting under the supervision of
the RHC or FQHC practitioner) are considered incident to the visit and
are included in the per-visit payment.
RHCs are paid an all-inclusive rate (AIR) for medically necessary
medical and mental health services and qualified preventive health
services furnished on the same day (with some exceptions). In general,
the A/B Medicare Administrative Contractor (MAC) calculates the AIR for
each RHC by dividing total allowable costs by the total number of
visits for all patients. Productivity, payment limits, and other
factors are also considered in the calculation. Allowable costs must be
reasonable and necessary and may include practitioner compensation,
overhead, equipment, space, supplies, personnel, and other costs
incident to the delivery of RHC services. The AIR is subject to a
payment limit, except for certain provider-based RHCs that have an
exception to the payment limit.
FQHCs were paid under the same AIR methodology until October 1,
2014, when, in accordance with section 1834(o) of the Act (as added by
section 10501(i)(3) of the Affordable Care Act), they began to
transition to an FQHC PPS system in which they are paid based on the
lesser of the FQHC PPS rate or their actual charges. The FQHC PPS rate
is adjusted for geographic differences in the cost of services by the
FQHC PPS geographic adjustment factor (GAF). The rate is increased by
34 percent when an FQHC furnishes care to a patient that is new to the
FQHC, or to a beneficiary receiving an Initial Preventive Physical
Examination (IPPE) or has an Annual Wellness Visit (AWV).
Both the RHC AIR and FQHC PPS payment rates were designed to
reflect the cost of all services and supplies that an RHC or FQHC
furnishes to a patient in a single day. The rates are not adjusted for
the complexity of the patient health care needs, the length of the
visit, or the number or type of practitioners involved in the patient's
care.
b. Current CCM Requirements and Payment for RHCs and FQHCs
In the CY 2016 PFS final rule with comment period (80 FR 71080), we
finalized policies for payment of CCM services in RHCs and FQHCs.
Payment for CCM services in RHCs and FQHCs was effective beginning on
January 1, 2016, for RHCs and FQHCs that furnish a minimum of 20
minutes of qualifying CCM services during a calendar month to patients
with multiple (two or more) chronic conditions that are expected to
last at least 12 months or until the death of the patient, and that
would place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline. The requirement
that RHC or FQHC services be furnished face-to-face was waived for CCM
services.
In the CY 2017 PFS final rule (81 FR 80256), we finalized revisions
to the CCM requirements for RHCs and FQHCs. Specifically, we revised
Sec. 405.2413(a)(5) and Sec. 405.2415(a)(5) to state that services
and supplies furnished incident to CCM and TCM services can be
furnished under general supervision of an RHC or FQHC practitioner,
consistent with Sec. 410.26(b)(5), which allows CCM and TCM services
and supplies to be furnished by clinical staff under general
supervision when billed under the PFS. We also revised requirements
pertaining to the provision of CCM services, consistent with the same
revisions for practitioners billing under the PFS to reduce the burden
of furnishing these services and promote beneficiary access to these
services. These revisions were effective beginning on January 1, 2017,
and included:
Revising the requirement that CCM be initiated during a
comprehensive evaluation and management (E/M), AWV, or IPPE visit, to
require a separately billable initiating visit only for new patients or
patients that have not had an E/M, AWV, or IPPE visit within the
previous year;
Revising the requirement that CCM services be available
24/7 with an RHC or FQHC practitioner who has access to the patient's
electronic care plan, to allow 24/7 access to auxiliary personnel with
a means to make contact with an RHC or FQHC practitioner;
Removing the restriction on faxing information, and no
longer requiring that care plan information be available on a 24/7
basis;
Removing the requirement that clinical summaries must be
formatted according to certified EHR technology, and instead requiring
that the RHC or FQHC create, exchange, and transmit continuity of care
document(s) in a timely manner with other practitioners and providers;
Removing the description of the format of the care plan
that is given to the patient or caregiver; and
Revising the requirement that RHCs and FQHCs obtain a
written agreement that the elements of CCM were discussed, to allowing
this information to be documented in the medical record.
In the CY 2017 PFS final rule, we stated that although CCM is
typically associated with primary care conditions, patient eligibility
is determined by the RHC or FQHC practitioner, and mental health
conditions are not excluded. We invited comments on whether an
additional code specifically for mental health conditions is necessary
for RHCs and FQHCs that want to include beneficiaries with mental
health conditions in their CCM services. We received a few comments
regarding mental health services in RHCs and FQHCs and appreciate the
information that was provided.
The CCM payment rate for RHCs and FQHCs is set annually based on
the PFS national non-facility payment rate, and is paid when CPT code
99490 is billed alone or with other payable services on an RHC or FQHC
claim. The 2017 rate for RHCs and FQHCs is $42.71 for 20 minutes or
more of CCM services. This is the only RHC and FQHC service that is
paid in this manner, and RHCs and FQHCs are not currently authorized to
be paid for any other CCM or other care management codes. Also, RHCs
and FQHCs cannot bill for CCM services for a beneficiary during the
same service period as billing for TCM or any other program that
provides additional payment for care management services (outside of
the RHC AIR or FQHC PPS payment) for the same beneficiary.
Additional information on CCM requirements is available on the CMS
Care Management Web page at https://www.cms.gov/Medicare/Medicare-Fee-
[[Page 34082]]
for-Service-Payment/PhysicianFeeSched/Care-Management.html and on the
CMS RHC and FQHC Web pages at https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html and https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html.
c. Payment for Care Management Codes under the PFS
CCM Services (CPT Code 99487 and CPT Code 99489)
As we stated in the CY 2017 PFS final rule (81 FR 80244), the
initial claims data for CCM services billed under the PFS showed that
although utilization was increasing steadily, use of CPT code 99490 was
still relatively low, and interviews with practitioners indicated that
many believed that they were exceeding the 20-minute time threshold for
billing this code. To pay as accurately as possible and to encourage
access to CCM services, the CY 2017 PFS final rule established separate
payment for two additional CCM codes, CPT code 99487 and CPT code
99489, effective beginning on January 1, 2017, for practitioners
billing under the PFS. These codes are for complex CCM services that
reflect additional clinical staff time, more extensive care planning,
and higher complexity of the patient.
CPT code 99487 is for complex CCM services. It requires multiple
(two or more) chronic conditions expected to last at least 12 months,
or until the death of the patient; chronic conditions that place the
patient at significant risk of death, acute exacerbation/
decompensation, or functional decline; establishment or substantial
revision of a comprehensive care plan; moderate or high complexity
medical decision making; and 60 minutes of clinical staff time directed
by a physician or other qualified health care professional, per
calendar month.
CPT code 99489 is for each additional 30 minutes of clinical staff
time directed by a physician or other qualified health care
professional, per calendar month.
Practitioners paid under the PFS can bill either complex (CPT code
99487 and CPT code 99489) or non-complex (CPT code 99490) CCM services
during a given service period, and can submit only one professional
claim for CCM services for that service period.
General BHI Services (HCPCS Code G0507)
The types of chronic conditions that are eligible for CCM services
are not specified and could include chronic mental health or behavioral
health conditions or chronic cognitive disorders as long as the CCM
requirements are met. However, because not all behavioral health issues
fit into the CCM model, and Medicare beneficiaries with behavioral
health conditions often require extensive care management discussions,
information-sharing, and planning between a primary care practitioner
and a behavioral health specialist, the CY 2017 PFS final rule
established HCPCS code G0507 for 20 minutes or more of general BHI
services. Payment for this code was effective beginning on January 1,
2017, for practitioners billing under the PFS.
BHI is a team-based, collaborative approach to care that focuses on
integrative treatment of patients with primary care and mental or
behavioral health conditions. As finalized in the CY 2017 PFS final
rule, requirements for this code include an initial assessment or
follow-up monitoring (including the use of applicable validated rating
scales); behavioral health care planning in relation to behavioral/
psychiatric health problems (including revision for patients who are
not progressing or whose status changes); facilitating and coordinating
treatment such as psychotherapy, pharmacotherapy, counseling and/or
psychiatric consultation; and continuity of care with a designated
member of the care team.
Psychiatric CoCM Services (HCPCS codes G0502, G0503, and G0504)
Psychiatric CoCM is a specific model of care provided by a primary
care team consisting of a primary care provider and a health care
manager who works in collaboration with a psychiatric consultant. As
finalized in the CY 2017 PFS final rule, we provide Medicare payment
for psychiatric CoCM services to practitioners billing under the PFS
when these services are directed by a treating physician or other
qualified health care professional. We also finalized that the treating
physician or other qualified health care professional directs the
behavioral health care manager, who must be an individual with formal
education or specialized training in behavioral health, including
social work, nursing, or psychology, working under the oversight and
direction of the physician or qualified health care professional. We
finalized that a psychiatric consultant must be a medical professional
trained in psychiatry and qualified to prescribe the full range of
medications. Finally, psychiatric CoCM services may be furnished to
beneficiaries with any psychiatric or behavioral health condition(s)
and may include substance use disorders. The three psychiatric CoCM
codes established in the CY 2017 PFS final rule were G0502, G0503, and
G0504.
HCPCS code G0502 is for 70 minutes or more of initial psychiatric
CoCM services in the first calendar month of behavioral health care
manager activities, in consultation with a psychiatric consultant, and
directed by the treating physician or other qualified health care
professional. Required elements include: outreach to and treatment of a
patient as directed by the treating physician or other qualified health
care professional; initial assessment of the patient, including
administration of validated rating scales, with the development of an
individualized treatment plan; review by the psychiatric consultant
with modifications of the plan, if recommended; entering of the patient
into a registry and tracking patient follow-up and progress using the
registry (with appropriate documentation), participation in weekly
caseload consultation with the psychiatric consultant; and provision of
brief interventions using evidence-based techniques such as behavioral
activation, motivational interviewing, and other focused treatment
strategies.
HCPCS code G0503 is for 60 minutes of subsequent psychiatric CoCM
services in a subsequent month and includes: tracking patient follow-up
and progress using the registry (with appropriate documentation);
participation in weekly caseload consultation with the psychiatric
consultant; ongoing collaboration with and coordination of the
patient's mental health care with the treating physician or other
qualified health care professional and any other treating mental health
providers; additional review of progress and recommendations for
changes in treatment, as indicated, including medications, based on
recommendations provided by the psychiatric consultant; provision of
brief interventions using evidence-based techniques (such as behavioral
activation, motivational interviewing, and other focused treatment
strategies); monitoring of patient outcomes using validated rating
scales; and relapse prevention planning with patients as they achieve
remission of symptoms and/or other treatment goals and are prepared for
discharge from active treatment.
HCPCS code G0504 is for each additional 30 minutes of initial or
subsequent psychiatric CoCM services in a calendar month.
[[Page 34083]]
3. Proposed Care Management Requirements and Payment for RHCs and FQHCs
To ensure that RHC and FQHC patients have access to new care
management services in a manner consistent with the RHC and FQHC per
diem payment methodologies, we are proposing the establishment of two
new G codes for use by RHCs and FQHCs. The first new G code, GCCC1,
would be a General Care Management code for RHCs and FQHCs, with the
payment amount set at the average of the national non-facility PFS
payment rates for CCM codes 99490 and 99487 and general BHI code G0507.
The second new G code for RHCs and FQHCs, GCCC2, would be a Psychiatric
CoCM code,with the payment amount set at the average of the national
non-facility PFS payment rates for psychiatric CoCM codes G0502 and
G0503. The following is a detailed discussion of our proposal, as well
as alternatives that we considered.
a. Proposed Establishment of a General Care Management Code for RHCs
and FQHCs
The RHC AIR and the FQHC PPS rate, which include all costs
associated with an RHC or FQHC visit, are based on the RHC's and FQHC's
costs. Although many RHCs and FQHCs have always provided some
coordination of care within and outside their facilities, the type of
structured care management services that are now billable under the PFS
are generally not included in the RHC AIR or the FQHC PPS rate. Because
CCM services are not required to be face-to-face encounters, and do not
require the skill level of an RHC or FQHC practitioner, they do not
meet the requirements for an RHC or FQHC billable visit. In addition,
RHC and FQHC services cannot be separately billed to the PFS.
Therefore, in the CY 2016 PFS final rule with comment period, we
established payment for CCM services at the PFS national non-facility
rate when CPT code 99490 is billed alone or with other payable services
on an RHC or FQHC claim to pay for the costs of CCM services that are
not already captured in the RHC AIR or the FQHC PPS payment.
When CCM services were first established for RHCs and FQHCs, CPT
code 99490 was the only CCM code that was billable under the PFS. Now
that there are additional codes for more complex CCM services and for
general BHI and psychiatric CoCM services, we believe it is necessary
to revise our payment approach for payment of care management services.
RHCs and FQHCs are paid per-visit rates that are not adjusted based
on the complexity of a service or the time spent furnishing services,
and the payment rate is not designed to be equal to the payment under
the PFS for a specific service. We sought to develop a methodology for
payment of care management services that is consistent with the RHC and
FQHC payment principles of bundling services and not paying for
services based on time increments. We also sought to develop a
methodology that would support the provision of care management
services without creating additional reporting burdens, while promoting
beneficiary access to comprehensive CCM and BHI services furnished by
RHCs and FQHCs.
Therefore, effective for services furnished on or after January 1,
2018, we are proposing to create General Care Management code GCCC1 for
RHCs and FQHCs, with the payment amount set at the average of the 3
national non-facility PFS payment rates for the CCM and general BHI
codes and updated annually based on the PFS amounts. The 3 codes are:
CPT 99490--20 minutes or more of CCM services
CPT 99487--at least 60 minutes of complex CCM services
HCPCS G0507--20 minutes or more of BHI services
RHCs and FQHCs could bill the new General Care Management code when
the requirements for any of these 3 codes (CPT codes 99490, 99487, or
HCPCS code G0507) are met. The General Care Management code would be
billed alone or in addition to other services furnished during the RHC
or FQHC visit. This code could only be billed once per month per
beneficiary, and could not be billed if other care management services
(such as TCM or home health care supervision) are billed for the same
time period. We note that CPT 99489 is an add-on code when CPT 99487 is
furnished, and is therefore not included as RHCs and FQHCs are not paid
for additional time once the minimum requirements have been met.
As previously noted, the program requirements for RHCs and FQHCs
furnishing CCM services were established in the CY 2016 PFS final rule
with comment period (80 FR 71080) and revised in the CY 2017 PFS final
rule (81 FR 80256). We are not proposing any changes to these
requirements at this time.
BHI refers to care management services that integrate behavioral
health services with primary care and other clinical services. To bill
for this service using the proposed General Care Management Code for
RHCs and FQHCs, 20 minutes or more of clinical staff time, directed by
an RHC or FQHC practitioner, must be furnished per calendar month. We
are proposing the following requirements for RHCs and FQHCs furnishing
BHI services:
Initiating Visit: An E/M, AWV, or IPPE visit with an RHC
or FQHC primary care practitioner (physician, NP, PA, or CNM) occurring
no more than one-year prior to commencing BHI services. This could be
the same initiating visit that is used for initiating CCM services, and
would be billed separately as an RHC or FQHC visit (if the RHC or FQHC
has not already billed for this visit).
Beneficiary Consent: Documentation in the medical record
that the beneficiary has consented to receive BHI services, given
permission to consult with relevant specialists as needed, and been
informed that there may be beneficiary cost-sharing, including
deductible and coinsurance amounts as applicable, for both in-person
and non-face-to-face services that are provided. The beneficiary
consent process would also include informing the patient that only one
practitioner/facility can furnish and be paid for these services during
a calendar month, and that the patient can stop care coordination
services at any time (effective at the end of the calendar month). This
could be obtained at the same time that beneficiary consent is obtained
for CCM services.
Billing Requirements: At least 20 minutes of care
management services per calendar month, furnished under the direction
of the RHC or FQHC primary care physician, NP, PA, or CNM, and
furnished by an RHC or FQHC practitioner, or by clinical personnel
under general supervision. These are the same billing requirements as
for CCM services. If both CCM and BHI services are furnished in the
same month, the time would be combined and billed as one under the new
care coordination code.
Patient Eligibility: One or more new or pre-existing
behavioral health or psychiatric conditions being treated by the RHC or
FQHC primary care practitioner, including substance use disorders,
that, in the clinical judgment of the RHC or FQHC primary care
practitioner, warrants BHI services.
Required Service Elements: An initial assessment or
follow-up monitoring, including the use of applicable validated rating
scales; behavioral health care planning in relation to behavioral/
psychiatric health problems, including revision for patients who are
not progressing or whose status changes; facilitating and
[[Page 34084]]
coordinating treatment such as psychotherapy, pharmacotherapy,
counseling and/or psychiatric consultation; and continuity of care with
a designated member of the care team.
Both CCM and general BHI services are intended to provide a
structured and coordinated approach to care management that is not
typically included in the RHC's AIR or the FQHC PPS payment
methodology. Care management services are directed by the RHC or FQHC
primary care practitioner, who remains involved through ongoing
oversight, management, collaboration and reassessment, while care
management services are typically furnished in a non-face-to-face
setting primarily by a non-RHC or FQHC practitioner working under
general supervision requirements. Time spent by administrative or
clerical staff cannot be counted towards the time required to bill
these services.
Table 16 compares the requirements for CCM and general BHI
services. We believe that even though there are some differences in the
requirements of CCM and general BHI, bundling them together will help
to promote integrated care management services for Medicare
beneficiaries who have either or both primary care and behavioral
health needs. It will also result in the least amount of reporting
burden for RHCs and FQHCs because once the 20-minute threshold is met
for either CCM or general BHI, reporting and tracking of additional
time increments is not required.
If this policy had been adopted for CY 2017, the payment amount for
General Care Management for RHCs and FQHCs would have been
approximately $61 (CPT 99490 at $42.71, + CPT 99487 at $93.67, + G0507
at $47.73 = $184.11/3 = $61.37). This is more than is the CY 2017 PFS
national non-facility rates for CPT code 99490 and HCPCS code G0507,
and less than the PFS national non-facility rate for CPT code 99487. We
believe that this bundling methodology is consistent with the RHC and
FQHC payment methodology of averaging costs to determine a payment rate
rather than paying for each individual service.
Table 16--Comparison of Proposed CCM and General BHI Requirements For
RHCs and FQHCs
------------------------------------------------------------------------
General BHI
Requirements CCM (CPT codes 99490 (proposed) (HCPCS
and 99487) code G0507)
------------------------------------------------------------------------
Initiating Visit............ An E/M, AWV, or IPPE Same.
visit occurring no
more than one-year
prior to commencing
care coordination
services.
Furnished by a Same.
primary care
physician, NP, PA,
or CNM.
Billed as an RHC/ Same.
FQHC visit.
Beneficiary Consent......... Obtained during or Same.
after initiating
visit and before
provision of care
coordination
services by RHC or
FQHC practitioner
or clinical staff.
Written or verbal, Same.
documented in the
medical record.
Includes Same.
information:.
On the
availability of
care coordination
services and
applicable cost-
sharing;.
That only
one practitioner
can furnish and be
paid for care
coordination
services during a
calendar month;.
That the
patient has right
to stop care
coordination
services at any
time (effective at
the end of the
calendar month);
and.
That the
patient has given
permission to
consult with
relevant
specialists..
Billing Requirements........ At least 20 minutes Same.
of care
coordination
services per
calendar month that
is:
Furnished
under the direction
of the RHC or FQHC
primary care
physician, NP, PA,
or CNM; and.
Furnished
by an RHC or FQHC
practitioner, or by
clinical personnel
under general
supervision.
Patient Eligibility......... Multiple (two or Any behavioral
more) chronic health or
conditions expected psychiatric
to last at least 12 condition being
months, or until treated by the RHC
the death of the or FQHC primary
patient, and place care practitioner,
the patient at including substance
significant risk of use disorders,
death, acute that, in the
exacerbation/ clinical judgment
decompensation, or of the RHC or FQHC
functional decline. practitioner,
warrants BHI
services.
[[Page 34085]]
Requirement Service Elements Includes: Includes:
Structured Initial
recording of assessment or
patient health follow-up
information using monitoring,
Certified EHR including the use
Technology and of applicable
includes validated rating
demographics, scales;
problems, Behavioral
medications, and health care
medication planning in
allergies that relation to
inform the care behavioral/
plan, care psychiatric health
coordination, and problems, including
ongoing clinical revision for
care;. patients who are
24/7 access not progressing or
to physicians or whose status
other qualified changes;
health care
professionals or Facilitating and
clinical staff coordinating
including providing treatment (such as
patients/caregivers psychotherapy,
with a means to pharmacotherapy,
make contact with counseling and/or
health care psychiatric
professionals in consultation); and
the practice to Continuity
address urgent of care with a
needs regardless of designated member
the time of day or of the care team.
day of week, and
continuity of care
with a designated
member of the care
team with whom the
patient is able to
schedule successive
routine
appointments;.
Comprehensive care
management
including
systematic
assessment of the
patient's medical,
functional, and
psychosocial needs;
system-based
approaches to
ensure timely
receipt of all
recommended
preventive care
services;
medication
reconciliation with
review of adherence
and potential
interactions; and
oversight of
patient self-
management of
medications;.
Comprehensive care
plan including the
creation, revision,
and/or monitoring
of an electronic
care plan based on
a physical, mental,
cognitive,
psychosocial,
functional, and
environmental
(re)assessment and
an inventory of
resources and
supports; a
comprehensive care
plan for all health
issues with
particular focus on
the chronic
conditions being
managed;.
Care plan
information made
available
electronically
(including fax) in
a timely manner
within and outside
the RHC or FQHC as
appropriate and a
copy of the plan of
care given to the
patient and/or
caregiver;.
Management
of care transitions
between and among
health care
providers and
settings, including
referrals to other
clinicians; follow-
up after an
emergency
department visit;
and follow-up after
discharges from
hospitals, skilled
nursing facilities,
or other health
care facilities;
timely creation and
exchange/transmit
continuity of care
document(s) with
other practitioners
and providers;.
Coordination with
home- and community-
based clinical
service providers,
and documentation
of communication to
and from home- and
community-based
providers regarding
the patient's
psychosocial needs
and functional
deficits in the
patient's medical
record; and.
Enhanced
opportunities for
the patient and any
caregiver to
communicate with
the practitioner
regarding the
patient's care
through not only
telephone access,
but also through
the use of secure
messaging,
Internet, or other
asynchronous non-
face-to-face
consultation
methods..
CY 2017 PFS Non-Facility CPT 99490--$42.71... G0507--$47.73.
Payment. CPT 99487--$93.67...
RHC/FQHC Payment for new Current: $42.71..... Current: N/A
General Care Management G Proposed: Average of Proposed: Average of
code. CPT codes 99490, CPT codes 99490,
99487 and G0507 (If 99487 and G0507 (If
using the 2017 using the 2017
payment amounts, payment amounts,
this would be this would be
$61.37). $61.37).
------------------------------------------------------------------------
We expect that utilization of care coordination services will
continue to increase as more health care practices, including RHCs and
FQHCs, implement these services. Because the separate payments for the
complex CCM codes have only been implemented this year for
practitioners billing under the PFS, we do not have adequate data to
determine the frequency of billing for CCM codes CPT codes 99487 by
practitioners billing under the PFS compared with CPT code 99490.
Although billing practices may vary between physician offices and RHCs
and FQHCs (and within and between RHCs and FQHCs), we believe that
utilization patterns under the PFS can provide a reasonable proxy for
utilization practices in RHCs and FQHCs of care coordination
utilization. If the PFS data starts to show definitive trends in
billing certain CCM and BHI codes, or if data becomes available that
provides information on the extent of these services in RHCs and FQHCs,
we may consider using a weighted average
[[Page 34086]]
in determining the payment rate in the future. Similarly, if the
proposal to create a new care management code for RHCs and FQHCs is
finalized, and any additional care management codes become available on
the PFS, we would review the new codes to determine if they should also
be factored into the RHC and FQHC General Care Management Code. Any
changes would be undertaken through future rulemaking.
b. Proposed Establishment of a Psychiatric CoCM Code for RHCs and FQHCs
Psychiatric CoCM is a defined model of care that integrates primary
health care services with care management support for patients
receiving behavioral health treatment, and includes regular psychiatric
inter-specialty consultation with the primary care team, particularly
regarding patients whose conditions are not improving. We recognize
that the requirements of this model may be challenging for some RHCs
and FQHCs, especially those who have difficulty maintaining adequate
primary care and mental health staffing in rural and or underserved
areas. For those RHCs and FQHCs that choose to offer these services, we
believe this model may be particularly helpful, especially for patients
with primary care and mental health conditions who have not benefited
from standard treatment.
Effective for services furnished on or after January 1, 2018, we
are proposing to create a psychiatric CoCM code for RHCs and FQHCs,
GCCC2, with the payment amount set at the average of the 2 national
non-facility PFS payment rates for CoCM codes, to be updated annually
based on the PFS amounts. The 2 codes are:
G0502--70 minutes or more of initial psychiatric CoCM
services
G0503--60 minutes or more of subsequent psychiatric CoCM
services
RHCs and FQHCs could bill the new psychiatric CoCM code when the
requirements for any of these 2 codes (G0502 or G0503) are met. The
psychiatric CoCM code would be billed alone or in addition to other
services furnished during the RHC or FQHC visit. To prevent duplication
of payment, this code could only be billed once per month per
beneficiary, and could not be billed if other care management services,
including the proposed General Care Management code, are billed for the
same time period. We note that G0504 is an add-on code when G0503 is
furnished and is therefore not included as RHCs and FQHCs are not paid
for additional time once the minimum requirements have been met.
If this policy had been adopted for CY 2017, the payment amount for
psychiatric CoCM for RHCs and FQHCs would have been approximately
$134.58 (G0502 at $142.84 + G0503 at $126.33 = $269.17/2 = $134.58).
All care management services, including psychiatric CoCM, require a
separately billable initiating visit (E/M, AWV, or IPPE) for new
patients or beneficiaries not seen within 1 year prior to commencement
of care management services. Prior to commencement of psychiatric CoCM
services, the beneficiary must provide consent for this service,
including permission to consult with a psychiatric consultant and
relevant specialists. Advance consent must also include information on
cost sharing for both face-to-face and non-face-to-face services, and
acceptance of these requirements must be documented in the medical
record.
Patients with mental health, behavioral health, or psychiatric
conditions, including substance use disorders, who are being treated by
an RHC or FQHC practitioner, may be eligible for psychiatric CoCM
services, as determined by the RHC or FQHC practitioner. Psychiatric
CoCM services, like CCM and general BHI services, are intended to
provide a structured and coordinated approach to care management that
is not typically included in the RHC's AIR or the FQHC PPS payment
methodology.
The psychiatric CoCM team must include the RHC or FQHC
practitioner, a behavioral health manager, and a psychiatric
consultant. Proposed specific requirements of the psychiatric CoCM team
are as follows:
Psychiatric CoCM Team--RHC or FQHC Practitioner
For psychiatric CoCM, the RHC or FQHC practitioner may be a primary
care physician, NP, PA, or CNM. The psychiatric CoCM requirements of
the RHC or FQHC practitioner are to:
Direct the behavioral health care manager and any other
clinical staff;
Oversee the beneficiary's care, including prescribing
medications, providing treatments for medical conditions, and making
referrals to specialty care when needed; and
Remain involved through ongoing oversight, management,
collaboration and reassessment.
Psychiatric CoCM Team--Behavioral Health Care Manager
For psychiatric CoCM, the behavioral health care manager is a
designated individual with formal education or specialized training in
behavioral health such as social work, nursing, or psychology. A
behavioral health care manager in an RHC or FQHC would be expected to
have a minimum of a bachelor's degree in a behavioral health field
(such as in clinical social work or psychology), or be a clinician with
behavioral health training, including RNs and LPNs. The behavioral
health care manager furnishes both face-to-face and non-face-to-face
services under the general supervision of the RHC or FQHC practitioner
and may be employed by or working under contract to the RHC or FQHC.
The psychiatric CoCM requirements of the behavioral health care manager
are:
Providing assessment and care management services,
including the administration of validated rating scales; behavioral
health care planning in relation to behavioral/psychiatric health
problems, including revision for patients who are not progressing or
whose status changes; provision of brief psychosocial interventions;
ongoing collaboration with the RHC or FQHC practitioner; maintenance of
the registry; acting in consultation with the psychiatric consultant;
Being available to provide services face-to-face with the
beneficiary; having a continuous relationship with the patient and a
collaborative, integrated relationship with the rest of the care team;
and
Being available to contact the patient outside of regular
RHC or FQHC hours as necessary to conduct the behavioral health care
manager's duties.
Psychiatric CoCM Team--Psychiatric Consultant
For CoCM, a psychiatric consultant is a medical professional
trained in psychiatry and qualified to prescribe the full range of
medications. The psychiatric consultant is not required to be on site
or to have direct contact with the patient and does not prescribe
medications or furnish treatment to the beneficiary directly. The CoCM
requirements of the psychiatric consultant are:
Participating in regular reviews of the clinical status of
patients receiving psychiatric CoCM services;
Advising the RHC or FQHC practitioner regarding diagnosis
and options for resolving issues with beneficiary adherence and
tolerance of behavioral health treatment; making adjustments to
behavioral health treatment for beneficiaries who are not progressing;
managing any negative interactions between beneficiaries'
[[Page 34087]]
behavioral health and medical treatments; and
Facilitating referral for direct provision of psychiatric
care when clinically indicated.
RHCs and FQHCs could bill the new psychiatric CoCM code, GCCC2,
when the requirements for HCPCS code G0502 or G0503 are met. This code
could only be billed once per month per beneficiary, and could not be
billed if other care management services, including the General Care
Management code GCCC1, are billed for the same time period.
As with the proposed General Care Management code GCCC1, we would
monitor PFS data to determine if a weighted average would be more
appropriate in determining the psychiatric CoCM payment rate for RHCs
and FQHCs, and whether any additional codes that may be added to the
PFS in the future should also be factored into the RHC and FQHC
psychiatric CoCM code. Any changes would be done through future
rulemaking.
Table 17 compares the requirements for general BHI, which would be
billed using the proposed General Care Management code GCCC1, and
psychiatric CoCM services, which would be billed using the proposed
psychiatric CoCM code, GCCC2.
Table 17--Comparison of Proposed General BHI and Psychiatric CoCM
Requirements for RHCs and FQHCs
------------------------------------------------------------------------
Psychiatric CoCM
General BHI (proposed) (HCPCS
Requirements (proposed) (HCPCS code G0502 and
code G0507) G0503)
------------------------------------------------------------------------
Initiating Visit............ An E/M, AWV, or IPPE Same.
visit occurring no
more than one-year
prior to commencing
care coordination
services.
Furnished by a Same.
primary care
physician, NP, PA,
or CNM.
Billed as an RHC or Same.
FQHC visit.
Beneficiary Consent......... Obtained during or Same.
after initiating
visit and before
provision of care
coordination
services by RHC or
FQHC practitioner
or clinical staff.
Written or verbal, Same.
documented in the
medical record.
Includes Same.
information:
On the
availability of
care coordination
services and
applicable cost-
sharing;
That only
one entity can
furnish and be paid
for care
coordination
services during a
calendar month;
That the
patient has the
right to stop care
coordination
services at any
time (effective at
the end of the
calendar month);
and
That the
patient has given
permission to
consult with
relevant
specialists.
Billing Requirements........ At least 20 minutes At least 70 minutes
of care management in the first
services per calendar month, and
calendar month that at least 60 minutes
is: in subsequent
Furnished calendar months of
under the direction psychiatric CoCM
of the RHC or FQHC services that is:
primary care Furnished
physician, NP, PA, under the direction
or CNM; and. of the RHC or FQHC
Furnished primary care
by an RHC or FQHC practitioner; and
practitioner, or by Furnished
clinical personnel by an RHC or FQHC
under general practitioner or
supervision.. behavioral health
care manager under
general
supervision.
Patient Eligibility......... Any mental, Same.
behavioral health,
or psychiatric
condition being
treated by the RHC
or FQHC primary
care practitioner,
including substance
use disorders,
that, in the
clinical judgment
of the RHC or FQHC
practitioner,
warrants BHI
services.
Requirement Elements........ Includes: Includes:
Initial RHC or FQHC primary
assessment or care practitioner:
follow-up Direct the
monitoring, behavioral health
including the use care manager or
of applicable clinical staff;
validated rating Oversee the
scales. beneficiary's care,
Behavioral including
health care prescribing
planning in medications,
relation to providing
behavioral/ treatments for
psychiatric health medical conditions,
problems, including and making
revision for referrals to
patients who are specialty care when
not progressing or needed; and
whose status Remain
changes. involved through
ongoing oversight,
Facilitating and management,
coordinating collaboration and
treatment (such as reassessment
psychotherapy, Behavioral Health
pharmacotherapy, Care Manager:
counseling and/or
psychiatric
consultation)
Continuity of care
with a designated
member of the care
team.
Provide
assessment and care
management
services, including
the administration
of validated rating
scales; behavioral
health care
planning in
relation to
behavioral/
psychiatric health
problems, including
revision for
patients who are
not progressing or
whose status
changes; provision
of brief
psychosocial
interventions;
ongoing
collaboration with
the RHC or FQHC
practitioner;
maintenance of the
registry; acting in
consultation with
the psychiatric
consultant;
[[Page 34088]]
Be
available to
provide services
face-to-face with
the beneficiary;
having a continuous
relationship with
the patient and a
collaborative,
integrated
relationship with
the rest of the
care team; and
Be
available to
contact the patient
outside of regular
RHC or FQHC hours
as necessary to
conduct the
behavioral health
care manager's
duties.
Psychiatric
Consultant:
Participate
in regular reviews
of the clinical
status of patients
receiving CoCM
services;
Advise the
RHC or FQHC
practitioner
regarding
diagnosis, options
for resolving
issues with
beneficiary
adherence and
tolerance of
behavioral health
treatment; making
adjustments to
behavioral health
treatment for
beneficiaries who
are not
progressing;
managing any
negative
interactions
between
beneficiaries'
behavioral health
and medical
treatments; and
Facilitate
referral for direct
provision of
psychiatric care
when clinically
indicated.
Cy 2017 PFS Non-Facility G0507--$47.73....... G0502--$142.84.
Payment. G0503--$126.33.
RHC/FQHC Payment for New Current: N/A........ Current: N/A
Psychiatric CoCM G Code. Proposed: Average of Proposed: Average of
CPT codes 99490, HCPCS codes G0502
99487, and G0507. and G0503. (If
(If using the 2017 using the 2017
payment amounts, payment amounts,
this would be this would be
$61.37). $134.58).
------------------------------------------------------------------------
c. Other Options Considered
We considered allowing RHCs and FQHCs to bill for the complex CCM
codes, the BHI code, and the psychiatric CoCM codes by allowing the
individual CPT or HCPCS codes to be added to an RHC or FQHC claim, in
the same manner as we currently allow CPT code 99490 to be added to a
claim. We do not believe this approach is in the best interest of RHCs
and FQHCs. There are now 5 separate care management codes that are
applicable to RHCs and FQHCs, and more codes could be added in the
future as we learn more about the benefits of non-face-to-face care
management services. Each of these codes has specific time increments
that must be tracked and reported for payment under the PFS. We believe
that bundling the CCM and BHI codes and the psychiatric CoCM codes into
2 G codes is more consistent with the RHC and FQHC payment methodology
of averaging actual costs to determine a payment rate and not paying
for services based on time increments. It also requires less record
keeping, monitoring, and coding expertise, while maintaining the same
quality of care standards.
We also considered bundling all 5 codes together into one G code,
or developing 3 G codes--one for the CCM codes, one for the BHI code,
and one for the psychiatric CoCM codes. We did not choose either of
these approaches because CCM and BHI are similar services that
complement each other, and bundling them together is consistent with an
integrated approach to care with reduced reporting requirements. We
also believe that psychiatric CoCM is different enough from both CCM
and BHI in its requirements, particularly in staffing and required
services, that it warrants a separate G code. We believe that our
proposal of creating 2 new G codes to encompass the 5 care management
codes is the best option for RHCs and FQHCs now and in the future if
new care management codes are developed. We welcome comments on the
proposal.
4. Implementation
RHCs and FQHCs are familiar with billing G codes. If this proposal
is finalized as proposed, RHCs and FQHCs would continue to receive
payment for CCM when CPT code 99490 is billed alone or with other
payable services on an RHC or FQHC claim until December 31, 2017.
Beginning on January 1, 2018, we propose that RHCs and FQHCs would use
the new General Care Management G code GCCC1 when billing for CCM or
general BHI services, and the new psychiatric CoCM G code GCCC2 when
billing for psychiatric CoCM services, either alone or with other
payable services on an RHC or FQHC claim. Claims submitted using CPT
99490 on January 1, 2018, or after, will not be paid.
Both the current RHC and FQHC payment rate for CCM, and the
proposed RHC and FQHC payment rates for General Care Management and
Psychiatric CoCM codes, are based on the PFS national non-facility
rates. The PFS rates are updated annually, and the new G codes for RHCs
and FQHCs would be updated accordingly and finalized when the PFS rates
are finalized for the year. No geographic adjustment would be applied
to the General Care Management or Psychiatric CoCM G codes. RHCs and
FQHCs are required to submit claims for RHC and FQHC services on an
institutional claim (electronically per the HIPAA compliant ANSI X12
837I or the Form CMS 1450, also known as the UB-04,) and are not
authorized to bill RHC or FQHC services separately to the PFS. Specific
information on billing and claims processing for the new G codes will
be provided when the policy is finalized.
We note that in section X of this proposed rule, G0502, G0503, and
G0507 are proposed to be replaced by new CPT codes. Corresponding
changes would be made for RHCs and FQHCs when the new CPT codes become
available.
5. Regulatory Changes
As previously noted, Sec. 405.2413(a)(5) and Sec. 405.2415(a)(5)
was revised
[[Page 34089]]
effective January 1, 2017, to state that services and supplies
furnished incident to CCM and TCM services can be furnished under
general supervision of an RHC or FQHC practitioner, consistent with
Sec. 410.26(b)(5), which allows CCM and TCM services and supplies to
be furnished by clinical staff under general supervision when billed
under the PFS. We propose to further revise Sec. 405.2413(a)(5) and
Sec. 405.2415(a)(5) to state that services and supplies incident to
the services of a physician, NP, PA, or CNM are furnished under the
direct supervision of a physician, NP, PA, or CNM, except for TCM,
General Care Management, and Psychiatric CoCM services, which can be
furnished under general supervision of a physician, NP, PA, or CNM when
these services or supplies are furnished by auxiliary personnel, as
defined in Sec. 410.26(a)(1).
B. Part B Drug Payment: Infusion Drugs Furnished Through an Item of
Durable Medical Equipment (DME)
Section 303(c) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted on December
8, 2003) revised the payment methodology for most Medicare-covered Part
B drugs and biologicals by adding section 1847A to the Act, which
established a new average sales price (ASP) drug payment methodology
beginning January 1, 2005. However, section 303(b) of the MMA specified
payments for certain drugs using methodologies other than the ASP
pricing methodology. Specifically, section 303(b) of the MMA added
section 1842(o)(1)(D)(i) of the Act that required that an infusion drug
furnished through an item of DME covered under section 1861(n) of the
Act be paid 95 percent of the average wholesale price (AWP) for that
drug in effect on October 1, 2003.
Section 5004(a) of the 21st Century Cures Act (Cures Act) (Pub. L.
114-255, enacted on December 13, 2016) revised sections 1842(o)(1)(C)
and (D) of the Act, changing the payment methodology for DME infusion
drugs from being based on AWP to the methodologies in sections 1847,
1847A, 1847B, or 1881(b)(13) of the Act, as the case may be for the
drug or biological. To implement the pricing changes required by
section 5004(a) of Cures Act, which modifies the payment for DME
infusion drugs to the amount under section 1847A of the Act (ASP
payment methodology), by the statutorily mandated effective date of
January 1, 2017, we incorporated the ASP-based infusion drug payment
amounts into the January 2017 quarterly ASP drug pricing files and
instructed claims processing contractors to use the updated payment
limits for DME infusion drugs.
To conform regulations with the new payment requirements in section
5004(a) of the Cures Act as they pertain to section 1847A of the Act,
we propose revising Sec. 414.904(e)(2). Currently, this describes an
exception to ASP-based payments and requires pricing DME infusion drugs
at 95 percent of the 2003 AWP. Consistent with section 5004(a) of the
Cures Act, the proposed revision limits the exception to infusion drugs
furnished before January 1, 2017. In addition, we propose at Sec.
414.904(e)(2) to delete the phrase ``and is not updated in 2006.'' We
believe this language is not relevant since there was no update for
pricing DME infusion drugs in 2006, and the proposed revision will
serve to simplify the language. Effective January 1, 2017, payment
limits for these drugs are determined under section 1847A of the Act.
C. Solicitation of Public Comments on Initial Data Collection and
Reporting Periods for Clinical Laboratory Fee Schedule
1. Background on Medicare Clinical Diagnostic Laboratory Tests Payment
System Final Rule
In the final rule published in the June 23, 2016 Federal Register
(81 FR 41036) entitled, ``Medicare Program; Medicare Clinical
Diagnostic Laboratory Tests Payment System,'' we implemented the
requirements of section 1834A of the Act, which requires extensive
revisions to the Medicare payment, coding, and coverage for clinical
diagnostic laboratory tests (CDLTs) paid under the Clinical Laboratory
Fee Schedule (CLFS).
Under the CLFS final rule, reporting entities are required to
report to CMS certain applicable information for their component
applicable laboratories. The applicable information includes, for each
CDLT furnished during a data collection period, the specific HCPCS code
associated with the test, each private payor rate for which final
payment has been made, and the associated volume of tests performed
corresponding to each private payor rate. In general, the payment
amount for a test on the CLFS furnished on or after January 1, 2018,
will be equal to the weighted median of private payor rates determined
for the test, based on the applicable information that is collected
during a data collection period and reported to us during a data
reporting period.
In the CLFS final rule, we established a data collection period
that is the 6 months from January 1 through June 30 during which
applicable information is collected and that precedes the data
collection period. We established a data reporting period that is the
3-month period, January 1 through March 31, during which a reporting
entity reports applicable information to CMS and that follows the
preceding data collection period. The first data collection period was
January 1, 2016 through June 30, 2016. The first data reporting period
was January 1, 2017 through March 31, 2017. This 6-month data
collection period and 3-month data reporting period schedule will be
repeated every 3 years for CDLTs that are not advanced diagnostic
laboratory tests (ADLTs), and every year for ADLTS that are not new
ADLTs.
For the first data reporting period, industry feedback suggested
that many reporting entities would not be able to submit a complete set
of applicable information to us by the March 31, 2017 deadline, and
that entities required additional time to review collected data,
address any issues identified during such review, and compile the data
into our required reporting format. As a result, on March 30, 2017, we
announced that we would exercise enforcement discretion until May 30,
2017, with respect to the data reporting period for reporting
applicable information under the Medicare CLFS and the application of
the Secretary's potential assessment of civil monetary penalties for
failure to report applicable information.\1\ The enforcement discretion
applied to entities that were subject to the data reporting
requirements adopted in the CLFS final rule (81 FR 41036). We noted in
the announcement that the 60-day enforcement discretion period was the
maximum amount of time we could permit to still have sufficient time to
calculate the CLFS payment rates scheduled to go into effect on January
1, 2018.
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The announcement stated that the enforcement discretion period
would not prevent reporting entities prepared to report applicable
information from doing so before May 30, 2017. We explained in the
announcement that we were committed to the successful implementation of
the new private payor rate-based CLFS and looked forward to working
with the laboratory industry to ensure accurate payment rates. Over the
coming months, we will be analyzing the applicable information we
received, holding our Annual
[[Page 34090]]
Laboratory Public Meeting, meeting with the Advisory Panel for Clinical
Diagnostic Laboratory tests, and posting preliminary payment rates.
2. Solicitation of Public Comments on Medicare Clinical Diagnostic
Laboratory Tests Payment System Initial Data Collection and Reporting
Periods
To better understand the applicable laboratories' experiences with
the data reporting, data collection, and other compliance requirements
for the first data collection and reporting periods, we are interested
in public comments from applicable laboratories and reporting entities
on the following questions:
Was the CMS data reporting system easy to use? Please
describe your overall experience with navigating the CMS data reporting
system. For example, describe the aspects of the CMS data reporting
system that worked well for your reporting entity and/or any problems
the reporting entity experienced with submitting applicable information
to us.
Did the applicable laboratory (or its reporting entity)
request and receive assistance from our Help Desk regarding the CMS
data reporting system? Please describe your experience with receiving
assistance.
Did the applicable laboratory (or its reporting entity)
request and receive assistance from the CMS CLFS Inquiries Mailbox
regarding policy questions? Please describe your experience with
receiving assistance.
Did the applicable laboratory (or its reporting entity)
use the subregulatory guidance on data reporting provided on the CMS
CLFS Web site? \2\ If so, was the information presented useful?
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Was the information that the applicable laboratory was
required to report readily available in the applicable laboratory's
record systems?
Did the reporting entity have a manual, automated, or
semi-automated remittance process for data reporting?
If the reporting entity used a manual or semi-automated
remittance process for data reporting, what percentage of the process
was manual?
How much time (hours) was required to assemble and report
applicable information to CMS?
Is there any other information that will inform us
regarding the reporting, recordkeeping, and other compliance
requirements from the first data collection and reporting periods?
We believe that industry feedback on these issues will help inform
us regarding potential refinements to the private payor rate-based CLFS
for future data collection and reporting periods. We welcome comments
on these questions from the public.
D. Payment for Biosimilar Biological Products Under Section 1847A of
the Act
In the CY 2016 Physician Fee Schedule (PFS) final rule with comment
period, we finalized a proposal to amend the regulation text at Sec.
414.904(j) to make clear that the payment amount for a biosimilar
biological product is based on the ASP of all NDCs assigned to the
biosimilar biological products included within the same billing and
payment code (80 FR 71096 through 71101, November 16, 2015 Federal
Register). In general, this means that products that rely on a common
reference product's biologics license application are grouped into the
same payment calculation for determining a single ASP payment limit and
that a single HCPCS code is used for such biosimilar products. The
regulation went into effect on January 1, 2016.
The comments received on the rule revealed that stakeholders had
varying opinions about payment for biosimilar biological products under
Part B. The commenters included individuals, pharmaceutical
manufacturers, patient advocate groups, providers, insurers, and
members of Congress. A number of commenters opposed a single payment
amount for all biosimilars that rely on a common reference product.
Most of these commenters believed that the proposed regulation would
decrease incentives for biosimilar development and that grouping
payment for biosimilar biological products is inconsistent with the
statute. Some commenters also expressed concerns that prescribers'
choices will be limited, that tracking or pharmacovigilance activities
will be impaired, and that innovation and product development will be
harmed, leading to market consolidation and increased costs for
biosimilar biological products. Many commenters who opposed our
proposal suggested that we determine a payment amount for each
biosimilar biological product. These stakeholders have expressed
concerns that the finalized policy restricts and threatens the
viability of their business models and expressed support for a market-
based solution. Some of these stakeholders believe that determining a
payment for each biosimilar product by using individual HCPCS codes,
would drive and reward innovators producing potential cost savings, of
at least 10-15 percent compared to the reference biologic ASP,
necessary for biosimilar products to compete with the reference
biological.
However, some commenters supported our proposed regulation, stating
that the potential marketplace for biosimilar biological products is
large and it is less risky than the marketplace for reference
biologicals. Commenters also expressed concern that separate payment
for each biosimilar biological product would result in less competition
among manufacturers, which in turn could lead to higher payment amounts
for Medicare and beneficiaries. Some commenters stated that separate
billing codes could be perceived as a type of price protection and
could artificially increase prices for biosimilars. Commenters who
supported the proposed regulation suggested that we remain mindful of
our policy as the biosimilar biological product marketplace evolves.
Several commenters requested that policy decisions be delayed while
issues such as naming conventions and interchangeability standards are
finalized by the FDA.
As CMS expected, since the regulation was finalized, the biosimilar
product marketplace has continued to grow, and several biosimilar
biological products that are paid under Part B have been licensed,
including one product that we expect will share a HCPCS code with
another biosimilar biological product. Over the next year or so, we
anticipate that several more biosimilar biological products will be
licensed for use in the United States and that during the following
years, the marketplace will continue to grow steadily. We also
anticipate that biological products will continue to be heavily
utilized in Part B. At the same time, we are aware of concerns that
current policy may discourage development of new biosimilars and other
innovation in this area potentially resulting in higher costs over time
due to a lack of competition in the market place.
In the 2016 PFS final rule, we stated that it is desirable to have
fair reimbursement in a healthy marketplace that encourages product
development (80 FR 71101). CMS seeks to promote innovation, to provide
more options to patients and physicians, and competition to drive
prices down, recognizing that even though these two goals may be
difficult to achieve concurrently, to delink them would be
counterproductive.
Although we believe that the United States biosimilar biological
product marketplace is still in an early phase (because only a few
products are on the market), we are interested in assessing
[[Page 34091]]
the effects of Medicare payment policy on this important portion of the
Part B drug marketplace at this time, particularly for fostering a
robust, and competitive marketplace and encouraging the innovation that
is necessary to bring these products to the marketplace. It is
essential to take a measured approach that considers all options given
the significant federal spending by Medicare on Part B drugs, the
effect of payment policies on program sustainability for taxpayers,
health care affordability and access for beneficiaries, and the
considerable investment the biosimilar industry is making in the
nascent market. Failure to do so could potentially restrict innovation
in the marketplace, increase costs to the American taxpayer, and limit
treatment options. With that in mind, it is CMS's goal to further
investigate a solution that allows market forces to provide a robust
and comprehensive selection of choices for patients at a fair price.
Additionally, we are interested in better understanding if and how the
innate differences in biological products and their current regulatory
environment should be reflected in Medicare payment policy for
biosimilars, particularly as it relates to biosimilars that are
licensed for fewer than all indications for which the reference product
is licensed or situations where different biosimilars may be licensed
for different subsets of indications for which the reference product is
licensed.
Thus, we are requesting comments regarding our Medicare Part B
biosimilar biological product payment policy. This comment solicitation
is seeking new or updated information on the effects of the current
biosimilar payment policy that is based on experience with the United
States marketplace. We are particularly interested in obtaining
material, such as market analyses or research articles that provide
data and insight into the current economics of the biosimilar market
place. This includes patient, plan, and manufacturer data both domestic
and, where applicable, from European markets that may be more
established than, and provide insight for, the current United States'
market.
We also seek data to demonstrate how individual HCPCS codes could
impact the biosimilar market, including innovation, the number of
biosimilar products introduced to the market, patient access, and drug
spending. Finally, we also seek comment regarding other novel payment
policies that would foster competition, increase access, and drive cost
savings in the biological product marketplace. These solutions may
include legislation, demonstrations, and administrative options. Please
note that this is a solicitation for comments on this issue for future
consideration. We are not making a proposal to change the existing
payment policy in this proposed rule.
E. Appropriate Use Criteria for Advanced Diagnostic Imaging Services
Section 218(b) of the Protecting Access to Medicare Act (PAMA)
amended Title XVIII of the Act to add section 1834(q) of the Act
directing us to establish a program to promote the use of appropriate
use criteria (AUC) for advanced diagnostic imaging services. The CY
2016 PFS final rule with comment period addressed the initial component
of the new Medicare AUC program, specifying applicable AUC. In that
rule (80 FR 70886), we established an evidence-based process and
transparency requirements for the development of AUC, defined provider-
led entities (PLEs) and established the process by which PLEs may
become qualified to develop, modify or endorse AUC. The first list of
qualified PLEs was posted on the CMS Web site at the end of June 2016
at which time their AUC libraries became specified applicable AUC for
purposes of section 1834(q)(2)(A) of the Act. The CY 2017 PFS final
rule addressed the second component of this program, specification of
qualified clinical decision support mechanisms (CDSMs). In that rule
(81 FR 80170), we defined CDSM, identified the requirements CDSMs must
meet for qualification including an opportunity for preliminary
qualification for mechanisms still working toward full adherence, and
established a process by which CDSMs may become qualified. We also
defined applicable payment systems under this program, specified the
first list of priority clinical areas and identified exceptions to the
requirements that ordering professionals consult specified applicable
AUC when ordering applicable imaging services. The first list of
qualified CDSMs will be posted on the CMS Web site in conjunction with
this proposed rule.
This rule proposes the start date of the Medicare AUC program for
advanced diagnostic imaging services. It is on and after this date that
ordering professionals must consult specified applicable AUC using a
qualified CDSM when ordering applicable imaging services and furnishing
professionals must report consultation information on the Medicare
claim. This rule also proposes to modify the policy related to
significant hardship exceptions and requests public feedback on details
regarding how AUC consultation information must be included on the
Medicare claim. To further this iterative process of implementation, we
also discuss briefly the potential for alignment with other Medicare
quality programs.
1. Background
AUC present information in a manner that links: a specific clinical
condition or presentation, one or more services and, an assessment of
the appropriateness of the service(s). For purposes of this program AUC
is a set or library of individual appropriate use criteria. Each
individual criterion is an evidence-based guideline for a particular
clinical scenario. Each scenario in turn starts with a patient's
presenting symptoms or condition. Evidence-based AUC for imaging can
assist clinicians in selecting the imaging study that is most likely to
improve health outcomes for patients based on their individual clinical
presentation.
AUC need to be integrated as seamlessly as possible into the
clinical workflow. CDSMs are the electronic portals through which
clinicians access the AUC during the patient workup. While CDSMs can be
standalone applications that require direct entry of patient
information, they may be more effective when they automatically
incorporate information such as specific patient characteristics,
laboratory results, and lists of co-morbid diseases from Electronic
Health Records (EHRs) and other sources. Ideally, practitioners would
interact directly with the CDSM through their primary user interface,
thus minimizing interruption to the clinical workflow.
Consistent with descriptions of clinical decision support by the
Agency for Healthcare Research and Quality (AHRQ) (http://www.ahrq.gov/professionals/prevention-chronic-care/decision/clinical/index.html),
and the Office of the National Coordinator for Health Information
Technology (ONC) (https://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds), within health IT
applications, a CDSM is a functionality that provides persons involved
in care processes with general and person-specific information,
intelligently filtered and organized, at appropriate times, to enhance
health and health care.
2. Statutory Authority
Section 218(b) of the PAMA added a new section 1834(q) of the Act
entitled, ``Recognizing Appropriate Use Criteria for Certain Imaging
Services,'' which
[[Page 34092]]
directs the Secretary to establish a new program to promote the use of
AUC. Section 1834(q)(4) of the Act requires ordering professionals to
consult with a qualified CDSM for applicable imaging services furnished
in an applicable setting and paid for under an applicable payment
system; and for the furnishing professional to include on the Medicare
claim information about the ordering professional's consultation with a
qualified CDSM.
3. Discussion of Statutory Requirements
There are four major components of the AUC program under section
1834(q) of the Act, and each component has its own implementation date:
(1) Establishment of AUC by November 15, 2015 (section 1834(q)(2) of
the Act); (2) identification of mechanisms for consultation with AUC by
April 1, 2016 (section 1834(q)(3) of the Act); (3) AUC consultation by
ordering professionals, and reporting on AUC consultation by furnishing
professionals by January 1, 2017 (section 1834(q)(4) of the Act); and
(4) annual identification of outlier ordering professionals for
services furnished after January 1, 2017 (section 1834(q)(5) of the
Act). As we will discuss later in this preamble and in prior PFS rules,
we did not identify mechanisms for consultation by April 1, 2016.
Therefore, we did not require ordering professionals to consult CDSMs
or furnishing professionals to report information on the consultation
by the January 1, 2017 date.
a. Establishment of AUC
In the CY 2016 PFS final rule with comment period, we addressed the
first component of the Medicare AUC program under section 1834(q)(2) of
the Act--the requirements and process for establishment and
specification of applicable AUC, along with relevant aspects of the
definitions under section 1834(q)(1) of the Act. This included defining
the term PLE and finalizing requirements for the rigorous, evidence-
based process by which a PLE would develop AUC, upon which
qualification is based, as provided in section 1834(q)(2)(B) of the Act
and in the CY 2016 PFS final rule with comment period. Using this
process, once a PLE is qualified by CMS, the AUC that are developed,
modified or endorsed by the qualified PLE are considered to be
specified applicable AUC under section 1834(q)(2)(A) of the Act. We
defined the term PLE to include national professional medical
societies, health systems, hospitals, clinical practices and
collaborations of such entities such as the High Value Healthcare
Collaborative or the National Comprehensive Cancer Network. Qualified
PLEs may collaborate with third parties that they believe add value to
their development of AUC, provided such collaboration is transparent.
We expect qualified PLEs to have sufficient infrastructure, resources,
and the relevant experience to develop and maintain AUC according to
the rigorous, transparent, and evidence-based processes detailed in the
CY 2016 PFS final rule with comment period.
In the same rule we established a timeline and process under Sec.
414.94(c)(2) for PLEs to apply to become qualified. Consistent with
this timeline the first list of qualified PLEs was published at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html (OMB Control
Number 0938-1288).
b. Mechanism for AUC Consultation
In the CY 2017 PFS final rule, we addressed the second major
component of the Medicare AUC program--the specification of qualified
CDSMs for use by ordering professionals for consultation with specified
applicable AUC under section 1834(q)(3) of the Act, along with relevant
aspects of the definitions under section 1834(q)(1) of the Act. This
included defining the term CDSM and finalizing functionality
requirements of mechanisms, upon which qualification is based, as
provided in section 1834(q)(3)(B) of the Act and in the CY 2017 PFS
final rule. We included an opportunity for mechanisms still working
toward full adherence to these requirements to receive preliminary
qualification during the preliminary qualification period that begins
June 30, 2017, and ends when the AUC consulting and reporting
requirements become effective. The preliminarily qualified CDSMs must
meet all requirements by that time. We defined CDSM as an interactive,
electronic tool for use by clinicians that communicates AUC information
to the user and assists them in making the most appropriate treatment
decision for a patient's specific clinical condition. Tools may be
modules within or available through certified EHR technology (as
defined in section 1848(o)(4) of the Act) or private sector mechanisms
independent from certified EHR technology or established by the
Secretary.
In the CY 2017 PFS final rule we established a timeline and process
in Sec. 414.94(g)(2) for CDSM developers to apply to have their CDSMs
qualified. Consistent with this timeline, the first list of qualified
CDSMs will be posted on the CMS Web site https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html in conjunction with this proposed rule (OMB
Control Number 0938-1315).
c. AUC Consultation and Reporting
The third major component of the Medicare AUC program is in section
1834(q)(4) of the Act, Consultation with Applicable Appropriate Use
Criteria. This section establishes, beginning January 1, 2017, the
requirement for an ordering professional to consult with a qualified
CDSM when ordering an applicable imaging service that would be
furnished in an applicable setting and paid for under an applicable
payment system; and for the furnishing professional to include on the
Medicare claim information about the ordering professional's
consultation with a qualified CDSM. The statute distinguishes between
the ordering and furnishing professional, recognizing that the
professional who orders an applicable imaging service is usually not
the same professional who bills Medicare for that service when
furnished. Since a list of qualified CDSMs was not available by January
1, 2017, we did not require ordering professionals to meet the
consultation requirement by that date.
Section 1834(q)(4)(C) of the Act provides for certain exceptions to
the AUC consultation and reporting requirements including in the case
of certain emergency services, inpatient services paid under Medicare
Part A, and ordering professionals who obtain an exception due to a
significant hardship. In the CY 2017 PFS final rule, we identified the
circumstances specific to ordering professionals under which consulting
and reporting requirements are not required. These include orders for
applicable imaging services: (1) For emergency services when provided
to individuals with emergency medical conditions as defined in section
1867(e)(1) of the Act; (2) for an inpatient and for which payment is
made under Medicare Part A; and (3) by ordering professionals who are
granted a significant hardship exception to the Medicare EHR Incentive
Program payment adjustment for that year under 42 CFR 495.102(d)(4),
except for those granted such an exception under Sec.
495.102(d)(4)(iv)(C). We propose changes to the significant hardship
exception later in this preamble.
Section 1834(q)(4)(D) of the Act specifies that the applicable
payment systems for the AUC consultation and reporting requirements,
and, in the CY 2017 PFS final rule we defined them as:
[[Page 34093]]
(1) The physician fee schedule established under section 1848(b) of the
Act; (2) the prospective payment system for hospital outpatient
department services under section 1833(t) of the Act; and (3) the
ambulatory surgical center payment system under section 1833(i) of the
Act.
d. Identification of Outliers
The fourth component of the Medicare AUC program is in section
1834(q)(5) of the Act, Identification of Outlier Ordering
Professionals. The identification of outlier ordering professionals
under this paragraph facilitates a prior authorization requirement for
outlier professionals beginning January 1, 2020, as specified under
section 1834(q)(6) of the Act. Given that we are proposing a program
start date of January 1, 2019, we anticipate that implementation of the
prior authorization component would be delayed. We expect to discuss
details around outlier calculations and prior authorization in the CY
2019 PFS proposed rule. However, we did finalize in the CY 2017 PFS
final rule the first list of priority clinical areas to guide
identification of outlier ordering professionals as follows:
Coronary artery disease (suspected or diagnosed).
Suspected pulmonary embolism.
Headache (traumatic and non-traumatic).
Hip pain.
Low back pain.
Shoulder pain (to include suspected rotator cuff injury).
Cancer of the lung (primary or metastatic, suspected or
diagnosed).
Cervical or neck pain.
As established in Sec. 414.94(e)(4) of our regulations, priority
clinical areas may be used in the identification of outlier ordering
professionals. By starting to identify these areas now, we believe
ordering professionals will have the opportunity to become familiar
with AUC within identified priority clinical areas prior to Medicare
claims for those services being part of the input for calculating
outlier ordering professionals.
We are not including proposals to expand or modify the list of
priority clinical areas in this rule.
4. Proposals for Continuing Implementation
We propose to amend Sec. 414.94 of our regulations, ``Appropriate
Use Criteria for Certain Imaging Services,'' to reflect the following
proposals.
a. Consultation by Ordering Professional and Reporting by Furnishing
Professional
We are proposing that ordering professionals must consult specified
applicable AUC through qualified CDSMs for applicable imaging services
furnished in an applicable setting, paid for under an applicable
payment system and ordered on or after January 1, 2019. This proposed
effective date for the consulting and reporting requirements is
necessary to allow time for ordering practitioners who are not already
aligned with a qualified CDSM to research and evaluate the qualified
CDSMs so they may make an informed decision. Although there will be
another rulemaking cycle next year before the consulting and reporting
requirement is effective as proposed on January 1, 2019, we are
establishing this date through rulemaking this year because the agency
expects practitioners and other stakeholders to begin preparing
themselves to report on that date and, in response to public comment
and stakeholder feedback, we want to ensure all impacted parties have
sufficient time to prepare to meet the requirements of this program.
After proposing the timeline and process for qualification of CDSMs
in the CY 2017 PFS proposed rule (81 FR 46392), we anticipated that
furnishing professionals may begin reporting as early as January 1,
2018. However, we received comments that these timelines did not allow
enough time to address the needs of different stakeholder groups. Some
commenters requested that CMS delay the timeline and process to give
practitioners sufficient time to obtain a qualified CDSM. Other
commenters cited insufficient time for CDSMs to incorporate
requirements between the release of the final CDSM requirements and
January 1, 2018, and requested that CMS fully implement the program at
a later date. Additionally, in the CY 2017 PFS final rule (81 FR 80411)
we discussed commenters' recommendations that CMS develop and launch an
educational campaign, including a Town Hall meeting. Some commenters
requesting additional time suggested that, for purposes of both CDSM
vendor readiness and practitioner readiness, consulting and reporting
requirements should not go into effect for an additional 12-18 months
after the initial list of CMS qualified CDSMs is posted.
By proposing the consulting and reporting requirements begin on
January 1, 2019 we believe that we are allowing needed time for
education and outreach efforts, time for practitioners and stakeholders
to prepare, and time for CDSMs to continue current strides in being
more user-friendly and less burdensome. We note that the statute
required publication of qualified CDSMs by April 1, 2016, and required
AUC consultation and reporting by January 1, 2017; therefore, our
proposal substantially lags the statutory requirements. As noted above
and in previous rulemaking, a delay in the statutory timeline is
necessary to maximize the opportunity for public comment and
stakeholder engagement, also a statutory requirement, and allows for
adequate advance notice to practitioners, beneficiaries, AUC
developers, and CDSM developers.
Consistent with section 1834(q)(4)(B) of the Act, we are also
proposing that furnishing professionals report the following
information on Medicare claims for applicable imaging services,
furnished in an applicable setting, paid for under an applicable
payment system as defined in Sec. 414.94(b), and ordered on or after
January 1, 2019: (1) Which qualified CDSM was consulted by the ordering
professional; (2) whether the service ordered would adhere to specified
applicable AUC, would not adhere to specified applicable AUC, or
whether specified applicable AUC were not applicable to the service
ordered; and (3) the NPI of the ordering professional (if different
from the furnishing professional).
We believe that, unless a statutory exception applies, an AUC
consultation must take place for every order for an applicable imaging
service furnished in an applicable setting and under an applicable
payment system. We further believe that section 1834(q)(4)(B) of the
Act accounts for the possibility that AUC may not be available in a
particular qualified CDSM to address every applicable imaging service
that might be ordered; and thus, the furnishing professional can meet
the requirement to report information on the ordering professional's
AUC consultation by indicating that AUC is not applicable to the
service ordered. We remind readers as required under Sec.
414.94(g)(1)(iii) that qualified CDSMs must make available, at a
minimum, AUC that reasonably address common and important clinical
scenarios within all priority clinical areas. As discussed in the CY
2017 PFS final rule (81 FR 80170), the current list of priority
clinical areas represents about 40 percent of advanced diagnostic
imaging services paid for by Medicare in 2014. We also remind readers
that consistent with section 1834(q)(4)(A) of the Act, ordering
professionals must consult AUC for every advanced diagnostic
[[Page 34094]]
imaging service ordered. While section 218(b) of the PAMA allows
qualified CDSMs to return a response of ``not applicable'' if a
qualified CDSM does not contain specified applicable AUC for the
service ordered, we expect these situations to be limited in scope and
number, and to decrease over time. The ``not applicable'' responses
should decrease as qualified PLEs continue to build out their AUC
libraries and qualified CDSMs update their content and potentially
collaborate with more qualified PLEs so as to make available highly
comprehensive tools.
Section 1834(q)(4)(B) requires that payment may only be made if the
claim for the service includes the specific information discussed in
this proposed rule. This information, to the extent feasible, is
required across claim types (including both the furnishing professional
and facility claims) and across all three applicable payment systems
(PFS, hospital outpatient prospective payment system and ambulatory
surgical center payment system). In other words, we would expect this
information to be included on the practitioner claim that includes the
professional component of the imaging service and on the hospital
outpatient claim for the technical component of the imaging service.
Claims for services for which payment is not made under the three
identified payment systems would not be required to include
consultation related information.
To implement this requirement we propose to establish a series of
HCPCS level 3 codes. These G-codes would describe the specific CDSM
that was used by the ordering professional. Ultimately there would be
one G-code for every qualified CDSM with the code description including
the name of the CDSM. However, because the claims processing system can
only recognize new codes quarterly, we may not be able to update the G-
code descriptors simultaneously with the announcement of any new
qualified CDSMs which is expected to occur in June of each year. To
ensure that there is a code available to immediately describe newly
qualified CDSMs, we propose to establish a generic G-code that would be
used to report that a qualified CDSM was consulted, but would not
identify a specific qualified CDSM; clinicians would only be permitted
to use this code if a more specific named code did not yet exist for
that clinician's CDSM. Furnishing professionals would report this code
temporarily until a specific G-code describing the newly qualified CDSM
by name becomes available. We also propose to establish a G-code to
identify circumstances where there was no AUC consultation through a
qualified CDSM. The description of this code would indicate that a
qualified CDSM was not consulted by the ordering professional.
G-codes would be a line-item on both practitioner claims and
facility claims. We would expect that one AUC consulatation G-code
would be reported for every advanced diagnostic imaging service on the
claim. If there are two codes billed for advanced imaging services on
the claim then we would expect two G-codes. Each G-code would be
expected, on the same claim line, to contain at least one new HCPCS
modifier. We propose to develop a series of modifiers to provide
necessary information as to whether, when a CDSM is used to consult
AUC: (1) The imaging service would adhere to the applicable appropriate
use criteria; (2) the imaging service would not adhere to such
criteria; or (3) such criteria were not applicable to the imaging
service ordered. We propose to create additional modifiers to describe
situations where an exception applies and a qualified CDSM was not used
to consult AUC: (1) The imaging service was ordered for a patient with
an emergency medical condition or (2) the ordering professional has a
significant hardship exception. Based on this proposal we specifically
seek comments on any additional HCPCS modifiers that might be needed to
separately identify allowable scenarios for which a qualified CDSM was
not consulted by the ordering professional.
The proposed AUC consultation and reporting start date of January
1, 2019 is expected to allow adequate time for us to operationalize the
claims-based procedures and systems changes needed to accomplish the
processing of Medicare claims with AUC consultation information.
There are aspects of the AUC program that are novel and complex for
the CMS claims processing system and for ordering and furnishing
professionals. An AUC consultation by an ordering professional has
never before been required by fee-for-service Medicare with such a
broad application (all professionals ordering advanced diagnostic
tests). Additional considerations for the complex communication of AUC
consultation information from the ordering professional to the
furnishing professional and facility that must include that information
when billing for the service are warranted. Their billing systems will
need to translate the AUC consultation information onto Medicare claims
in the form of G-codes and HCPCS modifiers. These processes are new for
many professionals, and there are many areas for potential error. For
these reasons an educational and operations testing period is needed.
During this period, ordering professionals would consult AUC and
furnishing professionals would report AUC consultation information on
the claim, but we would continue to pay claims whether or not they
correctly include such information. This educational period allows
professionals to actively participate in the program while avoiding
claims denials during the learning curve. It also gives us an
opportunity to make any needed claims processing adjustments before
payments are impacted.
We believe it is preferable to begin implementation using a single
year educational and operations testing period, rather than possibly
further delaying the start-date of the program. We do not expect to
continue this educational and operations testing period beyond the
first year of the AUC program.
We look forward to receiving public comments on all aspects of our
proposal, and specifically, comments related to whether the program
should be delayed beyond the proposed start date of January 1, 2019.
Although our proposal is based in part on comments received in prior
rulemaking cycles, it is important to receive comments that help us
understand the current readiness of stakeholders. In addition, we have
proposed that the program begin with an educational and operations
testing period and are interested in comments regarding how long, if
longer than one year, such a period should be available.
We expect a voluntary reporting period to be available ahead of
January 1, 2019 and anticipate such a period will begin July 2018. The
timing for this opportunity for voluntary reporting is dependent on the
readiness of the Medicare claims system to accept and process claims
that include AUC consultation information. When the voluntary period
becomes available we will make announcements through our educational
channels such as the CMS Web site and listservs. It is important to
note that the proposed educational and operations testing period
beginning January 1, 2019, is separate from the anticipated voluntary
reporting period that we expect to allow before January 1, 2019. During
the voluntary reporting period, AUC consultation and reporting are not
required. However, for applicable imaging services ordered on and after
January 1, 2019, consulting specified applicable AUC and reporting
consultation information on the
[[Page 34095]]
Medicare claim would be required for all ordering and furnishing
professionals, respectively.
b. Alignment With Other Medicare Quality Programs
The CY 2017 Merit-based Incentive Payment System and Alternative
Payment Model final rule with comment period (Quality Payment Program
final rule) (81 FR 77008) finalized policies to improve physician and
other clinician payments by changing the way Medicare incorporates
quality measurement into payments and developing new policies to
address and incentivize participation in Advanced Alternative Payment
Models (APMs). We expect the Quality Payment Program to evolve over
multiple years and to continue iterating on these policies. To this
end, the AUC program has the potential to provide new opportunities to
improve care delivery by supporting and rewarding clinicians as they
find new ways to engage patients, families and caregivers as well as
improving care coordination and patient health management.
Therefore, we have proposed in the CY 2018 Quality Payment Program
proposed rule to develop a direct tie between MIPS and the AUC program
(See CY 2018 Quality Payment Program Proposed Rule (82 FR 30010)
published in the June 30, 2017 Federal Register). In that rule, we
proposed to give MIPS credit to ordering professionals for consulting
AUC using a qualified CDSM as a high-weight improvement activity for
the performance period beginning January 1, 2018 (82 FR 30484). We
believe this will incentivize early use of qualified CDSMs to consult
AUC by motivated eligible clinicians looking to improve patient care
and to better prepare themselves for the AUC program. Although the AUC
program would not officially begin until January 1, 2019, we are able
to support this proposed improvement activity because the first
qualified CDSMs will be announced in conjunction with this proposed
rule; therefore, ordering professionals will be able to begin
consulting AUC using those tools.
We are also considering how the AUC program could serve to support
a quality measure under the MIPS quality performance category and seek
feedback from the public regarding feasibility and value of pursuing
this idea further.
c. Significant Hardship Exceptions to Consulting and Reporting
Requirements
We are proposing to modify Sec. 414.94(i)(3) of our regulations to
reflect the sunsetting of the payment adjustments under the Medicare
EHR Incentive Program and to substitute an alignment with the advancing
care information performance category of MIPS. The categories that we
included in the CY 2017 PFS final rule for purposes of the AUC program
significant hardship exceptions were the following from Sec.
495.102(d)(4):
Insufficient Internet Connectivity (as specified in Sec.
495.102(d)(4)(i)).
Practicing for less than 2 years (as specified in Sec.
495.102(d)(4)(ii)).
Extreme and Uncontrollable Circumstances (as specified in
Sec. 495.102(d)(4)(iii)).
Lack of Control over the Availability of CEHRT (as
specified in Sec. 495.102(d)(4)(iv)(A)).
Lack of Face-to-Face Patient Interaction (as specified in
Sec. 495.102(d)(4)(iv)(B)).
In addition, in the CY 2017 Quality Payment Program final rule, we
finalized a policy (81 FR 77240-77243) to reweight the advancing care
information performance category to zero in the MIPS final score for
the year for MIPS eligible clinicians who meet the criteria in one of
the above listed categories of Sec. 495.102(d)(4), with the exception
of the category for clinicians practicing for less than 2 years. Under
section 1848(q)(1)(C)(v) of the Act, eligible clinicians who first
enroll in Medicare during the performance period for a year and have
not previously submitted claims under Medicare are not considered MIPS
eligible clinicians, and thus are excluded from MIPS. We believe it is
likely that many clinicians who have been practicing for less than 2
years would be excluded from MIPS on the basis that they are new
Medicare-enrolled MIPS eligible clinicians as defined in Sec.
414.1305. Because these clinicians are not MIPS eligible clinicians,
they would never meet the criteria for re-weighting of their MIPS
advancing care information performance category for the year.
Therefore, to implement a hardship exception for purposes of the AUC
program that is both operationally consistent and administratively
efficient, we propose to remove as a criterion for a significant
hardship exception for the AUC program the criterion specified in Sec.
495.102(d)(4)(ii) of our regulations for those practicing for less than
2 years. We propose to keep the remaining listed categories including
insufficient internet connectivity, extreme and uncontrollable
circumstances, lack of control over availability of CEHRT and lack of
face-to-face patient interaction. We note that section
1843(q)(4)(C)(iii) of the Act only allows the ordering professional to
seek a significant hardship exception, not the furnishing professional.
As such, we propose to amend the AUC significant hardship exception
regulation to specify that ordering professionals who are granted re-
weighting of the advancing care information performance category to
zero percent of the final score for the year under MIPS per Sec.
414.1380(c)(2) due to circumstances that include the criteria listed in
Sec. 495.102(d)(4)(i), (iii), (iv)(A) and (iv)(B) would be excepted
from the AUC consultation requirement during the same year that the re-
weighting applies for purposes of the MIPS payment adjustment.
There will be scenarios when a clinician's experience of a
significant hardship or extraordinary circumstance does not align with
the prospective identification of these ordering professionals with
reference to MIPS criteria and processes. However, we believe the
prospective identification process allows us to apply exceptions in
real-time for claims submitted for advanced imaging services. There are
timing differences between the MIPS and the AUC program (the MIPS
payment adjustment year is based on performance in a prior year while
the Medicare AUC program requires real-time AUC consultation and
claims-based reporting). In addition to the timing, there will be
instances when a clinician who is not a MIPS eligible clinician will
need to seek a significant hardship exception to the Medicare AUC
program. To accommodate these two separate scenarios, we propose to
establish a process to identify ordering professionals in need of a
significant hardship exception to the Medicare AUC program requirements
that is outside the MIPS re-weighting process. For purposes of these
scenarios, we propose to use the criteria for clinicians seeking an AUC
significant hardship exception described under Sec. 495.102(d)(4) to
include (i), (iii), (iv)(A) and (iv)(B) of our regulations. We propose
these criteria to align with the criteria used under MIPS for re-
weighting under the advancing care information performance category,
and to provide predictability and consistency to the determination of
significant hardship. We further propose that a significant hardship
exception from the Medicare AUC program requirements would be granted
for no longer than 12 months, and that we could establish an exception
for a shorter period where warranted by the circumstances.
Therefore we propose that ordering professionals who have not
received a re-weighting to zero for the MIPS
[[Page 34096]]
advancing care information performance category for the year, but
experience one of the circumstances described in Sec. 495.102(d)(4) to
include (i), (iii), (iv)(A) and (iv)(B), may be granted an AUC
significant hardship exception for no longer than one year. We expect
to provide further information on this execption process in future
rulemaking.
In addition to the proposals above, we invite the public to comment
on additional circumstances for which it may be appropriate for an
ordering professional to be granted a significant hardship exception
under the AUC program.
5. Summary
Section 1834(q) of the Act includes rapid timelines for
establishing a Medicare AUC program for advanced diagnostic imaging
services. The impact of this program is extensive as it will apply to
every physician or other practitioner who orders or furnishes advanced
diagnostic imaging services (for example, magnetic resonance imaging
(MRI), computer tomography (CT) or positron emission tomography (PET)).
This crosses almost every medical specialty and could have a particular
impact on primary care physicians since their scope of practice can be
quite broad. Stakeholders have expressed concern that program
requirements may inadvertently encourage physicians to order imaging
services that they do not believe are right for their patients. The
goal of evidence-based AUC is to assist clinicians in ordering the most
appropriate imaging service for their patients' specific clinical
scenarios. However, to ensure we are implementing the program
effectively, we are asking for public comment on such potential
unintended consequences. Additionally, as we continue to develop the
AUC program, we continue to engage a variety of stakeholders interested
in participating in the development of AUC. We seek comment about how
we can continue to engage interested participants, consistent with
statutory requirements at section 1834(q) of the Act, in developing AUC
in a transparent and scientifically robust manner. We are particularly
interested in how qualified PLEs develop or modify AUC in collaboration
with non-PLE entities and what additional challenges such entities
might face.
We continue to believe the best implementation approach is one that
is diligent, maximizes the opportunity for public comment and
stakeholder engagement, and allows for adequate advance notice to
physicians and practitioners, beneficiaries, AUC developers, and CDSM
developers. It is for these reasons we propose to continue a stepwise
approach, adopted through notice and comment rulemaking. We propose
policies to implement the third component of the AUC program--the
consulting and reporting requirements and the effective date on which
these requirements would begin. Under this proposal, ordering
professionals must begin consulting specified applicable AUC through
qualified CDSMs for applicable imaging services ordered on and after
January 1, 2019, and furnishing professionals must begin reporting AUC
consultation information on Medicare claims for advanced diagnostic
imaging services for which payment is made under an applicable payment
system as defined in Sec. 414.94(b) and ordered on or after January 1,
2019.
We also propose modifications to the significant hardship exception
to better align these exceptions under the AUC program with those under
existing quality programs.
In summary, we are proposing requirements necessary to implement
the third component of the AUC program. We invite the public to submit
comments on these proposals.
F. Physician Quality Reporting System (PQRS) Criteria for Satisfactory
Reporting for Individual EPs and Group Practices for the 2018 PQRS
Payment Adjustment
1. Background
Section 1848(a)(8) of the Act provides that for covered
professional services furnished by an EP during each of 2015 through
2018, if the EP does not satisfactorily report data on quality measures
for covered professional services for the reporting period for the
year, the PFS amount for services furnished by such professional during
the year (including the PFS amount for purposes of determining a
payment based on such amount) shall be equal to the applicable percent
of the PFS amount that would otherwise apply to such services. For 2016
through 2018, the applicable percent is 98.0 percent. Thus, individual
EPs and group practices who did not satisfactorily report data on
quality measures for the CY 2016 reporting period are subject to a
downward payment adjustment of 2.0 percent to the PFS payment amount
for covered professional services they furnish in 2018.
2. Previously Finalized Satisfactory Reporting Criteria for Individual
EPs and Group Practices for the 2018 PQRS Payment Adjustment
We previously finalized the satisfactory reporting criteria for
individual EPs and group practices for the CY 2016 reporting period to
avoid the 2018 PQRS payment adjustment in the CY 2016 PFS final rule
(80 FR 71140 through 71250) at Sec. 414.90(j)(8) and (9) and Sec.
414.90(k)(5).
Table 18 summarizes the previously finalized satisfactory reporting
criteria for individual EPs at Sec. 414.90(j)(8) and Sec.
414.90(k)(5).
[[Page 34097]]
Table 18--Summary of Requirements for the 2018 PQRS Payment Adjustment: Individual Reporting Criteria for the
Satisfactory Reporting of Quality Measures Data via Claims, Qualified Registry, and Electronic Health Records
(EHRs) and Satisfactory Participation Criteria in Qualified Clinical Data Registries (QCDRs)
----------------------------------------------------------------------------------------------------------------
Satisfactory reporting/
Reporting period Measure type Reporting mechanism satisfactory participation
criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31, 2016)...... Individual Measures... Claims................ Report at least 9 measures,
covering at least 3 of the
National Quality Strategy
(NQS) domains AND report
each measure for at least
50 percent of the EP's
Medicare Part B Fee-for-
Service (FFS) patients
seen during the reporting
period to which the
measure applies. Of the
measures reported, if the
EP sees at least 1
Medicare patient in a face-
to-face encounter, the EP
will report on at least 1
measure contained in the
PQRS cross-cutting measure
set. If less than 9
measures apply to the EP,
the EP would report on
each measure that is
applicable), AND report
each measure for at least
50 percent of the Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate would not
be counted.
12-month (Jan 1-Dec 31, 2016)...... Individual Measures... Qualified Registry.... Report at least 9 measures,
covering at least 3 of the
NQS domains AND report
each measure for at least
50 percent of the EP's
Medicare Part B FFS
patients seen during the
reporting period to which
the measure applies. Of
the measures reported, if
the EP sees at least 1
Medicare patient in a face-
to-face encounter, the EP
will report on at least 1
measure contained in the
PQRS cross-cutting measure
set. If less than 9
measures apply to the EP,
the EP would report on
each measure that is
applicable, AND report
each measure for at least
50 percent of the Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate would not
be counted.
12-month (Jan 1-Dec 31, 2016)...... Individual Measures... Direct EHR Product or Report 9 measures covering
EHR Data Submission at least 3 of the NQS
Vendor Product. domains. If an EP's direct
EHR product or EHR data
submission vendor product
does not contain patient
data for at least 9
measures covering at least
3 domains, then the EP
would be required to
report all of the measures
for which there is
Medicare patient data. An
EP would be required to
report on at least 1
measure for which there is
Medicare patient data.
12-month (Jan 1-Dec 31, 2016)...... Measures Groups....... Qualified Registry.... Report at least 1 measures
group AND report each
measures group for at
least 20 patients, the
majority (11 patients) of
which are required to be
Medicare Part B FFS
patients. Measures groups
containing a measure with
a 0 percent performance
rate will not be counted.
12-month (Jan 1-Dec 31, 2016)...... Individual PQRS QCDR.................. Report at least 9 measures
measures and/or non- available for reporting
PQRS measures under a QCDR covering at
reportable via a QCDR. least 3 of the NQS
domains, AND report each
measure for at least 50
percent of the EP's
patients. Of these
measures, the EP would
report on at least 2
outcome measures, OR, if 2
outcomes measures are not
available, report on at
least 1 outcome measures
and at least 1 of the
following types of
measures--resource use,
patient experience of
care, efficiency/
appropriate use, or
patient safety.
----------------------------------------------------------------------------------------------------------------
Table 19 summarizes the previously finalized satisfactory reporting
criteria for group practices via the group practice reporting option
(GPRO) at Sec. 414.90(j)(9) and Sec. 414.90(k)(5).
[[Page 34098]]
Table 19--Summary of Requirements for the 2018 PQRS Payment Adjustment: Group Practice Reporting Criteria for
Satisfactory Reporting of Quality Measures Data via the GPRO
----------------------------------------------------------------------------------------------------------------
Group practice Reporting Satisfactory reporting
Reporting period size Measure type mechanism criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 1, 2016)... 25-99 EPs; 100+ Individual GPRO Web Interface.... Report on all measures
EPs (if Consumer Measures in the included in the web
Assessment of Web Interface. interface; AND
Healthcare populate data fields
Providers and for the first 248
Systems (CAHPS) consecutively ranked
for PQRS does and assigned
not apply). beneficiaries in the
order in which they
appear in the group's
sample for each
module or preventive
care measure. If the
pool of eligible
assigned
beneficiaries is less
than 248, then the
group practice must
report on 100 percent
of assigned
beneficiaries. In
other words, we
understand that, in
some instances, the
sampling methodology
we provide will not
be able to assign at
least 248 patients on
which a group
practice may report,
particularly those
group practices on
the smaller end of
the range of 25-99
EPs. If the group
practice is assigned
less than 248
Medicare
beneficiaries, then
the group practice
must report on 100
percent of its
assigned
beneficiaries. A
group practice must
report on at least 1
measure for which
there is Medicare
patient data.
12-month (Jan 1-Dec 31, 2016).. 25-99 EPs that Individual GPRO Web Interface + The group practice
elect CAHPS for Measures in the CMS-Certified must have all CAHPS
PQRS; 100+ EPs Web Interface + Survey Vendor. for PQRS survey
(if CAHPS for CAHPS for PQRS. measures reported on
PQRS applies). its behalf via a CMS-
certified survey
vendor. In addition,
the group practice
must report on all
measures included in
the Web Interface;
AND populate data
fields for the first
248 consecutively
ranked and assigned
beneficiaries in the
order in which they
appear in the group's
sample for each
module or preventive
care measure. If the
pool of eligible
assigned
beneficiaries is less
than 248, then the
group practice must
report on 100 percent
of assigned
beneficiaries. A
group practice will
be required to report
on at least 1 measure
for which there is
Medicare patient
data.
Please note that, if
the CAHPS for PQRS
survey is applicable
to a group practice
who reports quality
measures via the Web
Interface, the group
practice must
administer the CAHPS
for PQRS survey in
addition to reporting
the Web Interface
measures.
12-month (Jan 1-Dec 31, 2016).. 2-99 EPs; 100+ Individual Qualified Report at least 9
EPs (if CAHPS Measures. Registry. measures, covering at
for PQRS does least 3 of the NQS
not apply). domains. Of these
measures, if a group
practice sees at
least 1 Medicare
patient in a face-to-
face encounter, the
group practice would
report on at least 1
measure in the PQRS
cross-cutting measure
set. If less than 9
measures covering at
least 3 NQS domains
apply to the group
practice, the group
practice would report
on each measure that
is applicable to the
group practice, AND
report each measure
for at least 50
percent of the
group's Medicare Part
B FFS patients seen
during the reporting
period to which the
measure applies.
Measures with a 0
percent performance
rate would not be
counted.
12-month (Jan 1-Dec 31, 2016).. 2-99 EPs that Individual Qualified The group practice
elect CAHPS for Measures + CAHPS Registry + CMS- must have all CAHPS
PQRS; 100+ EPs for PQRS. Certified Survey for PQRS survey
(if CAHPS for Vendor. measures reported on
PQRS applies). its behalf via a CMS-
certified survey
vendor, and report at
least 6 additional
measures, outside of
the CAHPS for PQRS
survey, covering at
least 2 of the NQS
domains using the
qualified registry.
If less than 6
measures apply to the
group practice, the
group practice must
report on each
measure that is
applicable to the
group practice. Of
the additional
measures that must be
reported in
conjunction with
reporting the CAHPS
for PQRS survey
measures, if any EP
in the group practice
sees at least 1
Medicare patient in a
face-to-face
encounter, the group
practice must report
on at least 1 measure
in the PQRS cross-
cutting measure set.
12-month (Jan 1-Dec 31, 2016).. 2-99 EPs; 100+ Individual Direct EHR Report 9 measures
EPs (if CAHPS Measures. Product or EHR covering at least 3
for PQRS does Data Submission domains. If the group
not apply). Vendor Product. practice's direct EHR
product or EHR data
submission vendor
product does not
contain patient data
for at least 9
measures covering at
least 3 domains, then
the group practice
must report all of
the measures for
which there is
Medicare patient
data. A group
practice must report
on at least 1 measure
for which there is
Medicare patient
data.
[[Page 34099]]
12-month (Jan 1-Dec 31, 2016).. 2-99 EPs that Individual Direct EHR The group practice
elect CAHPS for Measures + CAHPS Product or EHR must have all CAHPS
PQRS; 100+ EPs for PQRS. Data Submission for PQRS survey
(if CAHPS for Vendor Product + measures reported on
PQRS applies). CMS-Certified its behalf via a CMS-
Survey Vendor. certified survey
vendor, and report at
least 6 additional
measures, outside of
CAHPS for PQRS,
covering at least 2
of the NQS domains
using the direct EHR
product or EHR data
submission vendor
product. If less than
6 measures apply to
the group practice,
the group practice
must report all of
the measures for
which there is
Medicare patient
data. Of the
additional 6 measures
that must be reported
in conjunction with
reporting the CAHPS
for PQRS survey
measures, a group
practice would be
required to report on
at least 1 measure
for which there is
Medicare patient
data.
12-month (Jan 1-Dec 31, 2016).. 2+ EPs........... Individual PQRS QCDR............. Report at least 9
measures and/or measures available
non-PQRS for reporting under a
measures QCDR covering at
reportable via a least 3 of the NQS
QCDR. domains, AND report
each measure for at
least 50 percent of
the group practice's
patients. Of these
measures, the group
practice would report
on at least 2 outcome
measures, OR, if 2
outcomes measures are
not available, report
on at least 1 outcome
measures and at least
1 of the following
types of measures--
resource use, patient
experience of care,
efficiency/
appropriate use, or
patient safety.
----------------------------------------------------------------------------------------------------------------
3. Proposed Modifications to the Satisfactory Reporting Criteria for
Individual EPs and Group Practices for the 2018 PQRS Payment Adjustment
Since we finalized these requirements, we have heard from
stakeholders that EPs have had difficulty with the previously finalized
satisfactory reporting criteria for the CY 2016 reporting period, which
is the final reporting period for the PQRS. Specifically, we have heard
from stakeholders through written communications to CMS that EPs have
found the requirements complex, and had difficulty in understanding the
requirements to be a satisfactory reporter for PQRS. Stakeholders have
also requested that the requirements for the CY 2016 reporting period
be aligned with those of the Quality Payment Program, specifically the
Merit-based Incentive Payment System (MIPS). In particular, we have
heard requests to lower the previously finalized requirement from 9
measures across 3 NQS domains, where applicable, to only 6 measures
with no domain requirement associated with these measures. While the
PQRS and the MIPS are separate programs, we understand that
stakeholders would like to see greater continuity between the final
year of the PQRS and the beginning of the MIPS.
The final reporting period for the PQRS was CY 2016. The Quality
Payment Program, authorized by the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA), consolidates and replaces three
existing programs (the Medicare EHR Incentive Program for EPs, the
PQRS, and the Value-Based Payment Modifier (VM)). There are two ways
eligible clinicians can participate in this program: (1) Through the
MIPS; and (2) through Advanced Alternative Payment Models (APMs). The
initial performance period for the MIPS began on January 1, 2017. Under
MIPS, there are four connected pillars that affect how MIPS eligible
clinicians will be paid by Medicare: Quality; Improvement Activities;
Advancing Care Information; and Cost. For more information on the
Quality Payment Program, see https://qpp.cms.gov/.
While we understand that the data submission period for the CY 2016
reporting period has already ended and that all data that has been
submitted to CMS is based on the previously finalized satisfactory
reporting criteria for the CY 2016 reporting period, we are revisiting
our previously finalized policy because we want individual EPs and
groups to be assessed for purposes of the 2018 PQRS payment adjustment
based on satisfactory reporting criteria that are simpler, more
understandable, and more consistent with the beginning of MIPS. We
believe that such criteria will help clinicians more accurately gauge
their readiness for the beginning of MIPS and transition into the
Quality Payment Program successfully. Additionally, we want to be
responsive to the concerns of the clinician community. Therefore, while
we are not proposing to collect any additional data for the CY 2016
reporting period, we are proposing to modify the criteria we would
apply to the data already submitted for the CY 2016 reporting period to
determine whether an individual EP or group practice has satisfactorily
reported for purposes of avoiding the 2018 PQRS payment adjustment.
Specifically, we are proposing to revise the previously finalized
satisfactory reporting criteria for the CY 2016 reporting period to
lower the requirement from 9 measures across 3 NQS domains, where
applicable, to only 6 measures with no domain or cross-cutting measure
requirement. For individual EPs, this would apply to the following
reporting mechanisms: claims, qualified registry (except for measures
groups), QCDR, direct EHR product and EHR data submissions vendor
product. This proposal would not affect the criteria used to determine
whether an individual EP or group practice has satisfactorily reported
for purposes of avoiding the 2017 PQRS payment adjustment, with the
exception of the criteria applicable to individual EPs and group
practices reporting using the secondary reporting period established
under Sec. 414.90(j)(1)(ii) for the 2017 PQRS payment adjustment
(hereinafter referred to as the ``ACO Secondary Reporting Period''), as
discussed in section III.F.4. of this proposed rule.
Table 20 summarizes our proposed modifications to the previously
finalized satisfactory reporting criteria for individual EPs to avoid
the 2018
[[Page 34100]]
PQRS payment adjustment, based on data previously submitted for the CY
2016 reporting period. We are not proposing to collect any additional
data for the CY 2016 reporting period, as the data submission period
for the CY 2016 reporting period has already ended. As summarized in
Table 20, the NQS domain requirement would no longer apply. No changes
are being proposed for the measures groups criteria.
Additionally, we are also proposing that individual EPs and group
practices reporting via claims or qualified registry, as applicable,
would no longer be required to report a cross-cutting measure and that
individual EPs and group practices reporting via QCDR would no longer
be required to report an outcome or ``high priority'' measure (that is,
for purposes of PQRS, a resource use, patient experience of care,
efficiency/appropriate use, or patient safety measure). We note that
what is considered to be a ``high-priority'' measure in PQRS is
different from what is considered a ``high-priority'' measure in MIPS,
and we are not proposing to align this requirement with MIPS for the
last year of PQRS as this could cause confusion. While certain MIPS
eligible clinicians are required to report at least one outcome or
other high-priority measure (see Sec. 414.1335(a)(1)(i)), we are also
not aligning with that requirement because, while we agree that outcome
and high-priority measures are valuable for reporting, we want to
revise the satisfactory reporting criteria for the last year of PQRS to
be less complex for individual EPs and groups to understand.
Lastly, where we are proposing to lower the requirement to only 6
measures, if less than 6 measures apply to the individual EP or group
practice, each measure that is applicable would need to have been
reported. We define ``applicable'' to mean measures relevant to a
particular individual EP's or group practice's services or care
rendered. As previously finalized, individual EPs and group practices
would continue to be subject to the measure application validity (MAV)
process (80 FR 71140 through 71145). The MAV process seeks to identify
clinically similar measures and creates clusters of measures that can
be reported if one of the measures in the cluster is reported. We would
maintain the requirement that each required measure be reported for at
least 50 percent of the individual EP's or group practice's patients to
which the measure applies.
Table 20--Summary of Proposed Modifications to the Requirements for the 2018 PQRS Payment Adjustment: Individual
Reporting Criteria for the Satisfactory Reporting of Quality Measures Data via Claims, Qualified Registry, and
EHRs and Satisfactory Participation Criterion in QCDRs
----------------------------------------------------------------------------------------------------------------
Proposed satisfactory
Reporting period Measure type Reporting mechanism reporting criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-................... Individual Measures... Claims................ Report at least 6 measures,
Dec 31, 2016)...................... AND report each measure
for at least 50 percent of
the EP's Medicare Part B
FFS patients seen during
the reporting period to
which the measure applies.
If less than 6 measures
apply to the EP, the EP
must report on each
measure that is
applicable, AND report
each measure for at least
50 percent of the Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate will not
be counted (unless they
are inverse measures where
a lower rate reflects
better performance).
12-month (Jan 1-................... Individual Measures... Qualified Registry.... Report at least 6 measures,
Dec 31, 2016)...................... AND report each measure
for at least 50 percent of
the EP's Medicare Part B
FFS patients seen during
the reporting period to
which the measure applies.
If less than 6 measures
apply to the EP, the EP
must report on each
measure that is
applicable, AND report
each measure for at least
50 percent of the Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate will not
be counted (unless they
are inverse measures where
a lower rate reflects
better performance).
12-month (Jan 1-................... Individual Measures... Direct EHR Product or Report at least 6 measures.
Dec 31, 2016)...................... EHR Data Submission If an EP's direct EHR
Vendor Product. product or EHR data
submission vendor product
does not contain patient
data for at least 6
measures, then the EP must
report all of the measures
for which there is
Medicare patient data. An
EP must report on at least
1 measure for which there
is Medicare patient data.
12-month (Jan 1-................... Measures Groups....... Qualified Registry.... No proposed changes.
Dec 31, 2016)......................
12-month (Jan 1-................... Individual............ QCDR.................. Report at least 6 measures
Dec 31, 2016)...................... PQRS measures and/or available for reporting
non-PQRS measures under a QCDR AND report
reportable via a QCDR. each measure for at least
50 percent of the EP's
patients seen during the
reporting period to which
the measure applies. If
less than 6 measures apply
to the EP, the EP must
report on each measure
that is applicable, AND
report each measure for at
least 50 percent of the
EP's patients.
----------------------------------------------------------------------------------------------------------------
[[Page 34101]]
Accordingly, we are proposing to revise Sec. 414.90(j)(8) and
(k)(5) consistent with our proposals above. We believe these proposals
will result in fewer individual EPs being subject to the 2018 PQRS
payment adjustment, and will impose no additional burden on individual
EPs because this data has already been submitted to CMS. We request
comment on these proposals.
As discussed above, while we are not proposing to collect any
additional data for the CY 2016 reporting period, we are proposing to
modify the satisfactory reporting criteria for the CY 2016 reporting
period for purposes of the 2018 PQRS payment adjustment. Specifically,
we are proposing to lower the requirement from 9 measures across 3 NQS
domains, where applicable, to only 6 measures with no domain or cross-
cutting measure requirement. For group practices, this would apply to
the following reporting mechanisms: Qualified registry; QCDR; direct
EHR product; and EHR data submissions vendor product. This proposal
would not affect the criteria used to determine whether an individual
EP or group practice has satisfactorily reported for purposes of
avoiding the 2017 PQRS payment adjustment, with the exception of the
criteria applicable to individual EPs and group practices reporting
using the ACO Secondary Reporting Period, as discussed in section
III.F.4. of this proposed rule.
Table 21 summarizes our proposed modifications to the previously
finalized satisfactory reporting criteria for group practices to avoid
the 2018 PQRS payment adjustment, based on data previously submitted
for the CY 2016 reporting period. We are not proposing to collect any
additional data for the CY 2016 reporting period, as the data
submission period for the CY 2016 reporting period has already ended.
As summarized in Table 21, the NQS domain requirement would no longer
apply. No changes are being proposed for the Web Interface criteria.
Additionally, as discussed above, we are proposing that individual
EPs and group practices reporting via claims and qualified registry, as
applicable, would no longer be required to report a cross-cutting
measure and that individual EPs and group practices reporting via QCDR
would no longer be required to report an outcome or high priority
measure. We note that what is considered to be a ``high-priority''
measure in PQRS is different from what is considered a ``high-
priority'' measure in MIPS, and are not proposing to align this
requirement with MIPS for the last year of PQRS as this could cause
confusion. While certain MIPS eligible clinicians are required to
report at least one outcome or other high-priority measure (see Sec.
414.1335(a)(1)(i)), we are also not aligning with that requirement
because, while we agree that outcome and high-priority measures are
valuable for reporting, we want to revise the satisfactory reporting
criteria for the last year of PQRS to be less complex for individual
EPs and groups.
Where we are proposing to lower the requirement to only 6 measures,
if less than 6 measures apply to the individual EP or group practice,
each measure that is applicable would need to have been reported. We
define ``applicable'' to mean measures relevant to a particular
individual EP's or group practice's services or care rendered. As
previously finalized, individual EPs and group practices would continue
to be subject to the MAV process (80 FR 71140 through 71145). The MAV
process seeks to identify clinically similar measures and creates
clusters of measures that can be reported if one of the measures in the
cluster is reported. We would maintain the requirement that each
required measure be reported for at least 50 percent of the individual
EP's or group practice's patients to which the measure applies.
Lastly, for purposes of the 2018 PQRS payment adjustment, Sec.
414.90(j)(9)(viii) currently provides that if the CAHPS for PQRS survey
is applicable to the practice, group practices comprised of 100 or more
eligible professionals that register to participate in the GPRO must
administer the CAHPS for PQRS survey, regardless of the GPRO reporting
mechanism selected. For the reasons discussed above, we are proposing
to revise Sec. 414.90(j)(9)(viii) to provide that such group practices
may administer the CAHPS for PQRS survey, regardless of the GPRO
reporting mechanism selected, but are not required to do so. This
change would be consistent with the data submission criteria for the
MIPS quality performance category, under which groups may voluntarily
elect to participate in the CAHPS for MIPS survey (see Sec.
414.1335(a)(3)(i)). As summarized in Table 21, the previously finalized
satisfactory reporting criteria for group practices administering the
CAHPS for PQRS survey would continue to apply to group practices that
elected to administer the survey.
Table 21--Summary of Proposed Modifications to the Requirements for the 2018 PQRS Payment Adjustment: Group
Practice Reporting Criteria for Satisfactory Reporting of Quality Measures Data via the GPRO
----------------------------------------------------------------------------------------------------------------
Group practice Reporting Proposed satisfactory
Reporting period size \3\ Measure type mechanism reporting criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31,2016)... 25+ EPs.......... Individual GPRO Web Interface.... No proposed changes.
Measures in the
Web Interface.
12-month (Jan 1-Dec 31,2016)... 25+ EPs that Individual GPRO Web Interface + No proposed changes.
elect CAHPS for Measures in the CMS-Certified
PQRS. Web Interface+ Survey Vendor..
CAHPS for PQRS.
12-month (Jan 1-Dec 31,2016)... 2+ EPs........... Individual Qualified Report at least 6
Measures. Registry. measures AND report
each measure for at
least 50 percent of
the group's Medicare
Part B FFS patients
seen during the
reporting period to
which the measure
applies. If less than
6 measures apply to
the group, the group
practice must report
on each measure that
is applicable, AND
report each measure
for at least 50
percent of the
Medicare Part B FFS
patients seen during
the reporting period
to which the measure
applies. Measures
with a 0 percent
performance rate will
not be counted
(unless they are
inverse measures
where a lower rate
reflects better
performance).
[[Page 34102]]
12-month (Jan 1-Dec 31,2016)... 2+ EPs that elect Individual Qualified The group practice
CAHPS for PQRS. Measures+CAHPS Registry+CMS- must have all CAHPS
for PQRS. Certified Survey for PQRS survey
Vendor. measures reported on
its behalf via a CMS-
certified survey
vendor. In addition,
the group practice
must report at least
3 additional measures
using the qualified
registry AND report
each measure for at
least 50 percent of
the group's Medicare
Part B FFS patients
seen during the
reporting period to
which the measure
applies. If less than
3 measures apply to
the group practice,
the group practice
must report on each
measure that is
applicable, AND
report each measure
for at least 50
percent of the
Medicare Part B FFS
patients seen during
the reporting period
to which the measure
applies. Measures
with a 0 percent
performance rate will
not be counted
(unless they are
inverse measures
where a lower rate
reflects better
performance).
12-month (Jan 1-Dec 31,2016)... 2+ EPs........... Individual Direct EHR Report 6 measures. If
Measures. Product or EHR the group practice's
Data Submission direct EHR product or
Vendor Product. EHR data submission
vendor product does
not contain patient
data for at least 6
measures, then the
group practice must
report all of the
measures for which
there is Medicare
patient data. A group
practice must report
on at least 1 measure
for which there is
Medicare patient
data.
12-month (Jan 1-Dec 31,2016)... 2+ EPs that elect Individual Direct EHR The group practice
CAHPS for PQRS. Measures+CAHPS Productor EHR must have all CAHPS
for PQRS. Data Submission for PQRS survey
Vendor measures reported on
Product+CMS- its behalf via a CMS-
Certified Survey certified survey
Vendor. vendor. In addition,
the group practice
must report at least
3 additional measures
using the direct EHR
product or EHR data
submission vendor
product. If less than
3 measures apply to
the group practice,
the group practice
must report all of
the measures for
which there is
patient data. Of the
additional 3 measures
that must be reported
in conjunction with
reporting the CAHPS
for PQRS survey
measures, a group
practice must report
on at least 1 measure
for which there is
Medicare patient
data.
12-month (Jan 1-Dec 31,2016)... 2+ EPs........... Individual PQRS QCDR............. Report at least 6
measures and/or measures available
non-PQRS for reporting under a
measures QCDR AND report each
reportable via a measure for at least
QCDR. 50 percent of the
group practice's
patients seen during
the reporting period
to which the measure
applies. If less than
6 measures apply to
the group practice,
the group practice
must report on each
measure that is
applicable, AND
report each measure
for at least 50
percent of the group
practice's patients.
----------------------------------------------------------------------------------------------------------------
\3\ Please note that the group practice size descriptions have been revised for greater consistency with our
proposal to make the CAHPS for PQRS survey voluntary.
Accordingly, we are proposing to revise Sec. 414.90(j)(9) and
(k)(5) consistent with our proposals above. We believe these proposals
will result in fewer group practices being subject to the 2018 PQRS
payment adjustment, and will impose no additional burden on group
practices because this data has already been submitted to CMS. We
request comment on these proposals.
4. Accountable Care Organization (ACO) Participants Who Report PQRS
Quality Measures Separately During the Secondary Reporting Period
As discussed in the CY 2017 PFS final rule (81 FR 80441 through
80445), individual EPs and group practices who bill under the TIN of an
ACO participant may report separately from the ACO, if the ACO failed
to report on behalf of such individual EPs or group practices for the
applicable reporting period, during the CY 2016 reporting period for
purposes of the 2017 and 2018 PQRS payment adjustments, as applicable.
Please note that, in accordance with our previously established
policies for the ACO Secondary Reporting Period, our proposed
modifications to the satisfactory reporting criteria for individual EPs
and group practices for the CY 2016 reporting period would apply to
such individual EPs and group practices for purposes of the 2017 PQRS
payment adjustment. This proposal would not affect the 2017 PQRS
payment adjustment for any other individual EP or group practice.
[[Page 34103]]
5. Physician Compare Downloadable Database--Addition of Value Modifier
(VM) Data
We previously finalized in the CY 2016 PFS final rule (80 FR 71129
through 71130) a decision to publicly report three data points for the
2018 VM based on 2016 data in the Physician Compare downloadable file
in late 2017:
2018 VM quality tiers for cost and quality, based on the
2016 data, noting if the EP or group is high, low, or average on cost
and quality per the VM.
A notation of the payment adjustment received based on the
cost and quality tiers--upward, downward, or neutral--for each EP or
group.
An indication if the EP or group was eligible to but did
not report quality measures to CMS for CY 2016 under PQRS.
In light of the proposals to change the 2016 reporting criteria to
avoid the 2018 payment adjustment for PQRS (see section III.F. of this
proposed rule) and subsequent VM proposed policies to hold all
physician groups and solo practitioners who met minimum quality
reporting requirements harmless from downward payment adjustments for
performance under quality-tiering for the last year of the program (see
section III.I. of this proposed rule), and because the proposed
policies for PQRS and VM in this rule would change the nature of how
the PQRS data will be used under the VM, we are now proposing not to
report this data specific to the VM. Given the fact that VM data would
be available for posting in the Physician Compare downloadable database
for only one year and the VM data may not reflect an EP or group's
actual performance or payment adjustment given they could have chosen
to report fewer measures, we believe that proceeding with the posting
of this data could be confusing for the public.
Additionally, we have created other VM data files intended to
promote transparency. For each VM performance year, we will publish a
Public Use File (PUF) that contains VM performance results of de-
identified practices. Supporting documentation for each PUF that
contains the field name, length, type, label, description, and notes
for each variable included in the PUF. The Value Modifier program years
2015 and 2016 (performance year 2013 and 2014) are currently available
at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/VMPUF/Value-Modifier-PUF.html. In addition, three
Research Identifiable Files (RIFs) for Value Modifier program years
2015 and 2016 (performance year 2013 and 2014) are available through
the Research Data Assistance Center (ResDAC) and will be made available
for each program year. These files include a practice-level, an NPI-
practice level, and a beneficiary-level file, as described at: https://www.resdac.org/news/cms-creates-set-rif-data-files-support-value-based-payment-modifier-program/2017/06.
All other previously finalized policies related to 2016 PQRS data
available for public reporting on Physician Compare in late 2017 remain
unchanged (80 FR 71116 through 71132). Appreciating this, we believe
the best course of action is to not move forward with publicly
reporting this VM data for 2016. All data required to be reported by
law will remain available for public reporting as previously finalized
(80 FR 71116 through 71132). For more information on the public
reporting policies previously finalized and proposed for MIPS, we refer
readers to the Medicare Program; Merit-Based Incentive Payment System
(MIPS) and Alternative Payment Model (APM) Incentive Under the
Physician Fee Schedule, and Criteria for Physician-Focused Payment
Models (81 FR 77390 through 77399) and Medicare Program; CY 2018
Updates to the Quality Payment Program (82 FR 30163 through 30170),
respectively. We request comment on this proposal and specifically, if
we were to release this data, how it could be used by the public.
G. Clinical Quality Measurement for Eligible Professionals
Participating in the Electronic Health Record (EHR) Incentive Program
for 2016
1. Background
Sections 1848(o), 1853(l) and (m), 1886(n), and 1814(l) of the Act
provide the statutory basis for the Medicare incentive payments made to
eligible professionals (EPs), Medicare Advantage (MA) organizations
(for certain qualifying EPs and hospitals), subsection (d) hospitals,
and critical access hospitals (CAHs) that demonstrate meaningful use of
certified electronic health record (EHR) technology (CEHRT). Sections
1848(a)(7), 1853(l) and (m), 1886(b)(3)(B), and 1814(l) of the Act also
establish downward adjustments to Medicare payments, beginning with
calendar or fiscal year (FY) 2015, for EPs, MA organizations,
subsection (d) hospitals, and CAHs that are not meaningful users of
CEHRT for certain associated reporting periods. Sections 1903(a)(3)(F)
and 1903(t) of the Act provide the statutory basis for the Medicaid
incentive payments made to EPs and eligible hospitals for the adoption,
implementation, upgrade, and meaningful use of CEHRT. We have
implemented these statutory provisions in prior rulemakings to
establish the Medicare and Medicaid EHR Incentive Programs.
Under these statutory provisions and the regulations at 42 CFR
495.4, one of the requirements of being a meaningful EHR user is
successfully reporting the clinical quality measures selected by CMS to
CMS or the states, as applicable, in the form and manner specified by
CMS or the states, as applicable. Section 1848(o)(2)(B)(iii) of the Act
requires that in selecting clinical quality measures (CQMs) for EPs to
report under the EHR Incentive Program, and in establishing the form
and manner of reporting, the Secretary shall seek to avoid redundant or
duplicative reporting otherwise required, including reporting under
section 1848(k)(2)(C) of the Act (the Physician Quality Reporting
System). As such, we have taken steps to establish alignments among
various quality reporting and payment programs that include the
submission of CQMs.
2. Clinical Quality Measure (CQM) Requirements for Meaningful Use in
2016
Under sections 1848(o)(2)(A)(iii) and 1903(t)(6)(C)(i)(II) of the
Act and the definition of ``meaningful EHR user'' at Sec. 495.4, EPs
must report on CQMs selected by CMS using CEHRT, as part of being a
meaningful EHR user under the Medicare and Medicaid EHR Incentive
Programs. In the final rule titled ``Medicare and Medicaid Programs;
Electronic Health Record Incentive Program--Stage 3 and Modifications
to Meaningful Use in 2015 Through 2017,'' we finalized the options for
CQM submission for EPs in the Medicare EHR Incentive Program in 2016 as
follows (80 FR 62888 through 62889):
EP Options for Medicare EHR Incentive Program
Participation (single program Participation--EHR Incentive Program
only):
++ Option 1: Attest to CQMs through the EHR Registration &
Attestation System.
++ Option 2: Electronically report CQMs through Physician Quality
Reporting System (PQRS) Portal.
EP Options for Electronic Reporting for Multiple Programs
(for example: EHR Incentive Program plus PQRS participation):
++ Option 1: Report individual EP's CQMs through PQRS Portal.
++ Option 2: Report group's CQMs through PQRS Portal.
(NOTE: Under option 2, this may include an EP reporting using the
group
[[Page 34104]]
reporting option, either electronically using QRDA, or via the GPRO Web
Interface.)
For the Medicaid EHR Incentive Program, we specified (80 FR 62888)
that states would continue to be responsible for determining whether
and how electronic reporting of CQMs would occur, or if they wish to
allow reporting through attestation. Any changes that states make to
their CQM reporting methods must be submitted through the state
Medicaid Health IT Plan (SMHP) process for our review and approval
prior to being implemented.
We maintained a requirement that EPs report 9 CQMs covering at
least 3 NQS domains (80 FR 62888 through 62889). This requirement was
established in the final rule titled ``Medicare and Medicaid Programs;
Electronic Health Record Incentive Program--Stage 2'' (77 FR 54058).
We also continued (80 FR 62888 through 62889) our existing policy
that under Medicare, healthcare providers in any year of participation
for the EHR Incentive Program for 2015 through 2017 may electronically
report CQM data using the options previously outlined for electronic
reporting either for single program participation in the Medicare EHR
Incentive Program, or for participation in multiple programs if the
requirements of the aligned quality program are also met.
We noted that an EHR certified for CQMs under the 2014 Edition
certification criteria does not need to be recertified each time it is
updated to a more recent version of the eCQMs (80 FR 62889).
3. CQM Requirements for EPs and Groups Under the Medicare EHR Incentive
Program in 2016
As we discussed in section III.F. in this proposed rule, since we
finalized these requirements, we have heard from stakeholders through
written communications that EPs and groups have found the previously
finalized reporting criteria for the CY 2016 reporting period to be
complex and had difficulty in understanding the requirements to be a
satisfactory reporter, and these same EPs and groups subsequently
requested that the CQM reporting requirements for EPs and groups
participating in the Medicare EHR Incentive Program in 2016 who chose
to report CQMs electronically through the Physician Quality Reporting
System (PQRS) Portal be aligned with those of the Quality Payment
Program, specifically the Merit-based Incentive Payment System (MIPS).
Therefore, while we are not proposing to collect any additional
data for 2016, we are proposing to change the reporting criteria for
EPs and groups who chose to electronically report CQMs through the PQRS
Portal for purposes of the Medicare EHR Incentive Program.
Specifically, we are proposing to change the reporting criteria from 9
CQMs covering at least 3 NQS domains to 6 CQMs with no domain
requirement. We are proposing this change so that the reporting
criteria for the Medicare EHR Incentive Program would be in alignment
with the modified requirement that we are proposing for the final PQRS
reporting period (2016) in section III.F. of this proposed rule, as
well as the transition year of the Quality Payment Program. We are
proposing that an EP or group who satisfies the proposed reporting
criteria may qualify for the 2016 incentive payment under section
1848(o) of the Act and may avoid the downward payment adjustment in
2017 and/or 2018 under section 1848(a)(7)(A) of the Act, depending on
the EP or group's applicable EHR reporting period for the payment
adjustment year. This proposed change would help maintain alignment
with PQRS per the requirement under section 1848(o)(2)(B)(iii) of the
Act for the Secretary to seek to avoid redundant or duplicative
reporting otherwise required, including reporting under section
1848(k)(2)(C) of the Act (the PQRS). We are not proposing to change the
previously finalized requirements for CQM reporting in 2016 for
eligible hospitals and CAHs; or the previously finalized requirements
for EPs who chose to report CQMs through attestation in 2016 for the
Medicare EHR Incentive Program (80 FR 62888). Our reasoning for not
proposing to change the eligible hospital or CAH requirements for CQM
reporting is because the changes proposed for PQRS in section III.F. of
this proposed rule and the policies established for the transition year
of the Quality Payment Program would only affect clinicians and groups,
and therefore, there is no reason to propose changes to the established
policy for eligible hospitals or CAHs. We are not proposing to change
the requirements for EPs who reported CQMs through attestation because
those who attested were successful, therefore we believe there is no
need to change the requirement. Additionally, the Registration and
Attestation portal is scheduled to sunset as of October 1, 2017 before
this final rule is published.
Lastly, we are also not proposing to change the previously
finalized requirements for 2016 for EPs participating in the Medicaid
EHR Incentive Program. We have already proposed in ``Medicare Program;
Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals
and the Long-Term Care Hospital Prospective Payment System and Proposed
Policy Changes and Fiscal Year 2018 Rates; Quality Reporting
Requirements for Specific Providers; Medicare and Medicaid Electronic
Health Record (EHR) Incentive Program Requirements for Eligible
Hospitals, Critical Access Hospitals, and Eligible Professionals;
Provider-Based Status of Indian Health Service and Tribal Facilities
and Organizations; Costs Reporting and Provider Requirements; Agreement
Termination Notices'' that, for 2017, Medicaid EPs would be required to
report on any six CQMs that are relevant to the EP's scope of practice
(82 FR 20135). In proposing that change, we indicated that it is our
intention to align CQM requirements for Medicaid EPs with requirements
under the Medicare quality improvement programs, to the extent
practicable. However, we believe that due to the timing of when any
changes we might propose for 2016 through this rulemaking would take
effect (if finalized), the benefits of proposing to extend the policy
proposed for Medicare EPs for 2016 to Medicaid EPs for 2016 would not
be realized, and the burden on states to implement such a policy would
be significant. There is no negative payment adjustment for not
participating in the Medicaid EHR Incentive Program, so it is likely
that applying the proposed policy for Medicare EPs to Medicaid EPs for
2016 would benefit Medicaid EPs only if they are able to submit new
data to states for a Medicaid EHR incentive payment for 2016. Because
we anticipate that most states will have completed processing and
paying 2016 Medicaid EHR incentive payments by the time such a proposal
(if finalized) would take effect, we believe that applying this change
to the Medicaid EHR Incentive Program for 2016 would significantly
burden states. We seek comment on our assessment of the difficulty
states might face implementing this policy for 2016 for Medicaid EPs,
and on the number of Medicaid EPs who might benefit if we instead
decided to apply this policy in the Medicaid EHR Incentive Program for
2016, to the extent that doing so would be legally permissible.
H. Medicare Shared Savings Program
Under section 1899 of the Act, we established the Medicare Shared
Savings Program (Shared Savings Program) to facilitate coordination and
[[Page 34105]]
cooperation among health care providers to improve the quality of care
for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of
growth in expenditures under Medicare Parts A and B. Eligible groups of
providers and suppliers, including physicians, hospitals, and other
health care providers, may participate in the Shared Savings Program by
forming or participating in an Accountable Care Organization (ACO). The
final rule establishing the Shared Savings Program appeared in the
November 2, 2011 Federal Register (Medicare Program; Medicare Shared
Savings Program: Accountable Care Organizations; Final Rule (76 FR
67802) (hereinafter referred to as the ``November 2011 final rule'')).
A subsequent major update to the program rules appeared in the June 9,
2015 Federal Register (Medicare Program; Medicare Shared Savings
Program: Accountable Care Organizations; Final Rule (80 FR 32692)
(hereinafter referred to as the ``June 2015 final rule'')). A final
rule addressing changes related to the program's financial benchmark
methodology appeared in the June 10, 2016 Federal Register (Medicare
Program; Medicare Shared Savings Program; Accountable Care
Organizations--Revised Benchmark Rebasing Methodology, Facilitating
Transition to Performance-Based Risk, and Administrative Finality of
Financial Calculations (81 FR 37950) (hereinafter referred to as the
``June 2016 final rule'')). We have also made use of the annual
calendar year (CY) Physician Fee Schedule (PFS) rules to address
quality reporting and certain other issues. In addition, in the CY 2017
Quality Payment Program final rule (81 FR 77255 through 77256), we
finalized policies related to quality performance category scoring for
Merit-Based Incentive Payment System (MIPS) eligible clinicians that
participate in the Shared Savings Program. In that final rule, we
adopted an APM scoring standard that reduces burden for eligible
clinicians that participate in Shared Savings Program ACOs by using the
same quality data reported by the ACO using the the CMS web interface
for purposes of the Shared Savings Program to score the MIPS quality
performance category for these eligible clinicians.
In this CY 2018 PFS proposed rule, we propose further refinements
to the Shared Savings Program rules. This rule includes two proposed
modifications to the Shared Savings Program beneficiary assignment
methodology: (1) Revisions to the assignment methodology under 42 CFR
part 425, subpart E to reflect the requirement under section 17007 of
the 21st Century Cures Act (Pub. L. 114-255, December 13, 2016), that
for performance years beginning on or after January 1, 2019, the
Secretary determine an appropriate method to assign Medicare FFS
beneficiaries to an ACO based on their utilization of services
furnished by rural health clinics (RHCs) or federally qualified health
centers (FQHCs), and (2) addition of new chronic care management and
BHI service codes to our definition of primary care services. In
addition, we propose to revise the methodology used in our quality
validation audits and the manner in which the results of these audits
may be used to adjust an ACO's sharing rate. We also propose to reserve
the discretion to redesignate a measure reported through the CMS web
interface as pay-for-reporting when substantive changes are made to the
measure under the Quality Payment Program.
We also address proposals intended to reduce application burden for
stakeholders by reducing certain documentation submission requirements
included in the initial Shared Savings Program application and the
application for use of the skilled nursing facility (SNF) 3-Day Rule
Waiver. We also propose to establish specific procedures to address
situations where a Taxpayer Identification Number (TIN) that is an ACO
participant in more than one ACO begins to submit claims for services
used in the beneficiary assignment process and becomes out of
compliance with the ``exclusivity'' requirement in Sec. 425.306(b)(2).
Finally, we propose that, for performance year 2018 and subsequent
years, we would only include individually beneficiary identifiable
payments made under a demonstration, pilot or time limited program that
are final and not subject to further reconciliation in financial
calculations related to establishing and updating benchmarks and
determining performance year expenditures under the Shared Savings
Program.
1. Modifications to the Shared Savings Program Beneficiary Assignment
Methodology
a. Assignment of Beneficiaries to ACOs That Include RHCs and/or FQHCs
(1) Background
(a) General Shared Savings Program Assignment Methodology
As originally enacted in the Affordable Care Act, section 1899(c)
of the Act requires us to assign FFS beneficiaries to an ACO
participating in the Shared Savings Program based on the beneficiary's
utilization of primary care services rendered by physicians
participating in the ACO. Medicare FFS beneficiaries do not enroll in
the Shared Savings Program or with a particular ACO, and they retain
the right to seek Medicare-covered services from any Medicare-enrolled
provider or supplier of their choosing. Furthermore, no exclusions or
restrictions based on health conditions or similar factors are applied
in the assignment of Medicare FFS beneficiaries. Thus, a beneficiary's
choice to receive primary care services during a prior 12 month period
(the ``assignment window'') furnished by physicians and certain
nonphysician practitioners that are ACO professionals in the ACO
determines the beneficiary's assignment to an ACO under the Shared
Savings Program.
The regulations governing the assignment methodology under the
Shared Savings Program are in part 425, subpart E. Consistent with the
statutory requirement to base assignment on the utilization of primary
care services furnished by physicians who are ACO professionals, a
beneficiary is eligible for assignment to an ACO under Sec. 425.402 if
the beneficiary had at least one primary care service during the
applicable assignment window furnished by a physician who is an ACO
professional in the ACO and who is a primary care physician as defined
under Sec. 425.20 or has one of the primary specialty designations
specified in Sec. 425.402(c). This initial process for determining
whether a beneficiary is eligible for assignment is referred to as the
assignment ``pre-step''. Under the first step of the assignment
process, a beneficiary who is eligible for assignment to the ACO will
be assigned to the ACO if the allowed charges for primary care services
furnished to the beneficiary during the assignment window by all
primary care physicians who are ACO professionals and non-physician ACO
professionals in the ACO are greater than the allowed charges for such
services provided during the assignment window by primary care
physicians, nurse practitioners, physician assistants, and clinical
nurse specialists who are ACO professionals in another ACO or not
affiliated with any ACO and are identified by a Medicare-enrolled
billing TIN. The second step of the assignment process considers the
remainder of beneficiaries who have received at least one primary care
service during the assignment window from an ACO physician who is a
primary care physician as defined under Sec. 425.20 or who has one of
the primary specialty designations specified in Sec. 425.402(c),
[[Page 34106]]
but have received no primary care services during the assignment window
from a primary care physician, nurse practitioner, physician assistant,
or clinical nurse specialist either inside or outside the ACO. These
beneficiaries are assigned to the ACO if the allowed charges for
primary care services furnished during the assignment window by
physicians who are ACO professionals in the ACO with one of the
specialty designations specified in Sec. 425.402(c) are greater than
the allowed charges for primary care services furnished during the
assignment window by physicians with such specialty designations who
are ACO professionals in another ACO or who are not affiliated with any
ACO and are identified by a Medicare-enrolled billing TIN. Thus, the
assignment methodology simultaneously maintains the statutory
requirement to focus on physician primary care services in beneficiary
assignment, while recognizing the necessary and appropriate role of
specialists and non-physician practitioners in providing primary care
services, such as in areas with primary care physician shortages.
(b) Retrospective vs Prospective Assignment
As discussed in detail in the November 2011 final rule we finalized
a claims-based hybrid approach (called preliminary prospective
assignment with retrospective reconciliation) for assigning
beneficiaries to an ACO (76 FR 67851 through 67870), which is currently
applicable to ACOs participating under Track 1 or Track 2 of the Shared
Savings Program. Under this approach, beneficiaries are preliminarily
assigned to an ACO at the beginning of a performance year and quarterly
thereafter during the performance year, but the final beneficiary
assignment is determined after each performance year based on where
beneficiaries chose to receive a plurality of their primary care
services during the performance year. We adopted this policy because we
believe that the methodology balances beneficiary freedom to choose
healthcare providers under FFS Medicare during the performance year
with the ACO's desire to know in advance about beneficiaries who have
chosen to receive such services from practitioners participating in the
ACO in the past and who are likely to continue to choose to receive
such services during the performance year. Knowing in advance which
beneficiaries are likely to receive a plurality of their primary care
from ACO practitioners during the performance year gives ACOs greater
opportunities to proactively impact the quality and cost of care for
beneficiaries who may be assigned to the ACO at the end of the
performance year.
In the June 2015 final rule, and in response to stakeholders'
suggestions, we implemented an option for ACOs to participate in a new
two-sided performance-based risk track, Track 3 (80 FR 32771 through
32781). Under Track 3, beneficiaries are prospectively assigned to the
ACO at the beginning of the performance year using the same two-step
methodology described previously, based on where the beneficiaries have
chosen to receive a plurality of their primary care services during a
12-month assignment window offset from the calendar year that reflects
the most recent 12 months for which data are available prior to the
start of the performance year. The ACO is held accountable for
beneficiaries who are prospectively assigned to it for the performance
year. Under limited circumstances, a beneficiary may be excluded from
the prospective assignment list during or after the performance year.
For example, a beneficiary will be excluded from the prospective
assignment list if the beneficiary enrolls in Medicare Advantage during
the performance year or no longer lives in the United States or U.S.
territories and possessions, based on the most recent available data
regarding the beneficiary's residence at the end of the performance
year. A beneficiary is not excluded from the ACO's prospective
assignment list during the performance year or at the time of
reconciliation for most other reasons, such as if the beneficiary chose
to receive most or all of his or her primary care during the
performance year from providers and suppliers outside the ACO.
Additionally, no beneficiaries are added to the ACO's prospective
assignment list during the performance year or at the time of
reconciliation even if they chose to receive a plurality of their
primary care during the performance year from ACO professionals
participating in the ACO and were not previously identified on the
prospective assignment list. Offering this alternative approach to
beneficiary assignment responds to stakeholders who expressed a desire
for a prospective assignment approach. These stakeholders believe
prospective assignment will provide more certainty about the
beneficiaries for whom the ACO will be held accountable during the
performance year, thus enabling ACOs to redesign their patient care
processes to more efficiently and effectively improve care for specific
FFS beneficiaries rather than for all FFS beneficiaries. We note,
however, that such certainty is limited because prospectively assigned
beneficiaries who meet the exclusion criteria specified in Sec.
425.401(b) during the performance year will not be assigned to the ACO
at the end of the year; further, as noted, beneficiaries remain free
under FFS Medicare to choose the healthcare providers from whom they
receive services.
Finally, in the CY 2017 Physician Fee Schedule final rule (81 FR
80501 through 80510), we further enhanced the claims-based beneficiary
assignment methodology by finalizing a policy to incorporate data
gathered directly from beneficiaries who designate a ``main doctor''
they believe is responsible for coordinating their overall care.
Beginning in performance year 2017, beneficiaries may designate a
provider or supplier as responsible for coordinating their overall care
using MyMedicare.gov, a secure, online, patient portal. Notwithstanding
the assignment methodology in Sec. 425.402(b), beneficiaries who
designate an ACO professional whose services are used in assignment as
responsible for their overall care will be prospectively assigned to
the ACO in which that ACO professional participates, provided the
beneficiary meets the eligibility criteria established at Sec.
425.401(a) and has had at least one primary care service during the
assignment window with an ACO professional in the ACO who is a primary
care physician or a physician with one of the primary specialty
designations included in Sec. 425.402(c). Such beneficiaries will be
added prospectively to the ACO's list of assigned beneficiaries for the
subsequent performance year.
(c) Special Assignment Conditions for RHCs and FQHCs
RHCs and FQHCs are facilities that furnish services that are
typically furnished in an outpatient clinic setting. Prior to October
1, 2014, FQHCs were paid an all-inclusive rate (AIR) per visit for
qualified primary and preventive health services furnished to Medicare
beneficiaries. On October 1, 2014, FQHCs began to transition to a new
FQHC prospective payment system (PPS). FQHCs were required to use HCPCS
coding on all their claims starting on January 1, 2011, to inform the
development of the PPS and for limited other purposes, and are now
required to use HCPCS coding for payment purposes under the FQHC PPS.
[[Page 34107]]
RHCs are paid an AIR per visit for qualified primary and preventive
health services furnished to Medicare beneficiaries. Prior to April 1,
2016, RHCs were required to report HCPCS codes for a few services, such
as certain preventive services eligible for a waiver of the deductible
and/or coinsurance, services subject to frequency limits, and services
eligible for payments in addition to the AIR. Effective April 1, 2016,
all RHCs are required to report the appropriate HCPCS code for each
service furnished during the visit, along with the appropriate revenue
code (For additional background, please see the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Reporting-FAQs.pdf).
As we noted in the November 2011 final rule, RHC and FQHC claims
contain very limited information concerning the individual
practitioner, or even the type of health professional (for example,
physician, PA, or NP) who provided the service because this information
is not necessary to determine payment rates for services in RHCs and
FQHCs s (76 FR 67858 through 67861). Therefore, unlike physician fee
schedule claims, there is no direct way for us to determine if a claim
was for a service furnished by a physician at the RHC or FQHC.
In spite of the difference in claims billing, based on detailed
comments from some RHC and FQHC representatives, in the November 2011
final rule, we established a process that allows primary care services
furnished in RHCs and FQHCs to be considered in the assignment process
for any ACO that includes an RHC or FQHC as an ACO participant. This
process is set forth in Sec. 425.404. We assign beneficiaries to ACOs
that include RHCs or FQHCs as ACO participants in a manner generally
consistent with how we assign beneficiaries to other ACOs based on
primary care services performed by certain physicians and non-physician
practitioners who are ACO professionals in the ACO, as described
previously. However, to address the requirement under section 1899(c)
of the Act that beneficiaries be assigned to an ACO based on their use
of primary care services furnished by physicians, we require ACOs that
include RHCs or FQHCs to identify, through an attestation, the
physicians that directly provide patient primary care services in their
ACO participant RHCs or FQHCs (see Sec. Sec. 425.204(c)(5)(iii) and
425.404(a)). We use the combination of the RHC or FQHC ACO participant
TIN (and another unique identifier, such as a CCN, where appropriate)
and the NPIs of the RHC or FQHC physicians provided to us through the
attestation process to identify those beneficiaries who received a
primary care service from a physician in the RHC or FQHC and who are
therefore eligible to be assigned to the ACO as provided under Sec.
425.402(b)(1), which we refer to as the assignment ``pre-step''. Then,
we assign those beneficiaries to the ACO, using the step-wise
assignment methodology under Sec. 425.402(b), if they received the
plurality of their primary care services, as determined based on
allowed charges for the HCPCS codes and revenue center codes included
in the definition of primary care services at Sec. 425.20, from ACO
professionals in the ACO.
The special procedures that we have established for using RHC and
FQHC services in the assignment methodology are discussed in detail in
the June 2015 final rule (80 FR 32755 through 32756). RHC and FQHC
services are billed on an institutional claim form and require special
handling to incorporate them into the beneficiary assignment process.
For RHCs and FQHCs that are ACO participants, we treat an RHC or FQHC
service reported on an institutional claim as a primary care service
performed by a primary care physician if the claim includes a HCPCS or
revenue center code that is included in the definition of a primary
care service at Sec. 425.20 and the service was furnished by a
physician who was identified as directly providing primary care
services on the attestation provided under Sec. 425.404(a). All such
physicians are considered primary care physicians for purposes of the
assignment methodology and no specialty code is required for these
claims. If the claim is for a primary care service furnished by someone
other than a physician listed on the attestation, we treat the service
as a primary care service furnished by a non-physician ACO
professional. As a result, all primary care services furnished by an
ACO professional in an RHC or FQHC to a beneficiary eligible for
assignment to the ACO are considered in step 1 of the assignment
methodology. Finally, for RHCs and FQHCs that are not ACO participants,
we assume a primary care physician performed all primary care services
so that all primary care services furnished by non-ACO RHCs/FQHCs are
considered in step 1 of the assignment methodology. We believe this
approach helps to ensure that we do not disrupt established
relationships between beneficiaries and their caregivers in non-ACO
participant RHCs and FQHCs by inappropriately assigning beneficiaries
to ACOs that are not primarily responsible for coordinating their
overall care.
We developed and implemented these regulatory and operational
policies to facilitate full participation of rural providers, including
RHCs and FQHCs, in the Shared Savings Program, within the statutory
requirements for the program. In general, stakeholders have been
appreciative of our policies to include rural providers and suppliers
in the Shared Savings Program. However, some stakeholders have
expressed concerns that the special conditions required for us to
consider RHC and FQHC institutional claims in beneficiary assignment
are burdensome and discourage ACOs from including RHCs and FQHCs as ACO
participants in the Shared Savings Program. Stakeholders have commented
that the requirement for ACOs that include an RHC or FQHC as an ACO
participant to provide an attestation identifying ACO professionals who
are physicians who directly furnish primary care services at the RHC or
FQHC is particularly burdensome. In addition, due to the operational
complexities of collecting identifying information about ACO
participants, screening them for program integrity and other potential
issues, and incorporating claims data for approved ACO participants
into beneficiary assignment and financial calculations, we have
implemented a policy that limits the addition of entities to the ACO
participant list, absent unusual circumstances, to an annual basis. The
limitation also applies to changes to the attestation to identify
additional physicians who directly furnish primary care services at an
ACO participant RHC or FQHC. In contrast, when a new ACO professional
begins billing for primary care services under the TIN of an ACO
participant that is not an RHC or FQHC, those services will be
considered for purposes of assignment in the current performance year.
As a result, there are a number of unique burdens and anomalies in the
way in which RHC and FQHC institutional claims are used for purposes of
assignment under the Shared Savings Program. First, as noted by
stakeholders, the required attestation process for submitting physician
identifiers requires more effort to ensure the accuracy of the ACO
participant list (including the attestation that includes the physician
identifiers) than the level of effort required for ACOs that do not
include RHCs and FQHCs. Second, we have recognized that the required
attestation process for submitting physician identifiers is also prone
to error because some RHCs and FQHCs
[[Page 34108]]
(particularly rural FQHCs) have multiple locations with potentially
hundreds of NPIs to report which, in turn, increases the likelihood
that ACOs that include RHCs or FQHCs as ACO participants will make
inadvertent clerical errors, such as transposing digits, in submitting
the required information. Errors that are not identified and corrected
by the specified deadline for additions to the ACO participant list may
result in fewer claims being considered for purposes of assignment
under the Shared Savings Program than would otherwise occur.
(2) Proposals
Section 17007 of the 21st Century Cures Act, amended section
1899(c) of the Act (42 U.S.C. 1395jjj(c)) to require the Secretary to
assign beneficiaries to ACOs participating in the Shared Savings
Program based not only on their utilization of primary care services
furnished by physicians but also on their utilization of services
furnished by RHCs and FQHCs, effective for performance years beginning
on or after January 1, 2019. The statute provides the Secretary with
broad discretion to determine how to incorporate services provided by
RHCs and FQHCs into the Shared Savings Program beneficiary assignment
methodology.
We believe that the 21st Century Cures Act provides the Secretary
with broad discretion to revise the assignment methodology to address
the concerns expressed by certain stakeholders regarding the burdens
placed on ACOs that include RHCs and FQHCs as ACO participants, as
described above. Section 17007 of the 21st Century Cures Act provides
that for performance years beginning on or after January 1, 2019,
Medicare services furnished in an FQHC or RHC should be considered in
beneficiary assignment for the Shared Savings Program, as may be
determined by the Secretary. Accordingly, in implementing section 17007
of the 21st Century Cures Act, we believe it would be appropriate to
reduce operational burdens for ACOs that include RHCs or FQHCs as ACO
participants and bring greater consistency to the operational method of
using claims to assign beneficiaries to ACOs. In order to promote
participation of RHCs and FQHCs under the Shared Savings Program, we
propose to remove the burdensome attestation requirement and instead
treat a service reported on an RHC or FQHC institutional claim as a
primary care service furnished by a primary care physician. Consistent
with the 21st Century Cures Act, under this proposal: (1) The
requirement for an attestation identifying physicians who directly
provide primary care services in each RHC or FQHC that is an ACO
participant and/or ACO provider/supplier in the ACO would be removed;
(2) all RHC and FQHC claims would be used to establish beneficiary
eligibility to be assigned to the ACO (pre-step); and (3) all RHC and
FQHC claims would be included in step 1. We would note that in
considering all services billed under the TIN of the ACO participant
RHC or FQHC, we would include services that do not meet the definition
of primary care services, and such services would not be limited to
those provided by a primary care physician, as defined under program
rules. This means that under the proposal, a beneficiary could be
furnished services in an RHC and FQHC only by a nurse practitioner,
physician assistant, clinical nurse specialist, or any other
practitioner in an RHC and FQHC and still be eligible for assignment to
the ACO.
More specifically, we are proposing the following changes to our
regulations: (1) Remove Sec. 425.204(c)(5)(iii) in its entirety; (2)
revise Sec. 425.404; and (3) make conforming changes to the definition
of primary care physician found at Sec. 425.20. Under our proposal,
for performance year 2019 and subsequent performance years, ACOs with
ACO participants that are RHCs and FQHCs would no longer be required to
submit NPIs or other identifying information for physicians who
directly provide primary care services in the ACO participant RHCs and
FQHCs as indicated in Sec. 425.204(c)(5)(iii)(A) and Sec. 425.404(a).
Therefore we propose to remove Sec. 425.204(c)(5)(iii) in its
entirety. Additionally, we propose revisions to Sec. 425.402 and Sec.
425.404 to reflect that for performance year 2019 and subsequent
performance years, we would assign beneficiaries to ACOs based on
services furnished in RHCs or FQHCs consistent with the general
assignment methodology in Sec. 425.402, by treating a service reported
on an RHC or FQHC institutional claim in the same way as a primary care
service performed by a primary care physician. We also propose to
remove revenue center codes from the definition of primary care
services (Sec. 425.20) for performance year 2019 and subsequent
performance years because all RHC and FQHC services will be used for
purposes of assignment for benchmark and performance years; therefore,
we believe it is appropriate to modify our definition of primary care
services for performance year 2019 and subsequent years to no longer
include revenue center codes. Additionally, we note that the
requirement for an attestation under Sec. 425.404 is also referenced
in the definition of primary care physician at Sec. 425.20;
accordingly, we propose to make a conforming revision to that
definition to remove the reference to the attestation requirement for
performance year 2019 and subsequent years.
Consistent with how we have implemented other changes to the
assignment methodology (see, for example, 80 FR 32757 through 32758),
we propose to adjust all ACO benchmarks at the start of the first
performance year in which the new assignment rules are applied so that
the ACO benchmarks reflect the use of the same assignment rules as will
apply in the performance year. Also consistent with how we have
implemented previous changes to the Shared Savings Program assignment
methodology, we would use the new methodology each time assignment is
determined for purposes of performance year 2019, including using the
new methodology in late CY 2018 to determine the eligibility of ACOs
wishing to enter into or renew a participation agreement beginning
January 1, 2019. Under the Shared Savings Program, ACOs must have and
maintain at least 5,000 assigned beneficiaries.
We believe this proposal would reduce administrative burden for
ACOs that include RHCs or FQHCs as ACO participants and support our
policy goal of assigning beneficiaries to the entity that is primarily
responsible for the beneficiary's overall care. That is, including all
services furnished by RHCs or FQHCs to establish beneficiary
eligibility to be assigned to an ACO (pre-step) and in the stepwise
assignment methodology should help to ensure that a beneficiary is
assigned to an ACO when the ACO participants in that ACO are providing
the plurality of care for that beneficiary and thus the ACO should be
accountable for the patient's overall care.
We welcome comments on our proposal to: (1) Remove Sec.
425.204(c)(5)(iii) and modify Sec. 425.402 and Sec. 425.404, for
performance year 2019 and subsequent performance years, to eliminate
the requirement for ACOs that include an RHC or FQHC as an ACO
participant to provide an attestation identifying physicians who
directly provide primary care services in each RHC or FQHC that is an
ACO participant and/or ACO provider/supplier in the ACO, and make
conforming changes to the definition of primary care physician at Sec.
425.20; and (2) for performance year 2019 and subsequent performance
years, to: (a)
[[Page 34109]]
Use all claims submitted by RHCs and FQHCs in the ``pre-step'' of the
assignment methodology under Sec. 425.402 to determine whether a
beneficiary is eligible for assignment to an ACO participating in the
Shared Savings Program, (b) treat a service reported on an RHC or FQHC
claim as if it were a primary care service performed by a primary care
physician, and (c) remove revenue center codes from the definition of
primary care services.
We recognize the unique needs and challenges of rural and
underserved communities and the important role played by providers and
suppliers serving these communities in assuring access to primary
health care. RHCs, FQHCs, and other providers furnishing care in rural
and underserved communities play an important role in the nation's
health care delivery system by serving as safety net providers of
primary care and other health care services, and we believe these
proposed changes will enhance their ability to participate in the
Shared Savings Program.
We also invite suggestions on how we might further support
participation of RHCs and FQHCs in the Shared Savings Program.
b. Revisions to the Definition of Primary Care Services
(1) Background
Section 1899(c) of the Act requires the Secretary to assign
beneficiaries to an ACO ``based on their utilization of primary care
services'' provided by a physician. However, the statute does not
specify which kinds of services may be considered primary care services
for this purpose, nor the amount of those services that would be an
appropriate basis for making assignments. In this section of this
proposed rule, we summarize how we currently identify the appropriate
primary care services on which we base assignment. In addition, we
propose a revision to our current policies for defining primary care
services for purposes of beneficiary assignment, consistent with our
statement in the November 2011 final rule (76 FR 67853), that we
intended to monitor this issue and would consider making changes to the
definition of primary care services to add or delete HCPCS codes used
to identify primary care services, if there were sufficient evidence
that revisions were warranted.
We currently define primary care services for purposes of the
Shared Savings Program in Sec. 425.20 as the set of services
identified by the following HCPCS/CPT codes: 99201 through 99215, 99304
through 99318 (excluding claims including the POS 31 modifier), 99319
through 99340, 99341 through 99350, 99495, 99496, 99490, the Welcome to
Medicare visit (G0402), and the annual wellness visits (G0438 and
G0439). In addition, we have established a cross-walk for these codes
to certain revenue center codes used by FQHCs (for services furnished
prior to January 1, 2011) and RHCs so that their services can be
included in the beneficiary assignment process. Lastly, we include
G0463 for services furnished in electing teaching amendment (ETA)
hospitals.
In the November 2011 final rule (76 FR 67853), we established the
initial list of codes that we considered to constitute primary care
services for several reasons. First, we believed the listed codes
represented a reasonable approximation of the kinds of services that
are described by the statutory language which refers to assignment of
``Medicare fee-for-service beneficiaries to an ACO based on their
utilization of primary care services'' furnished by physicians. In
addition, we selected this list to be largely consistent with the
definition of primary care services in section 5501 of the Affordable
Care Act. That section establishes the Primary Care Incentive Payment
Program to expand access to primary care services, and thus its
definition of primary care services provides a compelling precedent for
adopting a similar list of codes for purposes of the beneficiary
assignment process under the Shared Savings Program. We slightly
expanded the list of codes found in section 5501 of the Affordable Care
Act to include the Welcome to Medicare visit (HCPCS code G0402) and the
annual wellness visits (HCPCS codes G0438 and G0439) as primary care
services for purposes of the Shared Savings Program. These codes
clearly represent primary care services frequently received by Medicare
beneficiaries, and in the absence of the special G codes the services
provided during these visits would be described by one or more of the
regular office visit codes that are included in the list under Section
5501 of the Affordable Care Act.
In the June 2015 final rule (80 FR 32746 through 32748), we
expanded the definition of primary care services to include two
transitional care management (TCM) codes (CPT codes 99495 and 99496),
and one chronic care management (CCM) code, (CPT 99490). As discussed
in the final rule, the TCM codes were established to pay a patient's
physician or practitioner to coordinate the patient's care in the 30
days following a hospital or skilled nursing facility (SNF) stay.
Including these codes in the definition of primary care services
reflects our belief that the work of community physicians and
practitioners in managing a patient's care following discharge from a
hospital or nursing facility to ensure better continuity of care for
these patients and help reduce avoidable readmissions is a key aspect
of primary care.
In the CY 2017 PFS Final Rule, we finalized a separate payment for
three additional CCM service codes, CPT codes 99487 and 99489 (see 81
FR 80251), and an additional add-on code G0506 (see 81 FR 80245), to
support care management for the most complex and time-consuming cases
of beneficiaries with multiple chronic conditions. These codes are used
to report complex CCM services furnished to patients with multiple (two
or more) chronic conditions. CCM services generally include regular
development and revision of a plan of care, communication with other
treating health professionals, and medication management. We explained
in the CY 2017 PFS final rule that we believe the addition of the
complex CCM codes will retain elements of the CCM service that are
characteristic of the changes in medical practice toward advanced
primary care, while eliminating redundancy, simplifying provision of
the services, and improving access to the services. Additional
explanation of required elements for billing CCM services can be found
in the CY 2017 PFS Final Rule (81 FR 80243 through 80251).
Finally, in the 2017 PFS final rule (81 FR 80230 through 80243), we
finalized a policy to make separate payments to physicians and non-
physician practitioners for behavioral health integration (BHI)
services they furnish to beneficiaries over a calendar month service
period using four new Medicare Part B billing codes. Three of these BHI
codes (G0502, G0503, G0504) are used to bill for monthly services
furnished using the Psychiatric Collaborative Care Model (CoCM), an
approach to BHI shown to improve outcomes in multiple studies. CoCM is
a model of BHI that enhances ``usual'' primary care by adding two key
services: Care management support for patients receiving behavioral
health treatment; and regular psychiatric inter-specialty consultation
to the primary care team, particularly regarding patients whose
conditions are not improving. The fourth BHI service code (G0507) is
used to bill monthly services furnished using BHI models of care other
than CoCM that similarly include ``core'' service elements such as
systematic assessment and monitoring, care plan revision for
[[Page 34110]]
patients whose condition is not improving adequately, and a continuous
relationship with a designated care team member. The BHI service codes
may be billed by the treating practitioner. Physicians billing for
these services would typically be primary care physicians, but may be
of another specialty such as cardiology or oncology. Non-physician
practitioners (PAs, NPs, CNSs, or CNMs), may also bill for these
services.
(2) Proposals
As discussed above, we previously finalized the inclusion of CCM
code 99490 in the definition of primary care services for the Shared
Savings Program. For the same reason that we included CCM code 99490,
we believe that it would be also be appropriate to include the complex
CCM service codes 99487, 99489, and G0506 in the definition of primary
care services and to utilize these codes in the beneficiary assignment
methodology under the Shared Savings Program beginning in 2018 for
performance year 2019 and subsequent years. These three additional CCM
codes reflect the changes in medical practice toward advanced primary
care and differ from each other only in the amount of clinical staff
service time provided; the complexity of medical decision-making as
defined in the Evaluation and Management guidelines (determined by the
problems addressed by the reporting practitioner during the month); and
the nature of care planning that was performed (establishment or
substantial revision of the care plan for complex CCM versus
establishment, implementation, revision, or monitoring of the care plan
for non-complex CCM).
In addition, we believe that it would be also be appropriate to
include the four BHI codes G0502, G0503, G0504 and G0507 in the
definition of primary care services and to utilize these codes in the
beneficiary assignment methodology under the Shared Savings Program
beginning in 2018 for performance year 2019 and subsequent years. These
BHI codes reflect important enhancements in primary care to support
improvement and integration of care provided for patients receiving
behavioral health treatment. As discussed above, the BHI service codes
may be billed by the treating practitioner (a physician and/or non-
physician practitioner (PA, NP, CNS, CNM)). Physicians billing for
these services would typically be primary care physicians, but may be
of another specialty such as cardiology or oncology. (See fact sheet
available on our Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-Fact-Sheet.pdf.)
Therefore, we propose to revise the definition of primary care
services currently located in Sec. 425.20 to include three additional
CCM service codes 99487, 99489, and G0506, and four BHI service codes
G0502, G0503, G0504 and G0507, beginning in 2018 for performance year
2019 and subsequent performance years and to include these codes when
performing beneficiary assignment under Sec. 425.402. In addition, we
propose to move the list of service codes currently listed in the
definition in Sec. 425.20 to Sec. 425.400(c). We believe Sec.
425.400, which specifies general requirements related to the assignment
methodology and currently contains a cross-reference at Sec.
425.400(c) to the definition of primary care services under Sec.
425.20, is the more appropriate place to specify the particular primary
care codes that will be considered in the assignment methodology. We
also propose to reorganize the list of service codes, grouping HCPCS
codes, G codes, and revenue center codes together, respectively, by
relevant performance year(s). We seek comments on this proposal. In
addition, we seek comments as to whether there are any additional
existing HCPCS/CPT codes, that we should consider adding to the
definition of primary care services in future rulemaking for purposes
of assignment of beneficiaries to ACOs under the Shared Savings
Program.
We also propose to remove paragraph (3) from the definition of
primary care services. Paragraph (3) indicates that we will include
additional codes designated by us as primary care services, including
new HCPCS/CPT and revenue center codes and any subsequently modified or
replacement codes for the HCPCS/CPT and revenue center codes identified
in the definition. We finalized this policy in the June 2015 final rule
(80 FR 32746), explaining that it was intended to promote flexibility
for the Shared Savings Program and allow us to respond more quickly to
HCPCS/CPT coding changes made in the annual PFS rulemaking process. We
now believe this paragraph which directs CMS to respond to HCPCS/CPT
coding changes though rulemaking is unnecessary because we always have
the flexibility to propose, through the annual PFS rulemaking (or other
rulemaking for the Shared Savings Program), to make changes to the
definition of primary care services to reflect HCPCS/CPT coding changes
made elsewhere in the same PFS rulemaking or in a previous PFS final
rule. We therefore believe it would be reasonable to remove this
paragraph rather than move it to subpart E under part 425 along with
the other paragraphs making up the definition of primary care services.
2. ACO Quality Reporting
a. Changes to the Quality Measure Set Used in Establishing the Quality
Performance Standard
(1) Background
Section 1899(b)(3)(A) of the Act requires the Secretary to
determine appropriate measures to assess the quality of care furnished
by ACOs, such as measures of clinical processes and outcomes; patient
and, wherever practicable, caregiver experience of care; and
utilization, such as rates of hospital admission for ambulatory
sensitive conditions. Section 1899(b)(3)(B) of the Act requires ACOs to
submit data in a form and manner specified by the Secretary on measures
that the Secretary determines necessary for ACOs to report to evaluate
the quality of care furnished by ACOs. Section 1899(b)(3)(C) of the Act
states that the Secretary shall establish quality performance standards
to assess the quality of care furnished by ACOs and seek to improve the
quality of care furnished by ACOs over time by specifying higher
standards, new measures, or both. We designate the quality performance
standard that will apply for each performance year. The quality
performance standard is the overall standard the ACO must meet in order
to be eligible for shared savings.
In the November 2011 final rule (76 FR 67973), we initially
established a quality performance standard consisting of 33 measures
across 4 domains (see Sec. 425.502(d)), including patient experience
of care, care coordination/patient safety, preventive health, and at-
risk population and a methodology for scoring the measures submitted by
ACOs (see Sec. 425.502(e)). Quality measures are submitted by the ACO
through the CMS web interface, calculated by us from administrative and
claims data, and collected via a patient experience of care survey
based on the Clinician and Group Consumer Assessment of Healthcare
Providers and Systems (CG-CAHPS) survey. To qualify for shared savings
(see Sec. Sec. 425.604(c), 425.606(c), and 425.610(c)), an ACO must
meet or exceed its minimum savings rate, meet the minimum quality
performance standards established under Sec. 425.502, and otherwise
maintain its eligibility to participate in the Shared Savings Program.
For example, under the
[[Page 34111]]
regulation at Sec. 425.604(d), an ACO participating in the Shared
Savings Program under Track 1 that meets all the requirements for
receiving shared savings payments will receive a shared savings payment
of 50 percent of all savings under the updated benchmark (up to the
performance payment limit).
Since the November 2011 Shared Savings Program final rule, we have
continued to review the quality measures used for the Shared Savings
Program to ensure that they are up to date with current clinical
practice and are aligned with the CMS web interface reporting for PQRS,
and most recently, with reporting requirements under the Quality
Payment Program. Through the annual rulemaking for the PFS we have
reviewed and updated the quality measures reported by ACOs through the
CMS web interface, including adding new measures and retiring measures
that were redundant or no longer met the goals for group reporting, and
ensuring that the ACO CMS web interface reported measures align with
the measures reported through the CMS web interface by group practices
in other CMS initiatives such as PQRS and the Quality Payment Program.
The quality measure set currently includes 31 quality measures (see
Tables 42 and 43 at 81 FR 80488 and 80489). To avoid confusion and
duplication of rulemaking, and reduce provider burden, we also
finalized a policy in the 2017 PFS final rule that future changes to
the CMS web interface measure will be made through rulemaking for the
Quality Payment Program and will be applicable to ACO quality reporting
under the Shared Savings Program (81 FR 80499 and 80500). Under the APM
scoring standard finalized in the CY 2017 Quality Payment Program final
rule (81 FR 77255 through 77256), measures reported by Shared Savings
Program ACOs through the CMS web interface will also be used to
determine the Merit-Based Incentive Payment System (MIPS) quality
performance category score for eligible clinicians participating in a
Shared Savings Program ACO in 2017.
When scoring ACO quality performance in the Shared Savings Program,
we designate a performance benchmark and minimum attainment level for
each measure. Performance below the minimum attainment level for a
measure will receive zero points for that measure and performance equal
to or greater than the minimum attainment level for the measure will
receive points on a sliding scale based on the level of performance. We
update the quality performance benchmarks every 2 years. For the first
performance year of an ACO's first agreement period, we define the
quality performance standard at the level of complete and accurate
reporting for all quality measures. During subsequent performance years
of the ACO's first agreement period, the quality performance standard
is phased in such that the ACO must continue to report all measures but
the ACO will be assessed on performance based on the quality
performance benchmark and minimum attainment level for certain measures
that are designated a pay for performance. The quality performance
standard that applies to an ACO's final year in its first agreement
period also applies for each performance year of an ACO's subsequent
agreement period. A newly introduced measure is set at the level of
complete and accurate reporting for the first 2 reporting periods the
measure is required. For subsequent reporting periods, the quality
performance standard for the measure will be assessed according to the
phase-in schedule for the measure. Pay for reporting measures are worth
2 points each for complete and accurate reporting, whereas pay for
performance measures are worth 0-2 points based on ACO performance
compared to the established benchmark. The EHR measure (ACO-11),
however, is double-weighted and ACOs can earn up to 4 points based on
their performance on this measure.
Additionally, as discussed in the CY 2016 PFS final rule with
comment period (see 80 FR 71269), occasionally issues arise with
measures that cause us to reevaluate whether it is appropriate to hold
an ACO accountable for performance on a measure. For instance, in the
CY 2015 PFS final rule with comment period we retired measures that
were no longer consistent with updated clinical guidelines for
cholesterol targets, but we were unable to finalize retirement of the
measures for the 2014 reporting year due to the timing of the guideline
updates and rulemaking cycle. Because these measures did not align with
updated clinicial guidance, in February 2015, we issued an update to
the guidance document on the Medicare Shared Savings Program Quality
Measure Benchmarks for the 2014 Reporting Year that maintained these
measures, including the Diabetes Composite measure, as pay for
reporting for the 2014 reporting year. In order to address such issues
in the future, we finalized a policy in the CY 2016 PFS final rule with
comment period (80 FR 71269) under which we reserve the right to
maintain a measure as pay for reporting or revert a pay for performance
measure to pay for reporting when the measure owner determines the
measure no longer aligns with clinical practice or continued
application of the measure may result in patient harm (see Sec.
425.502(a)(5)).
(2) Proposals
As previously noted in the background section, we finalized a
policy that future changes to the CMS web interface measures will be
adopted through rulemaking for the Quality Payment Program and will be
applicable to ACO quality reporting under the Shared Savings Program
(81 FR 80501). We also note that, as discussed in the CY 2017 Quality
Payment Program final rule with comment period (81 FR 77136), section
1848(q)(2)(D)(i)(II) of the Act requires the Secretary to update the
final list of quality measures from the previous year (and publish an
updated list in the Federal Register) annually. Updates may include the
removal of quality measures the addition of new quality measures, and
the exclusion of existing quality measures that the Secretary
determines have gone through substantive changes. In the CY 2017
Quality Payment Program final rule with comment period, we indicated
that in the future we would use rulemaking for the MIPS program to
address substantive changes to measures (81 FR 77143). On June 20,
2017, HHS issued a proposed rule that includes a number of proposals to
revise certain policies under the Quality Payment Program for CY 2018,
including a proposal to make substantive changes to several measures
reported through the CMS web interface. For example, substantive
changes are proposed for the way ACO-17 Tobacco Use: Screening and
Cessation Intervention measure rate is calculated via the CMS web
interface (see Table E, 82 FR 30469). This measure was originally
developed as a two-part measure: The first part of the measure assessed
whether a patient had been screened for tobacco use within the past 24
months; the second part of the measure assessed whether those who had
been screened and identified as tobacco users in the first part of the
measure also received tobacco cessation intervention (either counseling
and/or pharmacotherapy). To date, the two parts of the measure have
been combined into a single performance rate. We have identified two
notable limitations with this approach, including (1) the performance
rate does not show the difference in performance with respect to how
well clinicians adhere to performing tobacco use screenings and how
well clinicians follow the guidelines to provide tobacco
[[Page 34112]]
cessation interventions, and (2) the measure is topped out, meaning it
continuously shows a high performance rate. The changes to the measure
proposed in the CY 2018 Quality Payment Program proposed rule would not
modify the sampling methodology or the data reported into the CMS web
interface. The proposed changes would simply revise the measure
specifications to measure the percent of tobacco users that received
cessation counseling; instead of measuring a combined performance rate
for beneficiaries that were screened for tobacco use and for the subset
of beneficiaries that are tobacco users that received tobacco cessation
counseling.
Substantive changes to other CMS web interface measures are also
proposed. A substantive change is proposed to the Influenza
Immunization measure (ACO-14), however, the changes apply only to the
Registry and EHR data submission methods and not the CMS web interface
reporting method (82 FR 30472). Finally, a substantive change is
proposed for the Body Mass Index Screening and Follow-Up Plan (ACO-16);
specifically, the frequency of documenting BMI will change from 6 to 12
months (82 FR 30471).
Consistent with how we have addressed previous changes to measures,
we reviewed the proposed substantive changes to the CMS web interface
measures proposed in the CY 2018 Quality Payment Program proposed rule
to assess whether the changes, if finalized, would warrant a change in
how the measures are used to assess ACO performance under the Shared
Savings Program. As part of this review, we considered whether the
proposed substantive changes might raise sampling issues or require
that we recalculate the measure benchmarks for purposes of the Shared
Savings Program. Based on our preliminary review of the Quality Payment
Program proposals, we believe the proposed ``substantive'' changes to
the CMS web interface measures would not require that we revert these
measures to pay for reporting for the 2018 performance year. The
Quality Payment Program proposals do not appear to modify the current
structure and reporting of the measures for which substantive changes
are proposed; rather, in the case of the Tobacco Use: Screening and
Cessation Intervention measure, the proposed change would only modify
the way the data are manipulated and calculated after the data are
submitted. Similarly, we do not believe that the proposed substantive
change to the BMI measure to change the frequency of reporting would
impact an ACO's ability to perform well compared to the established
benchmark for this measure. Finally, the substantive change to the
Influenza Immunization measure does not apply to the CMS web interface
reporting method. Therefore, we believe that we will have the data
necessary from past submission periods to calculate appropriate
benchmarks that could be used to assess ACO performance for the CMS web
interface measures under consideration for performance year 2018 and
subsequent years. Additionally, the recalculation of the benchmark
coincides with the biannual timing of the benchmark updates. Therefore,
if the proposed changes to the measures are finalized under the Quality
Payment Program, we do not believe it would be necessary or
appropriate, to revert the measures to pay for reporting under the
Shared Savings Program. Instead, we believe it would be appropriate
under the Shared Savings Program to: (1) Update the measure
specifications through subregulatory guidance in order to continue to
align the measures with the measure specifications used under the
Quality Payment Program and Million Hearts initiative, and (2) retain
the current phase-in schedule for the measures rather than
redesignating any of the measures as pay for reporting.
Because the particular substantive changes that are proposed in the
CY 2018 Quality Payment Program proposed rule do not appear to change
the information that must be collected for these measures (which makes
it possible for us to use data submitted previously to determine prior
performance under the new measure rate, and therefore calculate an
appropriate prospective quality benchmark), we do not believe any
changes to the measures' phase-in schedules are necessary. However, the
statutory directive under the Quality Payment Program to address
substantive changes to measures in rulemaking and the proposals in the
CY 2018 Quality Payment Program proposed rule to address substantive
changes to certain web interface measures have caused us to evaluate
what recourse we might have in the future under the Shared Savings
Program rules to modify a measure's phase-in in instances where a
substantive change to the measure makes it inappropriate to hold ACOs
accountable for performance on a measure that has been substantively
modified. We anticipate that there could be future substantive changes
to the CMS web interface measures made under the Quality Payment
Program that would give us reason to redesignate a measure as pay-for-
reporting under the Shared Savings Program. Currently, although the
Shared Savings Program rules afford flexibility to redesignate a
measure as pay for reporting whem the measure owner determines the
measure no longer aligns with clinical practice or causes patient harm,
there is no discretion to modify how we assess CMS web interface
measures in the event substantive changes are made to those measures
under the Quality Payment Program that make it inappropriate to hold
ACOs accountable for performance on the measure. Given the timing of
the Quality Payment Program proposals in relationship to the timing for
when the quality performance benchmarks must be established under the
Shared Savings Program, it may in some cases be necessary to have
flexibility to designate a pay for performance measure as pay for
reporting just before or following the start of a performance year
outside of the formal rulemaking process, consistent with the way in
which we have redesignated measures in the past when measure owners
have made changes after the start of a performance year. Accordingly,
we believe it would be appropriate to modify the Shared Savings Program
regulations to provide additional flexibility to address substantive
changes to CMS web interface measures that are made under the Quality
Payment Program and to continue to facilitate alignment of measures
with the Quality Payment Program and other CMS initiatives.
We are therefore proposing to modify Sec. 425.502(a)(5) to include
the right for CMS to redesignate a measure as pay-for-reporting when a
substantive change to a CMS web interface measure is made under the
Quality Payment Program. This proposed revision would supplement CMS's
existing discretion to redesignate a measure as pay-for-reporting when
the measure owner determines the measure no longer aligns with clinical
practice or causes patient harm. Specifically, we are proposing to
revise the regulation at Sec. 425.502(a)(5) to reserve CMS's right to
redesignate CMS web interface measures that have undergone a
substantive change as determined under the Quality Payment Program to
pay-for-reporting status. Such measures would not necessarily be
automatically redesignated as pay for reporting when a substantive
change occurs (for example, as indicated previously, we do not believe
the currently proposed substantive changes present an impediment to
holding ACOs accountable for performance on these measures in
performance year 2018 and
[[Page 34113]]
subsequent years); however, in the future, substantive changes made to
CMS web interface measures under the Quality Payment Program (such as
when the substantive change to a measure results in an issue with
sampling, calculating performance, or the calculating the quality
benchmark) may make it inappropriate to hold an ACO accountable for
performance on the measure for the time needed for CMS to obtain the
information necessary to calculate a quality benchmark for the
substantively changed measure in advance of a performance year and/or
until ACOs gain experience reporting the measure, as substantively
changed. Although we expect to conduct at least a preliminary
assessment of any substantive changes to the CMS web interface measures
as part of the annual PFS rulemaking in order to determine whether any
change to the phase in schedule for a measure is warranted, because we
cannot always anticipate the types of substantive changes that may be
finalized under the Quality Payment Program or the effect of those
changes on our ability to calculate performance on the measure, this
proposal would provide us with additional flexibility to redesignate
existing measures undergoing a substantive change as pay-for-reporting
on a measure by measure basis. We believe this additional flexibility
would enable us to more appropriately assess ACO quality performance,
by ensuring that ACOs are not held accountable for performance on a
measure when substantive changes to that measure affect our ability to
assess performance on that measure appropriately. Otherwise, ACOs could
be inappropriately held accountable for performance on such measures
until such time as we could undertake rulemaking to modify the phase-in
schedule for the measure. As with redesignations that occur when the
measure owner determines the measure no longer aligns with clinical
practice or causes patient harm, redesignations that occur due to
substantive changes to a measure would be communicated to ACOs as soon
as possible through operational documents and other typical methods we
use to communicate with ACOs. We invite comments on this proposal.
b. Further Refining the Process Used To Validate ACO Quality Data
Reporting
(1) Background
In the November 2011 final rule, we finalized a proposal to retain
the right to validate the quality measure data ACOs enter into the web
interface (76 FR 67893 through 67894). We believe that the data
validation process implicitly incentivizes ACOs to keep organized and
up-to-date medical records and is necessary to protect against gaming.
This validation process, referred to as the Quality Measures Validation
audit, was based on the process used in Phase I of the Physician Group
Practice (PGP) demonstration. The policy was finalized at Sec.
425.500(e) and involved a process under which we selected a subset of
web interface measures and a random sample of 30 confirmed and
completely reported beneficiaries for each measure in the subset. The
ACO was required to provide medical records to support the data
reported in the web interface for those beneficiaries. A measure-
specific audit performance rate was then calculated using a multi-
phased audit process. If at the conclusion of the third phase there was
a discrepancy greater than 10 percent between the quality data reported
and the medical records provided during the audit, the ACO was not
given credit for meeting the quality target for any measure(s) for
which the mismatch rate existed.
In the CY 2017 PFS final rule (81 FR 80489 through 80492), we
revisited the quality validation audit process and finalized several
significant changes as a result of our experience in conducting audits
and in an effort to increase the statistical rigor of the audit
methodology while streamlining audit operations. We expressed our
intent to align the quality measures validation audit used in the
Shared Savings Program more closely with other CMS quality program
audits, including those performed in the Physician Quality Reporting
Program and the Hospital Inpatient and Outpatient Quality Reporting
programs. We therefore finalized four improvements to our audit process
that addressed the number of records to be reviewed per measure, the
number of audit phases, the calculation of an audit match rate and the
consequences if the audit match rate falls below 90 percent.
Specifically, we finalized a policy under which we will audit enough
medical records to achieve a 90 percent confidence interval; conduct
the audit in a single phase; and calculate an overall audit performance
rate. If at the conclusion of the audit process the overall match rate
between the quality data reported and the medical records provided by
the ACO is less than 90 percent, absent unusual circumstances, we will
adjust the ACO's overall quality score proportional to the ACO's audit
performance. The audit-adjusted quality score is calculated by
multiplying the ACO's overall quality score by the ACO's overall audit
match rate. For example, if an ACO's quality score is 75 percent and
the ACO's audit match rate is 80 percent, the ACO's audit-adjusted
quality score would be 60 percent. The audit-adjusted quality score is
the quality score that will be used to determine the percentage of any
earned savings that the ACO may share or the percentage of any losses
for which the ACO is accountable. We note that under the revised audit
methodology, our intent was to continue to audit a subset of ACOs,
which we would identify by looking for data anomalies such as high skip
rates, although we have flexibility to randomly select ACOs or specific
measures for audit as we have done in the past.
We also finalized a new requirement at Sec. 425.500(e)(3) that an
ACO that has an audit match rate of less than 90 percent may be
required to submit a corrective action plan (CAP) under Sec. 425.216
for our approval. In the CAP, the ACO would be required to explain the
reasons for the low audit match rate and how it plans to improve the
accuracy of its quality reporting in the future. In addition, we noted
that we maintain the right, as described in Sec. 425.500(f), to
terminate or impose other sanctions on any ACO that does not report
quality data accurately, completely, or timely. We indicated that we
would begin applying these policies to the quality validation audits
beginning in 2017 with the quality validation audits of quality
reporting for the 2016 performance year.
(2) Proposals
Since publication of the CY 2017 PFS final rule, we have gained
additional experience with the quality validation audits, and have
performed additional analyses related to these audits. Our analysis of
the 2016 quality measure validation audit results for Shared Savings
Program ACOs indicates that the average match rate of ACOs audited in
calendar year 2016 was 72 percent and the median performance was 80
percent. Typically, during the audit, we review medical record
documentation and work with ACOs to better understand the mismatch
between what was reported and what was documented and have determined
through our analyses that ACOs continue to experience challenges in
understanding certain aspects of the measure specifications,
coordinating collection of information across many different providers
and practices, and satisfying the requirements for supporting
documentation. Many of these errors are not indicative of poor quality
of care but rather reflect minor errors in process or
[[Page 34114]]
in understanding measure requirements. For instance, we have identified
errors by individuals abstracting data from the medical record. In one
case, a medical record abstractor incorrectly misinterpreted the less
than symbol (<) in the quality measure specifications for the ACO-31
Heart Failure: Beta Blocker Therapy for Left Ventricular Systolic
Dysfunction and ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy, and therefore, abstracted
the data incorrectly for reporting.
Under our newly finalized single-phase approach to quality
validation audits, minor errors are more likely to affect the final
audit results and impact the calculation of shared savings or shared
losses when the overall match rate is below 90 percent. Additionally,
we note that the match rate threshold under the Hospital Inpatient
Quality Reporting (HIQR) Program is 75 percent. The HIQR validates data
submitted by hospitals, which are entities that generally have more
experience with quality reporting, greater health record accessibility
and integration, and a longer history of validation of quality data
submitted to CMS.
In light of our analyses of the 2016 quality measure validation
audit results, we believe it is appropriate to consider making
additional modifications to our quality validation audit process.
First, we are concerned that the 90 percent match rate adopted in CY
2017 PFS final rule may be too high and could inappropriately penalize
ACOs that make quality data reporting errors that are unrelated to care
quality. In the early years of phasing in this new audit methodology,
we believe that the match rate should instead be based on actual ACO
experience in order to focus on holding ACOs accountable for clinically
related mismatches in reporting quality measures as they continue to
gain experience with how to measure, report and improve quality under
the program. We believe that basing the audit match rate threshold on
actual validation audit results would strike an appropriate balance
between ensuring the accuracy of ACO quality reporting while not unduly
penalizing ACOs for minor quality reporting errors that are not
necessarily indicative of poor quality care. Accordingly, we believe it
would be appropriate to set the audit match rate threshold based on the
median match rate (80 percent) for ACOs audited in calendar year 2016
rather than an alternative approach such as the mean match rate because
the median match rate would be less affected by data outliers.
Therefore, we are proposing to revise Sec. 425.500(e)(2) to indicate
that if an ACO has a match rate below 80 percent, absent unusual
circumstances, we would adjust the ACO's overall quality score
proportional to the ACO's audit performance.
Second, we propose to amend the method by which we adjust an ACO's
overall quality score to reflect the ACO's audit performance.
Specifically, we propose to revise the methodology described in the
2017 PFS final rule (81 FR 80490) under which the audit-adjusted
quality score is calculated by multiplying the ACO's overall quality
score by the ACO's audit match rate. Instead, we propose that for each
percentage point difference between the ACO's match rate and the match
rate considered passing the audit, the ACO's overall quality score
would be adjusted downward by 1 percent. That is, if we finalize the
proposal to establish an 80 percent match rate as the threshold for
passing the quality validation audit, and the ACO's match rate is 75
percent, then under this proposal we would adjust the ACO's overall
quality score downward by 5 percent. To illustrate, assuming a match
rate threshold of 80 percent, an ACO with an overall quality score of
90 percent would have an audit-adjusted quality score of 85.50 percent,
that is, (90-[.05x90]) = 85.50.
Finally, we propose a conforming change to Sec. 425.500(e)(3) to
reflect the 80 percent threshold such that if at the conclusion of the
audit process CMS determines there is an audit match rate of less than
80 percent, the ACO may be required to submit a CAP.
We believe that over time, as ACOs become more experienced with
quality reporting requirements, improve their quality reporting
processes and become better clinically integrated, quality validation
audit results that show a significant mismatch between the information
reported and the underlying medical records will more consistently
reflect meaningful, clinically related quality reporting errors for
which ACOs should be held accountable. In addition, because the audit
process involves the exchange of information regarding medical record
review and communication between ACOs and us, the audit process,
itself, provides additional education on the quality measures and
quality reporting. Accordingly, we will periodically review the audit
match threshold and seek to increase the match rate over time. We may
also consider requiring a higher match rate for ACOs that have been in
the program longer. Therefore, we anticipate that we will continue to
closely monitor quality validation audit results and the reasons for
mismatches and, over time, seek to increase the audit match rate
threshold.
Although at this time we are proposing the change the audit match
rate threshold to 80 percent, we also seek comment on an alternative
approach we considered to address the quality validation audit match
rate and the resulting impact on an ACO's overall quality score.
Consistent with the approach used under the HIQR program, we
considered revising Sec. 425.500(e)(2) to provide that we would adjust
the ACO's overall quality score if an ACO has a match rate below 75
percent. We did not propose this approach because the results of the
Quality Measures Validation Audits conducted on Shared Savings Program
ACOs in calendar year 2016 yielded a median match rate of 80 percent,
suggesting that a match rate of 75 percent would be too low.
We invite comment on the proposed refinements to the process used
to validate ACO quality data reporting and to adjust an ACO's overall
quality score to reflect the ACO's audit performance, and on the
alternative that was considered, but not proposed.
3. Reducing Shared Savings Program Application Burden
a. SNF 3-Day Rule Waiver Application Requirement That ACOs Report Their
Financial Relationships
(1) Background
The Medicare SNF benefit is for beneficiaries who require a short-
term intensive stay in a SNF, requiring skilled nursing or skilled
rehabilitation care, or both. Under section 1861(i) of the Act,
beneficiaries must have a prior inpatient hospital stay of no fewer
than 3 consecutive days in order to be eligible for Medicare coverage
of inpatient SNF care. In the June 2015 final rule (80 FR 32804 through
32806, 32808), we provided ACOs participating in Track 3 with
additional flexibility to attempt to increase quality and decrease
costs by allowing these ACOs to apply for a waiver of the SNF 3-day
rule to permit their prospectively assigned beneficiaries to receive
coverage for inpatient SNF care without a prior 3-day inpatient
hospital stay when they are admitted to a ``SNF affiliate,'' that is, a
SNF with which the ACO has executed a SNF affiliate agreement, and
certain additional eligibility criteria are met (see Sec.
425.612(a)(1)). Waivers are effective upon our notification to the ACO
of approval for the waiver or the start date of the ACO's participation
agreement, whichever is later (see Sec. 425.612(c)). We stated in the
June 2015 final rule that the SNF 3-day rule waiver
[[Page 34115]]
would be effective for services furnished on or after January 1, 2017.
Program requirements for this waiver are codified at Sec. 425.612.
These requirements are primarily based on criteria previously developed
under the Pioneer ACO Model. Specifically, under Sec. 425.612(a)(1),
we waive the requirement in section 1861(i) of the Act for a 3-day
inpatient hospital stay prior to a Medicare covered post-hospital
extended care service for eligible beneficiaries prospectively assigned
to ACOs participating in Track 3 (and as provided in Sec.
425.612(a)(1)(iv) for certain other beneficiaries), who receive
otherwise covered post-hospital extended care services furnished by an
eligible SNF that has entered into a written agreement to partner with
the ACO for purposes of this waiver. All other provisions of the
statute and regulations regarding Medicare Part A post-hospital
extended care services continue to apply.
We believe that clarity regarding whether SNF services furnished to
a particular beneficiary are eligible for payment under the SNF 3-day
rule waiver is important to help ensure compliance with the conditions
of the waiver and also improve our ability to monitor waivers for
misuse. Therefore, in the June 2015 final rule, we limited the waiver
to ACOs in Track 3 because under the prospective assignment methodology
used in Track 3, beneficiaries are assigned in advance to the ACO for
the entire performance year (unless they meet any of the exclusion
criteria under Sec. 425.401(b)), so it will be clearer to a Track 3
ACO and its SNF affiliates whether the waiver applies to SNF services
furnished to a particular beneficiary than it would be to an ACO in
Track 1 or 2, where beneficiaries are assigned using a preliminary
prospective assignment methodology with retrospective reconciliation
(80 FR 32804). An ACO's use of the SNF 3-day rule waiver will be
associated with a distinct and easily identifiable event, specifically,
admission of a prospectively assigned beneficiary to a previously
identified SNF affiliate without prior inpatient hospitalization or
after an inpatient hospitalization of fewer than 3 days.
Based on our experiences under the Pioneer ACO Model, and in
response to comments, we established certain requirements under Sec.
425.612 that ACOs, ACO providers/suppliers, SNF affiliates, and
beneficiaries must meet for SNF services to be covered under the SNF 3-
day rule waiver under the Shared Savings Program. All ACOs electing to
participate in Track 3 are offered the opportunity to apply for a
waiver of the SNF 3-day rule for their prospectively assigned
beneficiaries at the time of their initial application to participate
in Track 3 of the program and annually thereafter while participating
in Track 3. The program rules for a waiver of the SNF 3-day rule are
under Sec. 425.612 and are discussed in detail in the 2015 final rule
(80 FR 32804 through 32806).
To qualify to use the SNF 3-day rule waiver, ACOs must submit a SNF
3-Day Rule Waiver application that includes supplemental information
sufficient to demonstrate that the ACO has the capacity to identify and
manage beneficiaries who would be either directly admitted to a SNF or
admitted to a SNF after an inpatient hospitalization of fewer than 3
days. Required application materials include but are not limited to the
following:
Narratives describing how the ACO plans to implement the
waiver. Narratives must include a communication plan between the ACO
and its SNF affiliates, a care management plan for beneficiaries
admitted to a SNF affiliate, a beneficiary evaluation and admission
plan approved by the ACO medical director and the health care
professional responsible for the ACO's quality improvement and
assurance processes, and a description of any financial relationships
between the ACO, SNF, and acute care hospitals.
A list of SNFs with which the ACO will partner along with
executed written SNF affiliate agreements between the ACO and each
listed SNF. The agreements must include elements determined by CMS
including but not limited to the following:
++ Agreement to comply with the requirements and conditions of the
Shared Savings Program.
++ The effective dates of the SNF affiliate agreement.
++ Agreement to implement and comply with the ACO's beneficiary
evaluation and admission plan and care management plan.
++ Agreement to validate the eligibility of a beneficiary to
receive covered SNF services in accordance with the waiver prior to
admission.
++ Remedial processes and penalties that will apply for non-
compliance.
Documentation demonstrating that each SNF included on the
submitted list of SNF affiliates has an overall rating of 3 or higher
under the CMS 5-star Quality Rating System as reported on CMS's Nursing
Home Compare Web site.
In addition, Sec. 425.612(b)(3) provides that we will evaluate the
information submitted with the ACO's application for the SNF 3-day rule
waiver and any supplemental information submitted in response to a CMS
request for information to determine whether the ACO's waiver request
satisfies the requirements of Sec. 425.612(a)(1). The effective date
and termination date of the waiver are determined in accordance with
Sec. 425.612(c). Section 425.612(d) provides for monitoring of the use
of the waiver and termination of the waiver, and includes a requirement
that ACOs that have been approved for the SNF 3-day rule waiver post
their approval to use the waiver as part of public reporting under
Sec. 425.308. If our monitoring of an ACO's use of the waiver reveals
misuse of the waiver, we may revoke the ACO's approval to use the
waiver. Additionally, we may revoke an ACO's approval to use a waiver
if the ACO does not successfully meet the quality performance standard
or we identify another program integrity issue affecting the ACO's use
of the waiver.
To be eligible to receive covered services under the SNF 3-day rule
waiver, a beneficiary must be prospectively assigned to the ACO for the
performance year in which he or she is admitted to the SNF affiliate,
may not reside in a SNF or other long-term care setting, must be
medically stable and have an identified skilled nursing or
rehabilitation need that cannot be provided as an outpatient, and must
meet the other requirements set forth in Sec. 425.612(a)(1)(ii).
We noted in the 2015 final rule that we would continue to evaluate
the waiver of the SNF 3-day rule including further lessons learned from
Innovation Center models in which a waiver of the SNF 3-day rule is
being tested (80 FR 32806). We indicated that in the event we
determined that changes were necessary, we would propose these changes
through future rulemaking. Subsequently, based on initial experiences
with the SNF 3-day rule waiver under the Pioneer ACO Model and Next
Generation ACO Model, we proposed and finalized additional SNF 3-day
rule waiver beneficiary protections under Sec. 425.612(a)(1)(iv) and
(v). (See the CY 2017 PFS final rule (81 FR 80510 through 80515)).
We began accepting SNF 3-Day Rule Waiver applications in the summer
of 2016 and approved 26 Track 3 ACOs to begin using the SNF 3-day rule
waiver under the Shared Savings Program effective January 1, 2017.
(2) Proposal
As discussed in this proposed rule, the SNF 3-day rule waiver
requirements are primarily based on criteria previously developed under
the Pioneer
[[Page 34116]]
ACO Model. As a result of our recent experience implementing the waiver
in the Next Generation ACO Model and the Shared Savings Program, we
believe that the rules governing use of the SNF 3-day rule waiver are
generally reasonable. However, based on our initial experiences in
reviewing SNF 3-Day Rule Waiver applications, we believe there are two
requirements, in particular, that impose an unnecessary burden on
applicants, without a sufficient benefit to the administration of the
Shared Savings Program to justify the burden.
First, the requirement under Sec. 425.612(a)(1)(i)(A)(4) that ACOs
submit, as part of their application for the SNF 3-day rule waiver, a
narrative describing any financial relationships that exist between the
ACO, SNF affiliates, and acute care hospitals is burdensome for ACOs
and CMS. As explained in the 2015 final rule (81 FR 32806), the SNF 3-
day rule waiver only provides for coverage of SNF services that meet
all applicable requirements except the requirement for a prior 3-day
inpatient stay. The waiver does not protect financial or other
arrangements between or among ACOs, ACO participants, ACOs providers/
suppliers, or other individuals or entities providing services to
Medicare beneficiaries from liability under the fraud and abuse laws or
any other applicable laws (Sec. 425.612(e)(1)). The Shared Savings
Program regulations do not prohibit ACOs or SNFs from having financial
arrangements with acute care hospitals, nor do they require such
arrangements. Therefore, we have found that the narratives are not
useful to us for purposes of determining whether to approve a waiver
request. Based on our experience with the implementation of SNF 3-day
rule waivers, we are proposing to remove the requirement at Sec.
425.612(a)(1)(i)(A)(4) under which ACOs applying for the SNF 3-day rule
waiver must submit a narrative describing any financial relationships
between the ACO, SNF affiliate, and acute care hospitals. Removing this
requirement would not only reduce burden for ACOs applying for the
waiver but would also enable us to devote our application review
resources to a rigorous review of other, more relevant application
elements. Focusing our resources on the review of the information that
is most directly relevant to determining an ACO's capacity to manage
beneficiaries who are admitted to a SNF without a prior 3-day inpatient
hospital stay, along with ongoing oversight and program compliance
monitoring of the use of the waiver by approved ACOs (as described in
section III.G.3.a.(1) of this proposed rule), would also allow us to
more efficiently use our resources to ensure that the SNF 3-day rule
waiver is being used appropriately and to address any potential
concerns about use of the waiver. Although we do not believe it is
necessary for ACOs to submit separate narratives describing their
financial relationships for purposes of the SNF 3-day rule waiver, we
note that under the Shared Savings Program rules, ACOs, ACO
participants, ACO providers/suppliers, and other individuals or
entities performing functions or services related to ACO activities,
including SNF affiliates, must maintain and give us access to certain
documents and information related to items including financial
arrangements related to ACO activities (Sec. 425.314(b)(1)). We
continue to retain broad discretion under Sec. 425.316 to audit ACOs,
ACO participants, and ACO providers/suppliers for compliance with
program rules, and the program rules also make it clear that waivers
under Sec. 425.612 do not protect financial or other arrangements
between or among ACOs, ACO participants, ACO providers/suppliers, or
other individuals or entities providing services to Medicare
beneficiaries from liability under the fraud and abuse laws or any
other applicable laws (Sec. 425.612(e)).
Second, we believe that the requirement under Sec.
425.612(a)(1)(i)(C) that ACOs submit documentation demonstrating that
each SNF included on their list of SNF affiliates has an overall rating
of 3 or higher under the CMS 5-star Quality Rating System is
unnecessarily burdensome. In order to meet this requirement, ACOs
typically submit a screen shot from the CMS Nursing Home Compare Web
site or other Nursing Home Compare information that reflects the star
rating for each listed SNF. The submission of this documentation by the
ACO does not add value to our review and approval of SNFs included on
the ACO's SNF affiliate list. Instead, we obtain the information
directly from our Web site during the application review process. In
this way, we insure that the most current information is used during
the application review process. We also periodically monitor this
information after an ACO has been approved to use the waiver because
SNF affiliates are required to maintain an overall rating of 3 stars or
higher, under Sec. 425.612(a)(1)(iii)(A). Because we are able to
obtain the required information directly from the CMS Nursing Home
Compare Web site, the additional documentation submitted by the ACO as
part of its application does not add value to our ability to review and
approve SNF affiliates. Accordingly, we are proposing to eliminate this
documentation submission requirement by removing Sec.
425.612(a)(1)(i)(C). We note that we are not proposing to remove or
modify the requirement in Sec. 425.612(a)(1)(iii)(A) that SNF
affiliates must have and maintain an overall rating of 3 or higher
under the CMS 5-star Quality Rating System in order to remain eligible
to partner with the ACO for purposes of the SNF 3-day rule waiver. The
requirement for SNF affiliates to have and maintain a 3-star or higher
rating is retained. Furthermore, as part of the application process, we
intend to continue to verify that the ACO has met all requirements
related to the SNF 3-day rule waiver, but we believe that the
burdensome and duplicative submission of CMS 5-star Quality Rating
System documentation is not necessary to ensure compliance with the
requirement that the ACO's SNF affiliates have a star rating of 3 or
more.
We welcome comments on our proposal to remove Sec.
425.612(a)(1)(i)(A)(4) which requires SNF 3-Day Rule Waiver applicants
to submit a narrative describing any financial relationships that exist
between the ACO, SNF affiliate, and acute care hospitals. We further
welcome comments on our proposal to remove Sec. 425.612(a)(1)(i)(C)
which requires waiver applicants to submit documentation demonstrating
that each SNF affiliate on their SNF affiliate list has an overall
rating of 3 or higher under the CMS 5-star Quality Rating System. We
also welcome other suggestions on how we might further decrease the
burden for ACOs requesting approval to use the SNF 3-day rule waiver,
without compromising our ability to ensure that ACOs and their SNF
affiliates have the capacity to identify and manage beneficiaries
receiving covered SNF services pursuant to the waiver. We may consider
any such suggestions in future rulemaking.
b. Modifications to the Shared Savings Program Initial Application
(1) Background
In order to participate in the Shared Savings Program,
organizations must meet certain eligibility requirements, including the
statutory requirement to define processes to promote evidence-based
medicine and patient engagement, report on quality and cost measures,
and coordinate care. Additionally, the ACO
[[Page 34117]]
must demonstrate it meets patient-centeredness criteria specified by
the Secretary, such as the use of patient and caregiver assessments or
the use of individualized care plans. We discussed and finalized
details for ACO eligibility criteria, including the four required
processes and patient-centeredness criteria, in the November 2011 final
rule (76 FR 67826 and 67827) and made updates to them in the June 2015
final rule (80 FR 32722 through 32725).
Section 425.204(c)(1) articulates the supporting documents and
materials an ACO must submit to demonstrate that the ACO satisfies the
eligibility requirements to participate in the Shared Savings Program.
To obtain a determination regarding whether an ACO meets the
requirements to participate in the Shared Savings Program, a
prospective ACO must submit a complete application in the form and
manner required by us by the deadline established by us (Sec.
425.202(a)(1)). The content of the application is outlined at Sec.
425.204. Section 425.204(c) states that as part of the application, and
upon request thereafter, an ACO must submit to us certain supporting
documentation to demonstrate that the ACO satisfies the requirements of
the Shared Savings Program. Supporting documentation in this section
includes:
Documents (for example, ACO participant agreements,
agreements with ACO providers/suppliers, employment contracts, and
operating policies) sufficient to describe the ACO participants' and
ACO providers'/suppliers' rights and obligations in and representation
by the ACO, and how the opportunity to receive shared savings or other
financial arrangements will encourage ACO participants and ACO
providers/suppliers to adhere to the quality assurance and improvement
program and evidence-based clinical guidelines.
A description, or documents sufficient to describe, how
the ACO will implement the required processes and patient-centeredness
criteria under Sec. 425.112, including descriptions of the remedial
processes and penalties (including the potential for expulsion) that
will apply if an ACO participant or an ACO provider/supplier fails to
comply with and implement these processes.
Materials documenting the ACO's organization and
management structure, including an organizational chart, a list of
committees (including names of committee members) and their structures,
and job descriptions for senior administrative and clinical leaders.
Evidence that the ACO's governing body is an identifiable
body, represents a mechanism for shared governance for ACO
participants, is composed of representatives of its ACO participants;
and is at least 75 percent controlled by its ACO participants.
Evidence that the governing body includes a Medicare
beneficiary representative(s) served by the ACO who does not have a
conflict of interest with the ACO, and who has no immediate family
member with a conflict of interest with the ACO.
A copy of the ACO's compliance plan or documentation
describing the plan that will be put in place at the time the
participation agreement with CMS becomes effective. Additionally, Sec.
425.204(d) states that as part of the application to participate in the
Shared Savings Program, an ACO must describe the following:
++ How it plans to use shared savings payments, including the
criteria it plans to employ for distributing shared savings among its
ACO participants and ACO providers/suppliers.
++ How the proposed plan will achieve the specific goals of the
Shared Savings Program.
++ How the proposed plan will achieve the general aims of better
care for individuals, better health for populations, and lower growth
in expenditures.
Section 425.204(c)(1)(ii) includes a reference to the required
processes and patient centeredness criteria under Sec. 425.112. Of
note, Sec. 425.112(b)(4)(ii) requires that, as part of its
application, an ACO must submit a description of its individualized
care program, along with a sample individual care plan, that explains
how the ACO's program is used to promote improved outcomes for, at a
minimum, its high risk and multiple chronic condition patients (Sec.
425.112(b)(4)(ii)(A)). The ACO must also, as part of its application,
describe additional target populations that would benefit from
individualized care plans (Sec. 425.112(b)(4)(ii)(B)) and describe how
it will encourage and promote the use of enabling technologies for
improving care coordination for beneficiaries (Sec.
425.112(b)(4)(ii)(C)). Finally, as part of its application, the ACO
must describe how it intends to partner with long-term and post-acute
care providers, both inside and outside the ACO, to improve care
coordination for its assigned beneficiaries (Sec.
425.112(b)(4)(ii)(D)).
Once an applicant has submitted the information required under
Sec. 425.204, we evaluate it to determine whether the applicant
satisfies the Shared Savings Program requirements. We notify ACO
applicants during the application review process when information is
missing or when supplemental documentation or other information is
necessary to make a determination on the ACO's application and provide
opportunities for the ACO to submit the requested additional
information for review. At the end of the application review process,
we approve or deny the application and notify the ACO of our
determination.
(2) Proposals
In conducting Shared Savings Program application reviews, we have
found that many of the document submission requirements in Sec.
425.204(c)(1) substantially increase application and review burden
without lending significant value to our review of an organization's
application to confirm that the ACO meets the eligibility requirements
for participation in the Shared Savings Program. We believe it would
meet program needs and reduce applicant burden if we were to revise
Sec. 425.204(c)(1) to remove the requirement to submit supporting
documents or narratives and instead provide that we may request these
materials if additional information is needed in order to fully assess
the ACO's application before making a decision to approve or deny the
application.
To illustrate, as discussed in this proposed rule, we require under
Sec. 425.204(c)(1)(ii), as part of the application process, that the
ACO submit documentation addressing the required processes and patient
centeredness criteria under Sec. 425.112. This requirement is
addressed in the Medicare Shared Savings Program Initial Application
(see application on the CMS Web site at https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/application.html)
through the requirement that an applicant ACO submit narratives
describing how it will define, establish, implement, evaluate, and
periodically update each process. In these narratives, the ACO must
also describe certain additional details regarding the required
processes:
Process to promote evidence-based medicine. The ACO must
describe how it will:
++ Encourage the use of protocols grounded in evidence-based
medicine in the case of diagnoses with significant potential for the
ACO to achieve quality improvements, while taking into account the
circumstances of individual beneficiaries; and
[[Page 34118]]
++ Use the internal assessments of this process to continuously
improve the ACO's care practices.
Process to promote beneficiary engagement. The ACO must
describe how it will:
++ Evaluate the health needs of its assigned beneficiary population
(including consideration of diversity in its patient population) and
develop a plan to address the needs of its population;
++ Communicate clinical knowledge/evidence-based medicine to
beneficiaries in a way they can understand;
++ Engage beneficiaries in shared decision-making in ways that
consider beneficiaries' unique needs, preferences, values and
priorities;
++ Establish written standards for beneficiary access and
communication as well as a process for beneficiaries to access their
medical records; and
++ Use the internal assessments of this process to continuously
improve the ACO's care practices.
Process to internally report quality and cost metrics. The
ACO must describe how:
++ The ACO will use these results to improve care and service over
time; and
++ The ACO will use the internal assessments of this process to
continuously improve the ACO's care practices.
Process to promote coordination of care. The ACO must
describe:
++ The ACO's methods and processes to coordinate care throughout an
episode of care and during care transitions, such as discharge from a
hospital or transfer of care from a primary care physician to a
specialist (both inside and outside the ACO).
++ The ACO's individualized care program, along with a sample
individual care plan, and explain how the ACO uses this program to
promote improved outcomes for, at a minimum, high-risk and multiple
chronic-condition patients.
++ How individual care plans take into account the community
resources available to beneficiaries.
++ Additional target populations that would benefit from
individualized care plans.
++ How the ACO will use the internal assessments of this process to
continuously improve the ACO's care practices.
++ How the ACO will encourage and promote use of enabling
technologies for improving care coordination for beneficiaries.
++ How the ACO intends to partner with long-term and post-acute
care providers, both inside and outside of the ACO, to improve care
coordination for their assigned beneficiaries.
As a result of our experience in reviewing these narratives, we
have determined that while they can be helpful to verify that the ACO
has established the required processes and defined patient-centeredness
criteria prior to its entry into the Shared Savings Program, the
specific details of the processes the ACO has established are not
particularly important or relevant for purposes of assessing whether
the ACO is eligible to participate in the program. In fact, ACOs have
indicated that their initial plans for the processes required under
Sec. 425.112 as articulated in their program application often change
as a result of obtaining additional information about their ACO
participants' and ACO providers/suppliers' processes and gaining
additional experience during implementation of the processes. We
believe such improvements to ACO processes based on program experience
are reasonable to expect and should be encouraged. First, under Sec.
425.112(b), ACOs are required to evaluate and periodically update each
process and as they do so, initially implemented processes will
necessarily change to accommodate lessons learned. Moreover, once the
ACO begins to request claims information and other CMS data and to
incorporate this information into its operations, the ACO may discover
that certain assumptions it made at the time of application should be
adjusted to maximally improve the quality of care or cost efficiencies
for the ACO's assigned population. In rare instances, particularly in
the early days of the program before stakeholders fully understood the
implications of program participation, we found review of such
narratives useful to understand the level of an ACO's readiness for
participation in the Shared Savings Program. However, such narratives
have not been particularly useful in determining if the ACO meets the
requirements for participation in the Shared Savings Program. In a vast
majority of cases, we now believe it is sufficient that the ACO certify
at the time of application that it has defined the required processes
and patient centeredness criteria consistent with the requirements
specified in section Sec. 425.112. Therefore, we believe it would
reduce burden for ACOs, without compromising our ability to determine
whether an ACO meets the criteria for participation in the Shared
Savings Program, to require that the ACO certify that it meets the
requirements in Sec. 425.112, and only submit a narrative or other
documentation describing how the ACO will implement the required
processes and patient-centeredness criteria upon our request. Further,
we do not anticipate that this change would have a significant effect
on beneficiaries receiving services from ACO providers/suppliers
because as noted earlier, we anticipate that ACOs would update each
process as they gain experience and, as they do so, initially
implemented processes that might have been reflected in the narrative
or other supporting documentation submitted with their application
would necessarily change to accommodate lessons learned.
Similarly, as part of the application process, the Shared Savings
Program regulations require the ACO to submit materials documenting the
ACO's organization and management structure, including an
organizational chart, a list of committees (including names of
committee members) and their structures, and job descriptions for
senior administrative and clinical leaders (Sec. 425.204(c)(1)(iii)).
While we have found the organizational chart useful for purposes of our
review and approval of an ACO's application, and we anticipate
continuing to request this chart from many applicants, we have found
that further detail including lists of committees and job descriptions
for senior administrative and clinical leaders have not added
particular value to our review and approval of applications. Moreover,
the receipt of such materials as part of the ACO's application has not
significantly impacted our ability to determine whether the ACO meets
the requirements regarding leadership and management in Sec. 425.108.
We believe, on balance, that our need for such detailed information
from all applicants is outweighed by our desire to reduce application
burden. In particular circumstances where additional information would
aid our review, we believe our need for such detailed information can
be reasonably met by requiring applicants to submit such materials upon
our request. As a result, we believe it would be less burdensome for us
to require ACO applicants to certify that, for example, they meet the
leadership and management requirements found at Sec. 425.108 rather
than requiring all ACO applicants to submit detailed materials (such as
job descriptions) or narratives about the ACO's committees and
leadership.
While we do not anticipate having to routinely request such
materials to supplement our review and approval of ACO applications to
participate in the Shared Savings Program, we believe it is important
to retain the discretion to do
[[Page 34119]]
so in limited cases where such detail could be useful. Therefore, we
propose to make revisions to our application requirements as discussed
in this section. We would note that in cases where an ACO is requested
to submit additional material for review in conjunction with its
application, and we find that the material is inconsistent with program
requirements, then we may deny the ACO's application. Similarly, if we
discover the inconsistency after the ACO has already been approved to
participate in the program, the ACO may be subject to the pre-
termination actions set forth in Sec. 425.216, termination under Sec.
425.218, or both.
Additionally, we do not believe it is necessary for ACO applicants
to submit narratives describing how they would distribute shared
savings payments or how the proposed plan would achieve the specific
goals of the Shared Savings Program and the general aims of better care
for individuals, better health for populations, and lower growth in
expenditures, as required by Sec. 425.204(d). Based on our experience,
such narratives have not been useful in determining if the ACO meets
requirements for participation in the program or whether an ACO's
application should be approved. We believe it would be more useful to
us and less burdensome for ACOs if we were instead to require that, an
ACO, as part of its application to participate in the Shared Savings
Program, certify that it has a method and plan to receive shared
savings payments and to distribute those payments to its ACO
participants and ACO providers/suppliers, as required by the statute.
We note, however, that we continue to believe it is useful to
stakeholders to know how various ACOs have chosen to use or distribute
the shared savings they earn. Therefore, in the interest of
transparency, we will continue to require ACOs to publicly report
information on their dedicated Web pages about their shared savings and
shared losses, including information about the total proportion of
shared savings invested in infrastructure, redesigned care processes,
and other resources to support the three-part aim goals of better
health for populations, better care for individuals, and lower growth
in expenditures, including the proportion distributed among ACO
participants, as required under Sec. 425.308(b)(4).
In light of our experience with the review of the documentation
submitted as part of the ACO's initial application, we are proposing
several modifications to our requirements for document submission.
Under this proposal, we would retain all requirements related to ACO
eligibility criteria and public reporting, as currently specified under
the Shared Savings Program regulations. However, in order to reduce
application burden without compromising our ability to evaluate
applications effectively for compliance with Shared Savings Program
requirements, we propose to modify certain sections of our regulations
that require ACOs to submit supporting materials and documentation at
the time of application. Instead of requiring submission of certain
materials, narratives, or supporting documentation, as discussed in
this section, we propose to require ACOs to certify that they meet the
applicable eligibility and documentation requirements as specified
under our program rules. At the same time, while we are interested in
reducing burden, we recognize that there have been instances when the
review of supporting documentation and/or narratives has been helpful
in making a determination about an ACO's eligibility for participation
in the program. Therefore, although we are proposing to eliminate the
general requirement that ACOs submit certain documentation as part of
their initial application to participate in the Shared Savings Program,
we propose to retain the right to request the submission of supporting
materials and documentation in cases when such additional information
would be useful in making a determination regarding the ACO's
application. We believe that this proposed modification to the
regulations governing ACO applications would introduce additional
flexibility that would reduce the level of burden inherent in the
Shared Savings Program application process while also ensuring we are
still able to appropriately evaluate an ACO's eligibility for program
participation.
Accordingly, in order to reduce application burden while retaining
flexibility to obtain additional documentation when necessary to
determine ACO eligibility and compliance with program rules, we propose
to remove the requirements in Sec. Sec. 425.204(c)(1) and (d),
425.112(a)(3)(i) and (ii), and 425.112(b)(4)(ii) for the submission of
certain specified documents and narratives as part of an ACO's
application to participate in the Shared Savings Program. Specifically,
we propose to revise paragraph Sec. 425.204(c)(1) to require an ACO,
as part of its application, to certify that it satisfies the Shared
Savings Program requirements and to submit, upon CMS request,
supporting materials (including narratives) and documentation
demonstrating that the ACO satisfies program requirements indicated in
proposed revised Sec. 425.204(c). Additionally, we propose to revise
Sec. 425.204(d) to indicate that the ACO must certify, as part of its
application to participate in the Shared Savings Program, that it has a
mechanism and plan to receive and use payments for shared savings,
including criteria for distributing shared savings among its ACO
participants and ACO providers/suppliers. We also propose to make a
conforming change to remove paragraphs (d)(1) through (3) of Sec.
425.204, which relate to the submission of narratives related to the
ACO's use of shared savings payments. This proposal does not include a
requirement that the ACO submit information regarding its mechanism and
plan for receiving and using shared savings upon request. We do not
intend to request this information as part of the application process
because in our experience, how an ACO intends to use or distribute
shared savings has not been a relevant consideration during any
application cycle to determine whether the ACO has met the eligibility
requirements to participate in the Shared Savings Program. However, we
note that we continue to believe that information on how an ACO uses
and distributes its shared savings is useful for the public, and
therefore ACOs will continue to be required to publicly report this
information under Sec. 425.308(b)(4)(ii).
We also propose similar changes to the requirements in Sec.
425.112(a)(3)(i), (a)(3)(ii), and (b)(4)(ii) to remove reference to the
submission of narratives to explain or describe how the ACO will
implement the required elements of the ACO's care processes and
patient-centeredness criteria. ACOs must still implement these care
processes and adopt a focus on patient-centeredness, however, they will
no longer need to submit descriptions of how they will satisfy these
requirements as part of their initial application. We note, however,
that ACOs may still be required to submit upon request a description or
documentation sufficient to describe how the ACO will implement the
required processes and patient-centeredness criteria found at Sec.
425.112 because under the proposed revisions to Sec.
425.204(c)(1)(ii), CMS would retain the discretion to request such
documentation from the ACO at any time.
In summary, we believe these modifications to the application
requirements will significantly reduce
[[Page 34120]]
the burden of applying to participate in the Shared Savings Program
without reducing our ability to ensure that applicants meet the
established eligibility requirements. Rather than requiring every
applicant to submit detailed supporting documents or narratives for all
of these requirements, we would instead request supporting documents or
narratives only if additional information is needed in order to fully
assess an ACO's application before making a decision to approve or deny
the application. Further, we do not anticipate that the proposed
modifications to our application requirements would have any effect on
beneficiaries receiving care from providers and suppliers participating
in the Shared Saving Program, nor do we believe that the proposed
changes would affect our program integrity efforts, because we would
retain discretion to request such information (and more targeted and
appropriate information) as needed. We seek comment on these proposals
and on additional ways to reduce burden in the application process.
4. Addressing Compliance With ACO Participant TIN Exclusivity
Requirement
a. Background
Under the Shared Savings Program, ACO participant TINs are not
required to be exclusive to one Shared Savings Program ACO unless the
TIN submits claims for primary care services used to determine the
ACO's assigned population (Sec. 425.306(b)). The purpose behind this
requirement is to ensure that we are able to assign a unique set of
beneficiaries to each ACO participating in the Shared Savings Program.
Therefore, as part of the Shared Savings Program application process
and upon an ACO's request to add an ACO participant TIN, we check the
TIN against all other Shared Savings Program ACO participant lists. If
the TIN appears on the ACO participant list one or more other ACOs, the
TIN is considered to be ``overlapping.'' We then determine whether the
overlap is permissible under our program rules. If the overlap is not
permissible (because the TIN has a history of billing for primary care
services used in our assignment methodology) then we require the ACO
that is seeking to add the TIN to its ACO participant list to rectify
the overlap by the deadline we have established for making changes to
the next performance year's ACO participant list. If the overlap is
permissible (because the TIN does not have a history of billing for
primary care services used in our assignment methodology) then the ACO
participant TIN can be approved to be an ACO participant in more than
one ACO for the performance year. Each time we run the assignment
algorithm during the course of the performance year, we monitor
overlaps to ensure that the overlaps continue to be in compliance with
Sec. 425.306(b).
In a few instances, as a result of our monitoring, we have
discovered that ACO participant TINs that had been approved to
participate in multiple ACOs subsequently began billing for primary
care services used in assignment during a benchmark or performance
year. For example, for performance year 2016, we identified four TINs
that were initially permitted to overlap and participate in more than
one ACO because they had not previously billed Medicare for primary
care services used in our assignment methodology. At some point during
the performance year, however, the TINs began billing Medicare for
primary care services that are used to assign beneficiaries to the ACO
(including claims for services furnished during the performance year,
but submitted during the three-month claims runout for the performance
year). This can occur, for example, if a single specialty practice made
up of physician specialty types not used in assignment (for example, a
practice of ophthalmologists) hires a nurse practitioner who then
begins billing Medicare under the billing TIN of the ACO participant
for primary care services as defined under the Shared Savings Program
rules. Thus, the ACO participant TIN would be used to bill Medicare for
primary care services furnished by a practitioner used in our
assignment methodology (the nurse practitioner) and would therefore
trigger our requirement under Sec. 425.306(b)(2) that the ACO
participant TIN be exclusive to a single Shared Savings Program ACO.
Although our program rules permit us to take compliance action against
ACOs for violations of Shared Savings Program requirements, they do not
specifically address what compliance actions we would impose on ACOs in
instances where an ACO participant falls out of compliance with Sec.
425.306(b)(2) during a benchmark or performance year or when non-
compliance with Sec. 425.306(b)(2) is discovered during the 3-month
claims runout for a benchmark or performance year. Moreover, the
program rules do not address what modifications to our assignment
methodology could be made to account for this overlap. In the case of
the four overlapping TINs discovered during the 2016 performance year,
we notified the respective ACOs of the overlap and the ACO participant
TINs were required to terminate their participation in the ACO of their
choice. As a result, each ACO from which the TINs terminated was
required to recertify its ACO participant list for the 2016 performance
year. Depending on the timing of recertification, such changes to an
ACO participant list may also require us to recalculate performance
year beneficiary assignment and financial benchmarks. For example, if a
TIN, that was previously allowed to appear on more than one ACO
participant list, hires a nurse practitioner who begins billing primary
care claims in the month of December for the ACO's third benchmark
year, we would discover the now impermissible overlap when we begin
creating the historical benchmark reports after the 3-month claims
runout. We would contact the ACOs involved, each ACO would contact the
TIN and ask the TIN to select the ACO it wishes to remain aligned with.
The ACO not selected would be asked to remove the TIN from its ACO
Participant List and recertify the list. As a result of the
recertification of the list, the ACO's assigned population would need
to be redetermined and calculation of its benchmark would be delayed.
We are therefore concerned about the uncertainty the current process
(which includes recertification of ACO participant lists, recalculation
of assignment, and resulting delay of calculations for the benchmark or
performance year) could introduce for ACOs that may have little
influence over or knowledge of ACO participant TIN billing practices.
We believe it is important for ACOs, ACO participants, and ACO
providers/suppliers to have updated and accurate information regarding
their participation status in the Shared Savings Program. For example,
participation in a Shared Savings Program ACO has implications for ACO
providers/suppliers under the new Quality Payment Program (see 81 FR
80496 through 80501). The Quality Payment Program replaces a patchwork
system of Medicare programs with a flexible system that allows eligible
clinicians to choose from two paths that link payments to quality: The
Merit-Based Incentive Payment System (MIPS) and participation in
Advanced Alternative Payment Models (APMs). The Quality Payment
Program, through MIPS and the APM incentive, will impact eligible
clinicians' payments
[[Page 34121]]
beginning in payment year 2019 based on 2017 reporting.
Under the CY 2017 Quality Payment Program final rule with comment
period, eligible clinicians participating in Advanced APMs (including
Tracks 2 and 3 under the Shared Savings Program) may become Qualifying
APM Participants and receive a 5 percent APM Incentive Payment if they
have a sufficient percentage of payments for Part B covered
professional services, or a sufficient percentage of Medicare patients
that are attributable to services furnished through an Advanced APM for
a year. In addition to earning a 5 percent APM Incentive Payment,
Qualifying APM Participants are not subject to the MIPS reporting
requirements and payment adjustment for the year. As a result,
revisions to ACO participant lists that occur mid-year or following the
end of a benchmark or performance year could have widespread
implications not only for the ACO but also for its ACO providers/
suppliers under the Quality Payment Program.
b. Proposals
As participation in the Shared Savings Program grows and more ACOs
and ACO participants join the program, we believe the overlap situation
described previously is likely to become more common. We also believe
that changes to our program rules regarding the claims that will be
considered in assigning FFS beneficiaries to an ACO (specifically, the
policy finalized in the June 2015 final rule to exclude services
furnished by several physician specialty types from the assignment
methodology) may result in a greater number of permissible ACO
participant TIN overlaps (see 80 FR 32753 and 32754). As a result, we
anticipate there could also be an increased number of cases where ACO
participant TINs with initially permissible overlaps could become out
of compliance with the requirement at Sec. 425.306(b)(2) that an ACO
participant TIN be exclusive to a single Shared Savings Program ACO if
the TIN bills for primary care services that are used to assign
beneficiaries to the ACO. This could occur, for example, if a group
practice that initially includes only physician specialty types whose
services are excluded from the assignment methodology were to
subsequently employ a non-physician practitioner who bills for primary
care services. We believe these types of practice arrangements are
becoming increasingly common.
We therefore believe it is necessary to streamline our approach to
handling such situations in order to reduce the burden and uncertainty
for ACOs when changes in ACO participant billing practices result in an
ACO participant falling out of compliance with the exclusivity
requirement at Sec. 425.306(b)(2). Rather than the current policy
under which an ACO may be required to remove an overlapping ACO
participant and recertify its ACO participant list for the performance
year (thus necessitating redetermination of beneficiary assignment and
delays in or revisions to benchmark or performance year calculations),
we believe it would be less disruptive for ACOs if we were to permit
overlapping TINs that begin billing for services used in assignment
during a benchmark or performance year (including claims for services
furnished during the benchmark of performance year, but submitted
during the 3-month claims runout) to remain on the ACO participant
lists for all affected ACOs for the remainder of the performance year
in which we determine that an overlap exists. For example, assume that,
based on an analysis of claims for services furnished in performance
year 2018, we were to identify an impermissibly overlapping TIN in
January 2019 after the ACO participant lists for performance year 2019
had already been certified. Under this proposal, the TIN would be able
to remain on the ACO participant lists of all affected ACOs for the
2018 performance year as well as the remainder of performance year
2019. In order to ensure that the TIN overlap does not inadvertently
result in assignment of the same beneficiaries to multiple ACOs, we
would simply exclude any claims for services furnished by the
overlapping TIN from the assignment methodology when conducting final
beneficiary assignment for any benchmark or performance year in which
the TIN bills Medicare for services used in our assignment methodology.
The affected ACOs would be required to resolve the overlap prior to
recertification of their ACO participant lists for the subsequent
performance year. If the overlap remains unresolved when the ACOs
certify their ACO participant lists for the next performance year, we
would remove the TIN from the ACO participant lists of all ACOs seeking
to include the TIN, in accordance with our current policy for resolving
overlaps. For example, in the hypothetical case above, if the overlap
were to remain unresolved when the ACOs certify their ACO participant
lists for performance year 2020, we would remove the TIN from the ACO
participant lists for all ACOs seeking to include the TIN as an ACO
participant for performance year 2020.
We therefore propose to modify our program rules in Sec. 425.306
and subpart E of part 425 to address this issue. We propose to modify
Sec. 425.306(b) to indicate that if, during a benchmark or performance
year (including the 3-month claims run out period for such benchmark or
performance year), an ACO participant that participates in more than
one ACO begins billing for services that would be used in assignment,
we would not consider any services billed through that TIN during the
relevant performance year when performing beneficiary assignment for
the applicable benchmark or performance year. As part of this proposed
modification, we would also eliminate the references to ``primary
care'' when describing the services used to determine the ACO's
assigned beneficiary population in order to conform with our proposal
to implement section 17007 of the 21st Century Cures Act under which we
would consider all services furnished in FQHCs and RHCs in the
assignment methodology as primary care services starting in the 2019
performance year. In addition, the ACOs in which the overlapping TIN is
an ACO participant may be subject to compliance action (as provided
under Sec. 425.216) or termination under Sec. 425.218. Compliance
actions may include requiring each ACO that includes the TIN as an ACO
participant to submit a corrective action plan explaining how the ACO
plans to work with the overlapping ACO participant to resolve the
overlap for the next performance year. If the overlap remains
unresolved by the date specified by us in our request for a corrective
action plan, we would remove the overlapping ACO participant TIN from
the ACO participant list of each ACO for the subsequent performance
year.
We also propose to revise our general assignment methodology at
Sec. 425.400(a)(1) to add new paragraph (a)(1)(iii) to indicate that
when we determine final assignment after the end of each benchmark or
performance year, we will exclude claims for services furnished during
the benchmark or performance year by an ACO participant that
participates in more than one ACO. We believe that this policy will
ensure a uniquely assigned beneficiary population for each ACO and
prevent the same beneficiaries from being included in determining
benchmark or performance year expenditures for more than one ACO.
We believe that implementing this proposed process would improve
ACO
[[Page 34122]]
and ACO participant understanding of our policies and requirements
regarding ACO participant overlaps while also reducing burden for ACOs
that currently must recertify ACO participant lists and may be subject
to retrospective modifications or delays in assignment and other
dependent benchmark or performance year calculations. We also note that
this policy allows us to preserve the flexibility that is currently
extended to ACO participants that do not bill for services used in
assignment, while recognizing the possibility for mid-year changes in
care and billing practices by these ACO participants. Additionally, ACO
participant TINs and the eligible clinicians that bill through those
TINs would be provided greater certainty regarding whether they qualify
as participating in an APM or Advanced APM for a performance year.
Under this proposed policy, an ACO participant would know for the
entire performance year with certainty that it is participating in a
particular APM entity.
5. Treatment of Individually Beneficiary Identifiable Payments Made
Under a Demonstration, Pilot, or Time Limited Program
a. Background
Under section 1899(d) of Act, ACOs participating in the Shared
Savings Program are accountable for the total Parts A and B costs for
the Medicare fee-for-service beneficiaries assigned to the ACO.
Therefore, we include all payments made from the Medicare Trust Fund
for Parts A and B services furnished to assigned Medicare FFS
beneficiaries, including individually beneficiary identifiable non-
claims based payments made under a demonstration, pilot or time limited
program, when computing average per capita Medicare expenditures for an
ACO during both the benchmark period and performance years. We believe
it is appropriate to take into account non-claims based payments from a
demonstration, pilot, or time limited program in Medicare Shared
Savings Program financial calculations to ensure that the final shared
savings payments that are made to ACOs are accurate and reflect all
Parts A and B expenditures for the ACO's assigned beneficiaries. We
also review individually beneficiary identifiable payments made under a
demonstration, pilot, or time-limited program as part of our efforts to
ensure there is no duplication of payments for beneficiaries that may
be assigned to both the Shared Savings Program and other Innovation
Center models. This general policy of considering individually
beneficiary identifiable non-claims based payments made under a
demonstration, pilot or time limited program was initially established
in the 2011 final rule implementing the Shared Savings Program (76 FR
67915) for:
Establishing, adjusting, and updating the benchmark for an
ACO's first agreement period under Sec. 425.602(a)(1)(ii),
Calculation of savings under the one-sided model (Track 1)
at Sec. 425.604(a)(6)(ii), and
Calculation of shared savings and losses under Track 2 at
Sec. 425.606(a)(6)(ii).
This policy has also been included in subsequent program
modifications to the program for:
Resetting, adjusting, and updating the benchmark for a
subsequent agreement period under Sec. Sec. 425.603(c)(1)(ii) and
425.603(e)(2)(ii), and
Calculation of shared savings and losses under Track 3 at
Sec. 425.610(a)(6)(ii).
More specifically, in addition to Medicare Parts A and B claims, we
include non-claims based individually beneficiary identifiable payments
when performing financial calculations for the Shared Savings Program,
including setting the preliminary and final benchmarks, updating the
financial benchmark at the time of reconciliation and calculating
performance year expenditures. We internally track non-claims based
beneficiary identifiable payments (that is, payments made outside the
Medicare fee-for-service claims system) through a separate CMS system
that receives and stores these non-claims based payments made from the
Medicare Trust Funds under a demonstration, pilot or time limited
program. The non-claims based payments are loaded into the separate
system at various points in time, depending on the terms of payment
under each specific demonstration, pilot or time limited program. The
amounts that are reflected in this separate system include interim
payment amounts that are subject to final reconciliation and may not
reflect the actual final payments to the provider or site. For example,
the Bundled Payments for Care Improvement (BPCI) initiative is
comprised of four broadly defined models of care, which link payments
for the multiple services beneficiaries receive during an episode of
care. (See the CMS Web site at https://innovation.cms.gov/initiatives/bundled-payments/). Under the retrospective BPCI payment models,
Medicare continues to make fee-for-service (FFS) payments for the Part
A and Part B services furnished to a beneficiary during an episode;
but, the total Part A and Part B expenditures for the episode are later
reconciled against a bundled payment amount (the target price)
determined by CMS. A payment or recoupment amount is determined by
comparing the aggregate expenditures to the target price. Interim
payment and recoupment amounts are calculated quarterly but it is only
after the BPCI claims run out period that the final reconciliation can
be performed and the final expenditure amount is known. In contrast,
under certain other demonstrations, pilots, or time limited programs
only final non-claims based payment data are loaded into the system.
For example, under the Community-based Care Transitions Program (CCTP),
the participating community-based organizations were paid an all-
inclusive rate per eligible discharge. This final non-claims based
payment was then loaded into the system and was not subject to
subsequent reconciliations.
To date, when we perform ACO benchmarking and financial
calculations under the Shared Savings Program, we have included (in
addition to all Medicare Parts A and B claims) all non-claims based
beneficiary identifiable payments for the applicable benchmark or
performance year that are included in the separate CMS system,
including any payments made during the benchmark or performance year's
3-months claims run-out period. This means that to date we have
included some interim payments made under a demonstration, pilot or
time limited program that will undergo subsequent reconciliation to
determine the final payment amount in the calculation of historical
benchmarks and performance year expenditures. However, because the
various demonstrations, pilots or time limited programs may have
different operational schedules to the Shared Savings Program, it is
not possible for us to include all interim and final beneficiary
identifiable payments made under these initiatives in benchmarking and
financial reconciliation calculations for the Shared Savings Program;
and, as a result, these calculations have excluded some interim and
final non-claims based beneficiary identifiable payments made under
certain demonstrations, pilots or time limited programs. For example,
because of the timing and availability of BPCI non-claims based payment
amounts, to date we have included only up to two quarters of interim
payment data for BPCI in ACO benchmarking and financial reconciliation
calculations for the
[[Page 34123]]
Shared Savings Program and no final payment amounts.
To date, non-claims based individually beneficiary identifiable
payments represent a relatively minor proportion of an ACO's total Part
A and B beneficiary expenditure amounts as determined under the Shared
Savings Program (mean of 0.09 percent overall impact of ACO non-claims
based payments on total per capita expenditures and a mean of 137
person-years in an ACO's assigned beneficiary population with a non-
claims based payment during the year; minimum -0.72 percent, 0 person-
years; maximum 1.24 percent, 1,865 person-years). For the
demonstrations, pilots or time limited programs that include interim
and final reconciliations, the impact of including the non-claims based
payments could be positive or negative for an ACO for a given
performance year. Additionally, a preliminary analysis suggests that
interim payments made under select demonstrations, pilots or time-
limited program fluctuate on a quarterly basis. An examination of
trends in total per capita non-claims based payments in 2016 quarterly
program reports across 416 Track 1 and 2 ACOs found a mean decline of
14 percent from Quarter 1 to Quarter 2, followed by a mean increase of
144 percent from Quarter 2 to Quarter 3, and a mean increase of 742
percent from Quarter 3 to Quarter 4. Quarterly trends for individual
ACOs also tended to fluctuate. Per capita amounts in this analysis were
based on those ACOs with at least one non-claims based payment in each
quarterly report period. Almost half of the ACOs in the analysis (201
out of 416) had at least one quarter in 2016 with a net negative per
capita payment across all beneficiaries with at least one non-claims
based payment and at least one quarter with a net positive per capita
payment. A review of non-claims based payments incorporated in PY 2017
preliminary historical benchmarks also found similar swings between
negative and positive amounts, with roughly one third of ACOs receiving
a benchmark (156 of 480) having at least one benchmark year with a net
negative per capita payment across all beneficiaries with at least one
non-claims based payment and at least one benchmark year with a net
positive per capita payment.
These fluctuations in the non-claims based payments for certain
initiatives like BPCI have generated stakeholder concern. Further,
stakeholders note that the impact of including interim payments in
financial calculations may become greater in the future, given the
increasingly widespread interest in participation in alternative
payment models and the growing number of such models being tested
through the CMS Innovation Center. Stakeholders have therefore
suggested that we should revise our policies to clarify that only final
non-claims based payments made within the 3 months claims run out
period under a demonstration, pilot or time limited program will be
included in the calculation of an ACO's benchmark and performance year
expenditures.
b. Proposals
Our preliminary analysis, as discussed in the background section,
suggests that interim non-claims based payments (that is, payments that
are subject to reconciliation at a later date) made under a
demonstration, pilot, or time limited program can fluctuate
significantly from quarter to quarter and may not reflect the actual
final reconciled payment amount. Thus, we agree with the stakeholders
who have suggested that only final non-claims based payments made under
a demonstration, pilot or time limited program should be included in
financial calculations related to benchmarks and performance year
expenditures under the Shared Savings Program. We believe this would be
a reasonable approach to determining Parts A and B expenditures for
assigned beneficiaries for both benchmark and performance years given
the uncertain impact on ACOs' financial calculations of including
interim payments that will be subsequently revised to reflect the final
reconciled payment amounts. We also agree that use of interim payments
made under a demonstration, pilot or time limited program could have an
increasingly large effect on ACO benchmarks and performance year
expenditure calculations in the future given widespread stakeholder
interest in participating in alternative payment models and CMS
interest in testing and expanding additional payment models that may
lead to higher quality and more coordinated care at a lower cost to
Medicare.
Therefore, we are proposing to revise the applicable regulations to
make clear that we would include only final individually beneficiary
identifiable payments made under a demonstration, pilot or time limited
program in financial calculations related to establishing and updating
benchmarks and determining performance year expenditures under the
Shared Savings Program. We propose that this policy would be applied to
calculations that are necessary to determine ACO performance for the
2018 performance year and subsequent performance years. For ACOs that
are in the middle of an agreement period when this revised policy takes
effect, we would adjust the benchmarks for these ACOs at the start of
the 2018 performance year and each subsequent performance year so that
the benchmark for the ACO reflects the use of the same payment
information that would apply in expenditure calculations for the
performance year. More specifically, we propose to modify our
regulations at Sec. Sec. 425.602(a)(1)(ii), 425.603(c)(1)(ii), and
425.603(e)(2)(ii) to add new provisions to indicate that, (1) when
establishing benchmarks for agreement periods before 2018, we will
include all individually beneficiary identifiable payments, including
interim payments, made under a demonstration, pilot, or time limited
program, (2) for agreement periods beginning in 2018 and subsequent
years, we would only include individually beneficiary identifiable
payments made under a demonstration, pilot or time limited program that
are final and not subject to further reconciliation, and (3) For the
2018 performance year and subsequent performance years in agreement
periods beginning in 2015, 2016 and 2017, the benchmark would be
adjusted to reflect only individually beneficiary identifiable final
payments made under a demonstration, pilot or time limited program.
Additionally, we propose to add new Sec. Sec. 425.604(a)(6)(ii)(A),
425.606(a)(6)(ii)(A) and 425.610(a)(6)(ii)(A) indicating that when
calculating expenditures for performance years before 2018, we will
include all individually beneficiary identifiable payments, including
interim payments, made under a demonstration, pilot, or time limited
program. We also propose to add new Sec. Sec. 425.604(a)(6)(ii)(B),
425.606(a)(6)(ii)(B) and 425.610(a)(6)(ii)(B) indicating that when
calculating expenditures for performance year 2018 and subsequent
performance years, we would only include individually beneficiary
identifiable payments made under a demonstration, pilot or time limited
program that are final and not subject to further reconciliation. To be
consistent with our treatment of claims-based payments, such final
payments would have to be available in the separate CMS system by the
end of the 3-month claims run out period.
We invite comments on this proposal.
[[Page 34124]]
I. Value-Based Payment Modifier and Physician Feedback Program
1. Overview
Section 1848(p) of the Act requires the establishment of a value-
based payment modifier (VM) that applies to specific physicians and
groups of physicians the Secretary determines appropriate starting
January 1, 2015, and to all physicians and groups of physicians by
January 1, 2017. On or after January 1, 2017, section 1848(p)(7) of the
Act provides the Secretary discretion to apply the VM to eligible
professionals (EPs) as defined in section 1848(k)(3)(B) of the Act.
Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral.
The VM and Physician Feedback programs continue our initiative to
recognize and reward clinicians based on the quality and cost of care
provided to their patients, increase the transparency of health care
quality information and to assist clinicians and beneficiaries in
improving medical decision-making and health care delivery. As stated
in the CY 2016 PFS final rule with comment period (80 FR 71277), the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L.
114-10) was enacted on April 16, 2015. Under section 1848(p)(4)(B)(iii)
of the Act, as amended by section 101(b)(3) of MACRA, the VM shall not
be applied to payments for items and services furnished on or after
January 1, 2019. Section 1848(q) of the Act, as added by section 101(c)
of MACRA, establishes the Merit-based Incentive Payment System (MIPS)
that shall apply to payments for items and services furnished on or
after January 1, 2019.
2. Overview of Existing Policies for the VM
In the CY 2013 PFS final rule with comment period, we discussed the
goals of the VM and also established that specific principles should
govern the implementation of the VM (77 FR 69307). We refer readers to
that rule for a detailed discussion. In the CY 2013 PFS final rule with
comment period (77 FR 69310), we finalized policies to phase-in the VM
by applying it beginning January 1, 2015, to Medicare PFS payments to
physicians in groups of 100 or more EPs. A summary of the existing
policies that we finalized for the CY 2015 VM can be found in the CY
2014 PFS proposed rule (78 FR 43486 through 43488). Subsequently, in
the CY 2014 PFS final rule with comment period (78 FR 74765 through
74787), we finalized policies to continue the phase-in of the VM by
applying it starting January 1, 2016, to payments under the Medicare
PFS for physicians in groups of 10 or more EPs. Then, in the CY 2015
PFS final rule with comment period (79 FR 67931 through 67966), we
finalized policies to complete the phase-in of the VM by applying it
starting January 1, 2017, to payments under the Medicare PFS for
physicians in groups of 2 or more EPs and to physician solo
practitioners. In the CY 2016 PFS final rule with comment period (80 FR
71277 through 71279), we finalized that in the CY 2018 payment
adjustment period, the VM will apply to non-physician EPs who are
physician assistants (PAs), nurse practitioners (NPs), clinical nurse
specialists (CNSs), and certified registered nurse anesthetists (CRNAs)
in groups with 2 or more EPs and to PAs, NPs, CNSs, and CRNAs who are
solo practitioners.
In the CY 2016 PFS final rule with comment period (80 FR 71288 to
71291), we finalized that we would apply the following adjustments to
payments, for items and services furnished under the Medicare PFS in CY
2018, to physicians, PAs, NPs, CNSs, and CRNAs in groups with 10 or
more EPs and at least one physician:
Negative 4 percent (-4.0 percent) for those that fall into
Category 2, meaning that they did not meet the criteria to avoid the
2018 PQRS payment adjustment.
Negative 4 percent (-4.0 percent) under the quality-
tiering methodology for those classified as low quality/high cost and
negative 2 percent (-2.0 percent) for those classified as either low
quality/average cost or average quality/high cost.
An upward adjustment of four times an adjustment factor
(+4.0x) under the quality-tiering methodology for those classified as
high quality/low cost and two times an adjustment factor (+2.0x) for
those classified as either average quality/low cost or high quality/
average cost.
We finalized that we would apply the following adjustments to
payments, for items and services furnished under the Medicare PFS in CY
2018, to physician solo practitioners and physicians, PAs, NPs, CNSs,
and CRNAs in groups with 2 to 9 EPs and at least one physician:
Negative 2 percent (-2.0 percent) to those that fall into
Category 2, meaning that they did not meet the criteria to avoid the
2018 PQRS payment adjustment.
Negative 2 percent (-2.0 percent) under the quality
tiering methodology for those classified as low quality/high cost and
negative 1 percent (-1.0 percent) for those classified as either low
quality/average cost or average quality/high cost.