Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology

AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Proposed notice.

SUMMARY:

This proposed notice sets forth proposed revisions to work relative value units (RVUs) affecting payment for physicians' services. The statute requires that we review RVUs no less often than every 5 years. This is our third review of work RVUs since we implemented the physician fee schedule (PFS) on January 1, 1992. These revisions to work RVUs are proposed to be effective for services furnished beginning January 1, 2007. These revisions reflect changes in medical practice, coding changes, new data on relative value components, and the addition of new procedures that affect the relative amount of physician work required to perform each service as required by the statute. In addition, we are proposing revisions to our methodology for calculating practice expense (PE) RVUs, including changes based on supplemental survey data for PE. This revised methodology would be used to establish payment for services beginning January 1, 2007.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on Monday, August 21, 2006.

ADDRESSES:

In commenting, please refer to file code CMS-1512-PN. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (no duplicates, please):

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click on the link “Submit electronic comments on CMS regulations with an open comment period.” (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1512-PN, P.O. Box 8014, Baltimore, MD 21244-8014.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1512-PN, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850.

(Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT:

Diane Milstead, (410) 786-3355, or Gaysha Brooks, (410) 786-9649

SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on the proposed work RVUs set forth in Addendum C, the proposed practice expense methodology, and other issues set forth in this proposed notice to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1512-PN and the specific “issue identifier” that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they are received: http://www.cms.hhs.gov/eRulemaking. Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments.

Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Information on the PFS can be found on the CMS homepage. You can access this data by using the following directions:

1. Go to the following Web site http://www.cms.hhs.gov/PhysicianFeeSched/.

2. Select “Physician Fee Schedule Federal Regulation Notices.”

To assist readers in referencing sections contained in this preamble, we are providing the following table of contents.

Table of Contents

I. Background

A. Legislative History

B. Published Changes to the Physician Fee Schedule

C. Current Proposed Notice

D. The 5-Year Review Process

II. Discussion of Comments and Decisions

A. Review of Comments

B. Discussion of Comments by Clinical Area

1. Dermatology and Plastic Surgery

2. Orthopedic Surgery

3. Gynecology, Urology, Pain Medicine, and Neurosurgery

4. Radiology, Pathology, and Other Miscellaneous Services

5. Evaluation and Management Services

6. Cardiothoracic Surgery

7. General, Colorectal and Vascular Surgery

8. Otolaryngology and Ophthalmology

9. HCPAC Codes

C. Other Issues Under the 5-Year Review

1. Anesthesia Services

2. Discussion of Post-Operative Visits Included in the Global Surgical Packages

3. Codes Referred to CPT Editorial Panel from Five-Year Review of Work Relative Value Units

4. Budget Neutrality

5. Effect on Practice Expense Inputs Stemming From the 5-Year Review

6. Nature and Format of Comments on Work RVUs

D. Resource-Based Practice Expense (PE) RVUs

1. Current Methodology

2. PE Proposed Methodology for CY 2006

3. Modifications to PE Proposals

III. Collection of Information Requirements

IV. Response to Comments

V. Regulatory Impact Analysis

Addendum A: Explanation and Use of Addendum B

Addendum B: Relative Value Units and Related Information

Addendum C: Codes With Work RVUs Subject to Comment

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

AAD American Academy of Dermatology

AAN American Academy of Neurology

AANEM American Association of Neuromuscular and Electrodiagnostic Medicine

AAFP American Academy of Family Physicians

AAGP American Association for Geriatric Psychiatry

AAHCP American Academy of Home Care Physicians

AANS American Association of Neurological Surgeons

AAO American Academy of Ophthalmology

AAO-HNS American Academy of Otolaryngology-Head and Neck Surgery

AAOA American Academy of Otolaryngic Allergy

AAOS American Academy of Orthopaedic Surgeons

AAP American Academy of Pediatrics

AAPM American Academy of Pain Medicine

AAPMR American Academy of Physical Medicine and Rehabilitation

AATS American Association for Thoracic Surgery

ACC American College of Cardiology

ACG American College of Gastroenterology

ACNS American Clinical Neurophysiology Society

ACOG American College of Obstetricians and Gynecologists

ACR American College of Radiology

ACS American College of Surgeons

AFROC Association of Freestanding Radiation Oncology Centers

AGA American Gastroenterological Association

AGS American Geriatric Society

AK Actinic keratoses

AMA American Medical Association

AMDA American Medical Directors Association

AOA American Optometric Association

ASA American Society of Anesthesiologists

ASC Ambulatory surgical center

ASCRS American Society of Colon and Rectal Surgeons

ASGE American Society of Gastrointestinal Endoscopy

ASHA American Speech-Language-Hearing Association

ASPS American Society of Plastic Surgeons

ASSH American Society for Surgery of the Hand

ASTRO American Society for Therapeutic Radiology and Oncology

AUA American Urological Association

BBA 97 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)

BNF Budget neutrality factor

CAPU Coalition for the Advancement of Prosthetic Urology

CF Conversion factor

CNS Congress of Neurological Surgeons

CPEP Clinical Practice Expert Panels

CPT Current Procedural Terminology

CY Calendar year

DRG Diagnosis-Related Group

E/M Evaluation and management

FR Federal Register

HCPAC Health Care Professionals Advisory Committee

HCPCS Healthcare Common Procedure Coding System

HHS Health and Human Services

ICU Intensive care unit

IDTF Independent diagnostic testing facility

IWPUT Intra-service work per unit of time

JCAAI Joint Council of Allergy, Asthma, and Immunology

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173)

MMSV Minimum multi-specialty visit

MPC [the RUC's] Multi-Specialty Points of Comparison

NCQDIS National Coalition of Quality Diagnostic Imaging Services

NPWP Non-physician work pool

NSQIP National Surgical Quality Improvement Program

PC Professional component

PE Practice Expense

PE/HR Practice expense per hour

PEAC Practice Expense Advisory Committee

PERC Practice Expense Review Committee

PFS Physician fee schedule

RFA Regulatory Flexibility Act

RIA Regulatory impact analysis

RN Registered nurse

RUC [AMA's Specialty Society] Relative [Value] Update Committee

RVU Relative value unit

SMS [AMA's] Socioeconomic Monitoring System

SNF Skilled nursing facility

STS Society of Thoracic Surgeons

SVS Society for Vascular Surgery

TC Technical component

VA [Department of] Veterans Affairs

I. Background

[If you choose to comment on issues in this section, please include the caption “BACKGROUND” at the beginning of your comments.]

A. Legislative History

Since January 1, 1992, Medicare has paid for physicians' services under section 1848 of the Social Security Act (the Act), “Payment for Physicians' Services.” Section 1848 of the Act contains three major elements: (1) A fee schedule for the payment of physicians' services; (2) a sustainable growth rate for the rates of increase in Medicare expenditures for physicians' services; and (3) limits on the amounts that nonparticipating physicians can charge beneficiaries. The Act requires that payments under the fee schedule be based on national uniform relative value units (RVUs) based on the resources used in furnishing a service. Section 1848(c) of the Act requires that national RVUs be established for physician work, practice expense (PE), and malpractice expense.

Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs may not cause total physician fee schedule (PFS) payments for the year to differ by more than $20 million from the amount that would have been paid had the adjustments not been made. If this tolerance is exceeded, we must make adjustments to the conversion factors (CFs) to preserve budget neutrality.

B. Published Changes to the Physician Fee Schedule

On an annual basis, we publish regulations relating to updates to the RVUs and revisions to the payment policies under the PFS. In the Calendar Year (CY) 2006 Physician Fee Schedule final rule with comment period that appeared in the Federal Register on November 21, 2005 (70 FR 70116) (hereinafter referred to as the CY 2006 PFS final rule with comment period), we finalized the CY 2005 interim physician work RVUs, issued new interim work RVUs for new and revised codes for CY 2006, and finalized several other payment policies related to the PFS. This final rule with comment also discussed the status of the third 5-Year Review of work RVUs.

C. Current Proposed Notice

This proposed notice sets forth proposed revisions to work RVUs affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than every 5 years. We implemented the PFS effective for services furnished beginning January 1, 1992. The first 5-Year Review of work was initiated in December 1994 and was effective for services furnished beginning January 1, 1997. The second 5-Year Review of work was initiated in November 1999 and was effective for services furnished beginning January 1 2002. The third 5-Year Review of work was initiated in November 2004. Revisions of physician work RVUs proposed in this proposed notice are subject to a 60-day public comment period. We will review public comments, make adjustments to our proposals in response to comments, as appropriate, and include revised values in our CY 2007 Physician Fee Schedule final rule with comment period, effective for services furnished beginning January 1, 2007.

D. The 5-Year Review Process

We initiated the third 5-Year Review by soliciting public comments on potentially misvalued work RVUs for all services in the CY 2005 Physician Fee Schedule final rule with comment period that appeared in the Federal Register on November 15, 2004 (69 FR 66370) and provided a 60-day comment period.

We received comments from approximately 35 specialty groups, organizations, and individuals involving over 500 Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. As explained in the CY 2006 PFS final rule with comment period (70 FR 70283), we shared these comments with the American Medical Association (AMA) Specialty Society Relative Value Update Committee (RUC). The RUC was formed in November 1991 and grew out of a series of discussions between the AMA and major national medical specialty societies. The work of the RUC is supported by the RUC Advisory Committee, which is made up of representatives of 100 specialty societies in the AMA's House of Delegates.

The RUC currently makes annual recommendations to us on RVUs for new and revised CPT codes. The RUC also provided recommendations on changes to the work RVUs for existing codes during the previous 5-Year Reviews. We believe that the RUC's participation was beneficial because the RUC is experienced in recommending RVUs for the codes that have been added to or revised by the CPT Editorial Panel since we implemented the PFS in 1992. By virtue of its multispecialty membership and consultation with specialty societies, the RUC involves the medical community in formulating its recommendations. For codes used primarily by nonphysician practitioners, the Health Care Professionals Advisory Committee (HCPAC), a companion to the RUC, has made recommendations to us.

As we stated in the previous 5-Year Reviews, we retain the responsibility for analyzing any comments and recommendations received, developing the proposed rule, evaluating the comments on the proposed rule, and deciding whether and how to revise the work RVUs for any given service.

After we sent the RUC the comments we received on potentially misvalued services, as well as a list of approximately 160 services that we had identified as being potentially misvalued, the RUC identified the specialty societies that expressed interest in making presentations concerning those services. To prepare for presentations to the RUC, most specialty societies compiled data using a standard survey instrument whereby respondents compared the surveyed service with similar “reference” services that have established, agreed upon work values. Respondents were asked to estimate: the work for the survey code; the time to perform the “pre-”, “intra-”, and “post-” service activities; and the technical skill, risk, and judgment involved with performing the service. Post-service activities were broken down into hospital and office visits and were assigned an appropriate evaluation and management (E/M) code by the respondent. Each specialty society selected the physician sample that was surveyed. A minimum of 30 responses was required by the RUC for the survey to be considered adequate.

For this 5-Year Review, the RUC permitted a specialty society to use a “minisurvey” for some codes if the number of codes a specialty society was reviewing was extremely high. These minisurveys required less information from the respondent, but were similar in design. In addition, the RUC approved the use of information from the National Surgical Quality Improvement Program (NSQIP) database and the Society of Thoracic Surgeons (STS) national database in the valuation of some services.

The NSQIP was started by the Department of Veterans Affairs (VA) for quality improvement purposes in 1991 with 128 VA medical centers, but now includes a large volume of surgical procedures from non-VA medical centers as well. The total number of cases for VA and non-VA medical centers is greater than one million. The NSQIP database contains pre-, intra-, and post-operative data, including intra-service times and length of stay data.

The STS National database is a voluntary reporting system for the collection of outcomes data related to thoracic surgical services. This database currently contains over two million patient records collected from more than 450 practices (from 1995 through 2004). Over 70 percent of the hospitals currently performing heart surgeries in the U.S. reportedly participate in this database.

Some specialty societies used a “building-block” approach to validate the survey results for surgical services. In constructing the building blocks, a service is divided into pre-, intra-, and post-service components. The pre-service component consists of all services furnished before the physician makes the skin incision (for example, pre-operative evaluation and scrubbing); the intra-service component consists of the “skin-to-skin” time; and the post-service component includes immediate post-surgery services and subsequent hospital and office visits. Each component (or building block) is then assigned work RVUs. Pre-service and intra-service work RVUs are based on time and the intensity of the activities, and post-service work is based on the specified E/M service for each post-operative visit. These three values are then summed to compute “building-block” work RVUs.

The results of the surveys were reviewed and organized by the specialty societies and then presented to the RUC. The RUC used eight workgroups, comprised of RUC members, to evaluate a series of clinically related codes based on the survey results and additional discussion. The workgroups also evaluated the relative work (time and intensity) for each service compared to other services on the fee schedule. The workgroups submitted their recommendations to the full RUC, which then considered the workgroup reports and then sent the final RUC recommendations to us.

II. Discussion of Comments and Decisions

A. Review of Comments

As previously stated, we sent the RUC a list of codes for review. The RUC submitted work RVU recommendations for these codes, with the exception of the codes that were withdrawn or referred to the CPT Editorial Panel for further review or action, and one CPT code (32020) for which no specialty society expressed an interest in conducting a survey. In the future, we will consider an alternative method to re-evaluate codes when no specialties express an interest in conducting a survey and we would appreciate suggestions from commenters on what alternative methods could be used.

We analyzed all of the RUC recommendations by evaluating the methodology used by each workgroup to develop the recommendations, the recommended work RVUs, and the rationale for the recommendations. When appropriate and feasible, if we had concerns about the application of a particular methodology, we assessed whether the recommended work RVUs were appropriate by using alternative methodologies.

In conducting our review of the RUC recommendations we considered whether: (1) The code was part of a completed survey process; (2) the methodology used by the specialty society followed the standard RUC process; (3) the survey respondents stated the work had or had not changed in the past 5 years; (4) databases (for example, STS, NSQIP, and Medicare diagnosis-related group (DRG)) were used in lieu of the standard RUC methodology or as a supplement to the standard methodology; and (5) the intra-service work per unit of time (IWPUT) calculation was used to determine work RVUs in lieu of the standard RUC process. (The IWPUT is derived from components of the “building-block” approach, described above, and is used as a measure of service intensity.) Although CMS recognizes that the work values of codes may change over time, it is the responsibility of the specialty society to present compelling evidence that a code is misvalued.

We have some concerns that many of the codes that were reviewed in the second 5-Year Review have been brought back again for further consideration. The main purpose of the 5-Year Review is to identify those services that need to be revalued because the work involved in performing the service has changed. Since there have been three opportunities for specialties to have services that are believed to be undervalued reviewed, we expect that, for the most part, only those services where there is compelling evidence of a change in the work will be considered for further review. However, because there has been little incentive for specialties to bring codes that may be overvalued for review, such services will still need to be identified for the next 5-Year Review.

Table 1, Five-Year Review of Work Relative Value Units, lists the codes reviewed during the 5-Year Review. This table includes the following information:

• CPT/HCPCS Code. This is the CPT or alphanumeric HCPCS code for a service.
• Modifier. A modifier -26 is shown if the work RVUs represent the professional component of the service.
• Description. This is an abbreviated version of the narrative description of the code.
• 2005 Work RVU. The work RVUs that appeared in the CY 2005 Physician Fee Schedule final rule with comment period are shown for each reviewed code.
• Requested Work RVU. This column identifies the work RVUs requested by the commenting specialty society or individual commenter. If we received more than one comment on a code, the code is listed more than once with the recommended RVUs. If the commenters did not recommend specific RVUs, we indicate this by “N/A”. A “WD” (withdrawal) indicates that the commenter withdrew the request for review of a code and chose not to pursue review of the code under the 5-Year Review and that no RUC recommendation was received.
• RUC Recommendation. This column identifies the work RVUs recommended by the RUC. “CPT” indicates that the RUC referred this code to the AMA CPT Editorial Panel for review and clarification and recommended maintaining the current work RVUs. An “(a)” indicates the commenting specialty society withdrew the proposal, and therefore, the RUC recommends maintaining the current work RVUs. A “(b)” in this column indicates there was no RUC recommendation.

HCPAC Recommendation. This column identifies the work RVUs recommended by the HCPAC. An “(a)” indicates that the commenting specialty society withdrew the proposal; therefore, the HCPAC recommends maintaining the current work RVUs. A “(b)” in this column indicates there was no HCPAC recommendation.

• CMS Proposal. This column indicates whether we agreed with the RUC recommendation (“Agree”); we are instead proposing to maintain the present work RVUs (“Disagree”); we are proposing work RVUs higher than the RUC recommendation (“Disagree/+”); or we are proposing work RVUs that are less than the RUC recommendation (“Disagree/-”). Codes for which we did not accept the RUC recommendation are discussed in greater detail following Table 1. A “(c)” in this column indicates that in the absence of a RUC/HCPAC recommendation we are proposing to maintain the present work RVUs.
• Proposed base work RVU. This column contains the 2007 proposed work RVUs. The proposed work RVUs for surgical services with a 10- or 90-day global period do not include the application of the RUC-recommended work values for E/M services. However, the additional work value attributed to the increase for E/M services included as part of the global period is reflected in the work RVUs contained in Addenda B and C of this proposed rule. (Note: ** denotes codes that were deleted for 2006.)

The following is a summary of our response to the RUC-recommended work RVUs for the 5-Year Review of work. We sent the RUC approximately 709 codes to review. The RUC referred 136 codes to the CPT Editorial Panel for review and 151 codes were withdrawn by the specialty societies. We accepted the RUC's recommended work RVUs for 299 of the services reviewed and disagreed with the RUC's recommended work RVUs for 123 of the services reviewed. Of the 123 services for which we did not accept the RUC's recommended work RVUs, we increased the work RVUs for 3 services, recommended maintaining the current work RVUs for 48 services, and decreased the work RVUs for 72 services. (Note: 12 CPT codes for nursing facility and rest home services that were referred to the AMA CPT Editorial Panel were deleted for 2007.)

Additionally, the HCPAC reviewed a total of 7 services as part of the 5-Year Review. Of the 7 services reviewed by the HCPAC, we accepted the HCPAC recommendations for 1 service, recommended maintaining the current work RVU for 1 service, decreased the work RVUs for 4 services, and 1 code was withdrawn by the specialty society.

B. Discussion of Comments by Clinical Area

1. Dermatology and Plastic Surgery

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS-DERMATOLOGY AND PLASTIC SURGERY” at the beginning of your comments.]

a. Hidradenitis

The American Society of Plastic Surgeons (ASPS) submitted the hidradenitis services (CPT codes 11450, 11451, 11462, 11463, 11470 and 11471) as undervalued but, based on the very low response rate to the survey they conducted the ASPS withdrew these codes from the 5-Year Review.

b. Craniofacial Surgery

The ASPS originally requested that 10 craniofacial reconstruction and fracture codes be reviewed. ASPS conducted a standard RUC survey for these services and, based on the low survey response rate, withdrew the following six CPT codes from the 5-Year Review: 21365, 21366, 21432, 21435, 21436, and 21470. ASPS presented survey data for the remaining four CPT codes listed in Table 2 to the RUC indicating there is compelling evidence that these codes had been valued based on an incorrect assumption regarding the value of the bone graft portion of each service.

RUC Recommendations

The RUC agreed that the appropriate increment of work for the bone graft should be 50 percent of CPT code 20902, Bone graft, any donor area; major or large (7.54 work RVUs × 50 percent = 3.77 work RVUs). The RUC recommended that this increment of 3.77 be used and added to the base code for each of these services.

The RUC-recommended work RVUs for these CPT codes are as follows: 21145 = 21.84 work RVUs; 21146 = 22.55 work RVUs, 21147 = 23.32 work RVUs; and 21395 = 13.88 work RVUs.

CMS Proposed Valuation

We agree with the RUC recommendations for craniofacial surgery services.

c. Other Plastic Surgery Services

ASPS initially submitted five additional services for review (see Table 3). However, the specialty society was unable to obtain an adequate survey response rate for these codes and withdrew them from the RUC review. In addition, the RUC recommended that CPT code 15831 should be referred to the CPT Editorial Panel for review to capture the new population of patients using this service.

We submitted four plastic surgery services for the 5-Year Review as services that had never been reviewed by the RUC (see Table 4). In addition, CPT code 15732 was submitted as it had been valued as an inpatient service and it is now performed as an outpatient service.

RUC Recommendations

The RUC was convinced that the survey data validated the current valuation of CPT codes 15100, 15240, and 15734. The RUC recommended that the current work RVUs be maintained for these CPT codes as follows: 15100 = 9.04 work RVUs; 15240 = 9.03 work RVUs; and 15734 = 17.76 work RVUs. The RUC reviewed and discussed the issue concerning the change in setting from inpatient to outpatient for CPT code 15732 and determined that this code describes two disparate procedures; therefore, the RUC recommended that this CPT code be forwarded to the CPT Editorial Panel for review.

CMS Proposed Valuation

We agree with the RUC recommendations for these plastic surgery services.

d. Other Dermatology Services

The American Academy of Dermatology (AAD) and a pharmaceutical company submitted CPT code 96567, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure session, for the 5-Year Review but, subsequent to discussions with the RUC regarding the need for potential CPT revisions, withdrew the code from the 5-Year Review.

We submitted the CPT codes for integumentary services in Table 5 for review because they had never been previously reviewed by the RUC.

We requested that CPT code 17003 be reviewed because we believe that advances in technology have likely resulted in a modification to the physician work required to accomplish the procedure. In discussions at the RUC meeting, we noted that new Medicare coverage policies related to actinic keratoses (AK) have increased the reporting of this service to describe cryosurgical destruction of AK. Standard RUC surveys were conducted for all of these services.

RUC Recommendations

Based on a review of the survey data, the RUC was convinced that the survey data validated the current valuation of the following services and recommended the work RVUs for these CPT codes be maintained as follows: 11100 = 0.81 work RVUs; 12052 = 2.77 work RVUs; 13121 = 4.32 work RVUs; 14040 = 7.86 work RVUs; 14060 = 8.49 work RVUs; 17262 = 1.58 work RVUs; and 17281 = 1.72 work RVUs.

For CPT code 17003, the RUC reviewed previous and current survey data and agreed that the application of cryosurgery to each lesion requires no more than two minutes of physician time. Therefore, the RUC recommended a work RVU of 0.07 for CPT code 17003. The RUC determined that the revision to the work RVUs for CPT code 17003 created a rank order anomaly in this family of codes. In addition to referring codes in this family to the CPT Editorial Panel to clarify the code descriptors, the RUC in February 2006 also recommended a change to the work RVUs for CPT code 17004, Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions. This was based on the understanding that when rank order anomalies were identified, the specialty could bring these additional codes forward for consideration for re-evaluation under the 5-Year Review at the next RUC meeting (that is, February 2006).

A standard RUC survey was conducted for this code and based on the survey responses, the specialty society recommended a change in the intra-service work descriptions to reflect a greater time based on their belief that the destruction of premalignant lesions requires more time than benign lesions. Thus, the intra-service period for CPT code 17004 was changed to 20 minutes which is twice as much as the time associated with the destruction of benign lesion in CPT code 17111, Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of flat warts, molluscum contagiosum, or milia; 15 or more lesions, of 10 minutes. The RUC agreed to this time change and recommended work RVUs of 1.80 for CPT code 17004.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work RVUs for these services with the exception of CPT code 17004. For CPT code 17004, we believe that the work associated with benign and premalignant lesions is comparable and, therefore, the work RVUs for CPT code 17004 should be more similar to that of CPT code 17111, which is 0.92. Based on our proposed valuation of 17003 (the code used for 2-14 lesions), of 0.07 work RVUs, the 14th lesion would equal 0.91 work RVUs (0.07 × 13 lesions) plus 0.6 work RVUs for the initial lesion, that is, base code CPT code 17000, which is billed once in conjunction with 17003. We are proposing to value CPT code 17004, for 15 or more lesions, at 1.58 work RVUs by adding the 0.07 work RVU increment of 17003 and the 0.6 work RVUs for the base code, CPT code 17000, which is not billed in conjunction with CPT code 17004.

e. Mohs Surgery

We referred the Mohs surgery codes for review because this family of services has never been surveyed and reviewed by the RUC (see Table 6).

The specialty society conducted surveys to collect data for these two codes. The workgroup then reviewed the history of these services, including the fact that the nomenclature for these services is not consistent with other integumentary coding conventions in CPT and that the RUC had previously indicated that the specialty society should work with the CPT Editorial Panel to redefine these services.

RUC Recommendations

The RUC recommended that these CPT codes be referred to the CPT Editorial Panel.

CMS Proposed Valuation

We will maintain the current valuation for these services pending the results of the review of the CPT Editorial Panel.

f. Excision of Lesions

We submitted all of the excision of lesion codes for review, noting that these services should be surveyed and reviewed by the RUC (see Table 7—benign: CPT codes 11400 through 11446, and malignant: CPT codes 11600 through 11646).

The work RVUs for the codes predominantly performed by the surgical specialties (CPT codes representing services to excise larger lesions) were all valued, with the exception of two CPT codes, by acceptable RUC surveys. However, there were no acceptable RUC surveys for the 18 services predominantly performed by the dermatologists (CPT codes representing services to excise smaller lesions) due to incomplete surveys and low response rates.

RUC Recommendations

The RUC agreed that the primary difference in the work between the family of codes for excision of benign lesions versus those codes for excision of malignant lesions (see Table 7) is in the pre-evaluation time (that is, additional planning, and discussions with the patient), the intensity of the intra-service time, and the level of post-operative visit.

The workgroup used the RUC surveys to determine the work RVUs for those services performed by the surgeons and then applied the building-block approach using the IWPUT values of the codes primarily performed by the surgical specialties to derive IWPUT values and corresponding work RVUs for the CPT codes primarily performed by dermatology. (The IWPUT is derived by dividing the intra-service work by the intra-service time, and is used to measure the relative intensity of the work between services.)

As a result of the application of the building-block methodology to the codes without RUC acceptable surveys, the RUC recommended that 24 codes retain their current work RVUs, 5 codes have decreased work RVUs, and 7 codes have increased work RVUs. The specific RUC recommendations for these CPT codes are presented in Table 7.

CMS Proposed Valuation

We are in agreement with the RUC recommendations for the excision of lesions services.

2. Orthopedic Surgery

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—ORTHOPEDIC SURGERY” at the beginning of your comments.]

a. Tumor Procedures

The American Academy of Orthopaedic Surgeons (AAOS) submitted CPT codes in the following three families of tumor procedures for review. (See Table 8, Table 9, and Table 10.)

The specialty subsequently withdrew CPT codes 21935, 24151, and 24153 from the 5-Year Review. A minisurvey methodology was used for all three families of codes.

RUC Recommendations

Based on a review of the survey results for the codes in Families 1 and 2, the RUC recommended referring these codes to the CPT Editorial Panel for clarification. The RUC indicated that the survey data from the specialty society described a hospitalized patient as the typical patient. However, our data indicates that the typical patient is not hospitalized and that this inconsistency could be the result of ambiguous CPT descriptors.

For the services in Family 3, the RUC discussion focused on the issue of whether there may also be different patient populations covered by each of these codes.

The RUC also recommended referring the codes in Family 3 to the CPT Editorial Panel for clarification.

CMS Proposed Valuation

We will maintain the current valuation for these services pending the results of the review by the CPT Editorial Panel.

b. Trauma Procedures

The AAOS submitted the following trauma procedure codes for review (see Table 11). Standard RUC surveys of these services were conducted.

RUC Recommendations

Based on a review of the compelling evidence, the RUC made the following recommendations.

For CPT code 20680, the RUC agreed that the intra-operative time for this code is misvalued based on the significant changes in physician work for the removal of deep implants due to changes in technology. Using the survey's 25th percentile value for the work RVUs along with the 25th percentile value for intra-service time, and adjusting for the fact that this procedure is typically performed in an outpatient setting, the RUC recommended a work RVU of 5.86 for this service.

For CPT code 24430, the workgroup did not believe that the current work value for CPT code 24430 accounts for all the work typically involved with this service. This is based on the survey's physician time and visit data and a comparison to CPT code 24515, Open treatment of humeral shaft fracture with plate/screws, with or without cerclage, which is a less complex procedure than CPT code 24430. The RUC recommended a work RVU of 14.00 and an intra-service time of 102 minutes for this service, which was the 25th percentile for work of the survey data.

Based on a comparison to CPT code 27506, Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without and/or locking screws, the workgroup determined that the current work RVUs for CPT code 27465, do not fully account for the work typically involved in shortening the femur because it typically includes the insertion of an intermedullary nail. However, the workgroup believed that CPT code 27465 should be valued lower than the reference service code, CPT code 27454, Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (e.g., Sofield type procedure), which has a work RVU of 17.53, and is a greater intensity procedure. The RUC-recommended work RVU for CPT code 27645 was 17.50, based on the median of the survey data.

Based on a review of the survey data, the workgroup did not believe that there was compelling evidence to change the work RVU for CPT code 27470. Therefore, the RUC recommended that the current work RVU of 16.05 be maintained for this service. However, the workgroup also recommended using the new survey times as they believed the Harvard times from the original Harvard relative value study, which was used to establish RVUs at the outset of the Medicare PFS, are inflated.

For CPT code 27709, Osteotomy; tibia and fibula, the RUC reviewed the survey time and compared this service to CPT code 27705, Osteomy, tibia, which has a work RVU of 10.36. The RUC recommended a work RVU of 16.50 for CPT code 27709 which would place the code in proper rank order with CPT code 27705.

The RUC recommended the referral of CPT codes 20692, 27472, and 27720 to the CPT Editorial Panel to clarify whether these 90-day global period codes should be exempt from modifier 51. (Modifier 51 denotes that a multiple procedure was performed.) The RUC was concerned that attempting to value these codes would lead to double counting some of the work.

The RUC-recommended valuation for these CPT codes was as follows: 20680 = 5.86 work RVUs; 24430 = 14.00 work RVUs; 27465 = 17.50 work RVUs; 27470 = 16.05 work RVUs; and 27709 = 16.50 work RVUs.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work values for these trauma services.

c. Total Elbow and General Procedures

AAOS submitted the following elbow athroplasty service for review (see Table 12).

In addition, we submitted the following CPT codes, in Table 13, for review.

Standard RUC surveys of these services were conducted.

RUC Recommendations

The RUC recommended maintaining the current work RVUs for CPT codes 20600, 20610, and 29075 because of the low response rate for the surveys and the lack of compelling evidence for changing the work value.

Based on a review of the survey data and information provided by the presenting specialty societies, AAOS and the American Society of Shoulder and Elbow Surgeons, the RUC concluded that the CPT code 24363 should be valued the same as CPT code 23472, Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder), and recommended a work RVU of 21.07 to maintain appropriate rank-order alignment with this family of codes. The RUC-recommended valuation for these CPT codes was as follows: 20600 = 0.66 work RVUs; 20610 = 0.79 work RVUs; 24363 = 21.07 work RVUs; and 29075 = 0.77 work RVUs.

CMS Proposed Valuation

We agree with the RUC-recommended work RVUs for these elbow and general procedure services.

d. Wrist, Hand and Finger

We submitted the CPT codes in Table 14 for review.

CPT code 64702, Neuroplasty; digital, one or both, same digit, was submitted by the American Society for Surgery of the Hand (ASSH) with the rationale that this code is based on inaccurate Harvard physician times that are low compared to other hand surgery codes. Standard RUC surveys of these services were conducted.

RUC Recommendations

Based on a review of the survey data, the RUC recommended that the current work RVUs be maintained for CPT codes 25447, 26055, 26160, and 64721.

For CPT code 26600, the workgroup examined the survey data presented by the specialty society and agreed that the current work value of 1.96 RVUs may not fully reflect the value of all post-operative visits that are the current standard of care and that the CPT code most frequently cited as a reference code (CPT code 26720, Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each), also understates the number of post-operative visits. The workgroup validated the survey median value of 2.40 work RVUs by performing a building-block calculation that added the value of an additional post-operative visit (CPT code 99212 at 0.43 work RVUs) to the current work value for CPT code 26600 of 1.96 for a total of 2.39 work RVUs. Since this value was almost identical to the median survey value of 2.40, the RUC recommended accepting this median value for the work RVUs for CPT code 26600.

For CPT code 26951, the RUC workgroup agreed that the current value of 4.58 work RVUs for this code creates a rank order anomaly when compared to the reference code (CPT code 26185, Sesamoidectomy, thumb or finger (separate procedure)), which has a work RVU of 5.24. Based on a review of survey data, the RUC recommended that CPT code 26951 should be assigned work RVUs of 5.25 (the 25th percentile survey value) but that the survey median intra-service time of 45 minutes should be used since that is equal to the reference code.

For CPT code 64702, the RUC workgroup agreed that the current value for this service of 4.22 work RVUs does not include the number of post-operative days typically associated with this procedure. The workgroup believed that adding the work RVUs (1.3 work RVUs) associated with two additional outpatient visits, represented by CPT code 99213, produces an appropriate work RVU for this service and also places CPT code 64702 in the proper rank order with the reference service. The RUC recommended 5.52 work RVUs for CPT code 64702.

The RUC-recommended work RVUs for these CPT codes are as follows: 25447 = 10.35 work RVUs; 26055 = 2.69 work RVUs; 26160 = 3.15 work RVUs; 26600 = 2.40 work RVUs; 26951 = 5.25 work RVUs; 64702 = 5.52 work RVUs; and 64721 = 4.28 work RVUs.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work values for wrist, hand and finger services.

e. Total Joint and Hip Fracture

We submitted three CPT codes for review (see Table 15).

The specialty society did not submit surveys for these codes, which is the accepted RUC method, for the RUC's consideration of changes to current work RVUs. Instead the specialty society developed proposed values for these services based on data obtained from the VA NSQIP database and the Medicare DRG database. The specialty society did survey its membership to obtain the data, but did not provide the workgroup or the RUC with this information, stating the vignettes did not describe a typical patient for this series of codes. Thus, the survey data for these codes was not available for the RUC workgroup to review at its August 2005 meeting.

The RUC requested that the specialty society survey its members on these three codes so that survey data could be used to evaluate the codes at the September 2005 RUC meeting. The specialty society used survey data, as well as NSQIP data and Medicare DRG data, to evaluate pre-service and intra-service times for these codes. The workgroup, as well as the RUC, was uncomfortable with mixing data from three separate sources in lieu of the established and accepted methodology of the RUC. The specialty society maintained the NSQIP data was more accurate than the survey data.

RUC Recommendations

The RUC did not find any compelling evidence to change the current work RVUs assigned to these services. Based on a review of the data, the RUC recommended maintaining the current work RVUs of 20.09 for CPT code 27130, 15.58 for CPT code 27236 and 21.45 for CPT code 27447, but also recommended using the new physician time data for each of these services.

CMS Proposed Valuation

For these three CPT codes (27130, 27236,and 27447), the specialty society used NSQIP and Medicare DRG data instead of the standard RUC survey methodology to create an intra-service time. Medicare DRG data has not been used by CMS or the RUC to evaluate new or existing CPT codes. CPT code 27130 has never been reviewed by the RUC. It currently has 20.09 work RVUs which is based on the following Harvard time data: pre-service time of 68 minutes, intra-service time of 128 minutes, post-service time of 36 minutes and eight hospital days. We believe that this service can be compared to CPT codes 43641, Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective), and 60260, Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid. Both codes were reviewed by the RUC during the second 5-Year Review. CPT code 43641 has 60 minutes pre-service time, 150 minutes intra-service time, 30 minutes post-service time, and 6 hospital days, resulting in work RVUs of 17.24. CPT code 60260 has 60 minutes pre-service time, 145 minutes intra-service time and 30 minutes post-service time with 2 hospital days, resulting in work RVUs of 17.44. We believe CPT code 27130 is similar in work and intensity to CPT code 43641, and if one removes 2 hospital days (code 99231), this would result in a work RVU of 15.96. Therefore, we recommend a work RVU of 15.96 for CPT code 27130.

CPT code 27236 has never been reviewed by the RUC. It has a pre-service time of 74 minutes, an intra-service time of 89 minutes, a post-service time of 27 minutes, 100 minutes for hospital days, and 57 minutes for office visits for a total time of 347 minutes based on the Harvard time data, resulting in work RVUs of 15.58. We believe CPT codes 34421, Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by leg incision, and 47600, Cholecystectomy, which were included in the second 5-Year Review, are similar in work intensity and time to CPT code 27236. CPT code 34421 has a pre-service time of 70 minutes, an intra-service time of 95 minutes, a post-service time of 221 minutes, and total time of 386 minutes, resulting in work RVUs of 11.98. CPT code 47600 has a pre-service time of 75 minutes, an intra-service time of 80 minutes, and a post-service time of 194 minutes for a total time of 349 minutes, resulting in work RVUs of 13.56. We propose a work RVU of 12.77 for CPT code 27236, which is the median value for these two codes and maintains relativity within this family of codes.

CPT Code 27447 has never been reviewed by the RUC. It has 21.45 work RVUs, which is based on the following Harvard time data: pre-service time of 60 minutes, intra-service time 139 minutes, post-service time of 37 minutes, 118 minutes for hospital days, and 54 minutes for office visits for a total time of 408 minutes. We believe this service is comparable to CPT code 35671, Bypass graft, with other than vein; popliteal-tibial or -peroneal artery, which was reviewed during the second 5-Year Review. This service has a pre-service time of 70 minutes, an intra-service time of 135 minutes, and a post-service time of 206 minutes for a total time of 411 minutes, resulting in work RVUs of 19.30. We believe CPT code 27447 is similar in work intensity and time to CPT code 35671 and propose work RVUs of 19.30 for CPT code 27447.

f. Additional Fracture Codes

The AAOS also submitted the following CPT codes listed in Table 16 and the ASSH submitted CPT code 25620. However, the specialty societies believed clarification was needed for the CPT descriptor for these services, as there was a question whether the current valuation for these codes includes the application of internal and external fixation to a fracture site.

RUC Recommendations

The RUC recommended that these CPT codes be referred to the CPT Editorial Panel for review and clarification.

CMS Proposed Valuation

We will maintain the current valuation for these services pending the results of the review by the CPT Editorial Panel.

3. Gynecology, Urology, Pain Medicine, and Neurosurgery

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—GYNECOLOGY, UROLOGY, PAIN MEDICINE, AND NEUROSURGERY” at the beginning of your comments.]

a. Obstetrics and Gynecology

The American College of Obstetricians and Gynecologists (ACOG) submitted the CPT codes in Table 17 for review.

However, the specialty society subsequently withdrew the following CPT codes: 49200, 49201, 56631, 56632, 56634, 56637, 56640, 57550, 57555, and 57556.

We identified five CPT codes for review but withdrew one code, CPT code 58260 (see Table 18).

A standard RUC survey with over 30 responses was used for these codes.

RUC Recommendations

The RUC recommended maintaining the existing RVUs for CPT codes 57160, 58120 and 58720. The RUC believed there was no compelling evidence presented to indicate that there had been a change in work for CPT code 57160. The RUC also agreed with the specialty society that the survey data collected validated the existing times and existing RVUs for CPT codes 58120 and 58720.

The RUC recommended increasing the work value for the remaining CPT codes. The RUC agreed with the specialty society that these procedures were currently undervalued because of rank-order anomalies, changes in patient population or incorrect assumptions made in the previous valuation of the service. However, the RUC-recommended work values for each service were below the level presented by the specialty society. The RUC recommended the use of the surveys' 25th percentile work RVUs for four of the services, CPT codes 57240, 57250, 57500 and 58150, and the 75th percentile for CPT codes 57260 and 57265. The 75th percentile was used because the workgroup believed that otherwise there would be a rank order anomaly between the more complex vagina repair services, CPT codes 57280 and 57265, and the simpler procedures, CPT codes 57240 and 57250.

The RUC-recommended work values for these services are as follows: 57160 = 0.89 work RVUs; 57240 = 10.56 work RVUs; 57250 = 10.56 work RVUs; 57260 = 13.50 work RVUs; 57265 = 15.00 work RVUs; 57500 = 1.20 work RVUs; 58120 = 3.27 work RVUs; 58150 = 15.98 work RVUs; and 58720 = 11.34 work RVUs.

CMS Proposed Valuation

We propose to accept the RUC recommendations for these obstetrics and gynecology services. We initially had concerns with the use of the surveys' 75th percentile for the recommendation of work RVUs for CPT codes 57260 and 57265, but in comparison with similar services, we believe that the RUC recommendations for these services create the correct rank order, both within the family of codes and with other similar services.

b. Urology

The American Urological Association (AUA) and the Coalition for the Advancement of Prosthetic Urology (CAPU) submitted five CPT codes for review (see Table 19). However, the specialty society subsequently withdrew four CPT codes (53445, 54400, 54405, and 54411).

In addition, we identified seven CPT codes for review because of possible changes in technology or because the service had never been reviewed by the RUC (see Table 20). A standard RUC survey with over 30 responses was used for the following codes.

RUC Recommendations

Of the eight codes presented with survey data, the RUC recommended maintaining the existing work RVUs for two codes. For CPT code 57288, the RUC believed that the survey median supported the specialty society's contention that the work currently associated with the code is accurate. For CPT code 50590, the RUC believed that the current work value more accurately reflected the work involved in the service than did the survey, which increased the work RVUs while decreasing the physician intra-time substantially.

The RUC recommended decreasing the current work RVUs for CPT code 51720 to reflect the median work RVU from the survey.

The RUC agreed with the specialty society's recommendations for an increase to the existing RVUs for CPT code 51798. This procedure was originally reviewed by the RUC in April 2002 with a recommendation 0.38 work RVUs to reflect the physician work believed to be typically associated with this procedure. However, in the CY 2002 Physician Fee Schedule final rule with comment period (66 FR 55246), we contended that there was no physician work associated with this service and assigned work RVUs of 0.00. This decision was upheld by the refinement process that is used to address comments received on the valuation of new and revised CPT codes and that was discussed in the CY 2004 Physician Fee Schedule final rule with comment period (67 FR 63227). However, the RUC agreed with the specialty society that this procedure is performed by physicians and reaffirmed its previous recommendation of 0.38 work RVUs for this procedure.

The RUC recommended increasing the work RVUs for four codes, but below the level requested by the specialty society (that is, recommending work RVUs equal to the surveys' 25th percentile for CPT codes 52000 and 55700, equal to the median for CPT code 52601 and less than the 25th percentile for CPT code 52204). The RUC agreed with the specialty society that these procedures were currently undervalued due to changes in technology, changes in patient populations and incorrect assumptions that were made in the previous valuation of the service.

The RUC-recommended work values for these CPT codes for urology services are as follows: 50590 = 9.08 work RVUs; 51720 = 1.50 work RVUs; 51798 = 0.38 work RVUs; 52000 = 2.23 work RVUs; 52204 = 2.59 work RVUs; 52601 = 14.00 work RVUs; 55700 = 2.58 work RVUs; and 57288 = 13.00 work RVUs.

CMS Proposed Valuation

We accept the RUC recommendations for these urology services except for CPT code 51798. The RUC recommendation for bladder ultrasound was based on CPT code 79857 (the pelvic ultrasound (nonobstetric) procedure) as the reference code. (CPT code 76857 should be used if the urinary bladder alone is imaged, whereas CPT code 51798 should be utilized if a bladder volume or post-void residual measurement is obtained without imaging the bladder.) We disagree that this is an appropriate reference code because the pelvic ultrasound procedure is very different from a bladder ultrasound procedure. The bladder ultrasound procedure only results in a “numerical reading” of milliliters of residual urine in the bladder and does not produce an image on a screen for a physician to interpret like many other ultrasound procedures (for example, the pelvic ultrasound). Therefore, we disagree with the RUC recommendation to use the 0.38 physician work RVUs for the professional component of code 76857 as the work RVUs for CPT code 51798 because we do not believe this procedure involves physician work since the machine only produces a numerical reading.

c. Spine Surgery

We identified the CPT codes in Table 21 for the 5-Year Review.

With approval of the RUC, the specialty society used a modified RUC survey that included surveys of time (pre-service, intra-service, immediate post-service), post-operative visits and estimates of total work. Two reference codes were used to survey the estimates of intensity and complexity. There were well over 100 responses to each survey.

RUC Recommendations

The RUC accepted the specialty society's recommendations to decrease the existing work RVUs for three procedures: CPT codes 22554, 63047 and 63075. The RUC agreed that these procedures were overvalued due to decreases in the length of stay and physician time. The RUC also accepted the specialty society's recommendation to maintain the work associated with CPT codes 22520 and 22840. The RUC agreed with the specialty society that the survey data collected validated the existing work RVUs associated with these codes. For CPT codes 22612 and 63048, the RUC recommended increases in the work RVUs, but less than the increases requested by the specialty society. The RUC agreed that these procedures were undervalued due to increases in length of stay and the incorrect assumptions made in the previous valuation of the service.

The specific RUC-recommended work RVUs were as follows: 22520 = 8.90 work RVUs; 22554 = 16.40 work RVUs; 22612 = 22.00 work RVUs; 22840 = 12.52 work RVUs; 63047 = 14.08 work RVUs; 63048 = 3.55 work RVUs; and 63075 = 18.58 work RVUs.

CMS Proposed Valuation

We accept the work RVUs recommended by the RUC for CPT codes 22520, 22554, 22840, 63047 and 63075. However, we have technical concerns with the recommendations for CPT codes 22612 and 63048.

The workgroup recommended the survey's 25th percentile for CPT code 22612 to keep the appropriate rank order with the reference service, CPT code 22595, which is a more complex procedure. However, there was a typographical error in the information presented by the specialty society that listed the work RVUs for the reference code as 23.36, rather than the correct value of 19.36 work RVUs. Therefore, the recommended work value of 22.00 RVUs is clearly inappropriate and we are proposing to maintain the current work RVUs of 20.97 for this service.

There is an additional typographical error in the specialty society survey data for CPT code 63048. The summary information lists the reference code as also being CPT code 63048. Therefore, there is no information given that compares the respondents' estimates of complexity and intensity between CPT code 63048 and the reference code. Because we do not have sufficient information to decide if the recommended work RVUs are appropriate, we are proposing to maintain the current work RVUs of 3.26 for CPT code 63048.

d. Spinal Pump Infusion and Stimulators

The American Academy of Pain Medicine (AAPM) and the American Society of Anesthesiologists (ASA) initially submitted several CPT codes that were subsequently withdrawn from the 5-Year Review (see Table 22).

e. Aneurysm, Epilepsy and Skull Procedures

The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) submitted six CPT codes for review (see Table 23).

We submitted two CPT codes for review (see Table 24).

A standard RUC survey with over 30 responses was used for six of the codes. The surveys for CPT codes 61537 and 61538 had only 12 and 14 responses, respectively.

RUC Recommendations

The RUC agreed with the specialty society that the existing RVUs for CPT code 61154 should be maintained because there was no compelling evidence that the work currently associated with this procedure has changed. The RUC accepted the specialty society's requested increase to the existing work RVUs, as reflected by the survey median, for CPT code 61312, agreeing with the specialty society that the increased use of anticoagulants by these patients has increased the intensity of the intra-service work. The RUC recommended increasing the work RVUs for CPT codes 61697, 61698, 61700 and 61702, but at or below the surveys' 25th percentile.

While the workgroup recommended maintaining the current work RVUs for CPT codes 61537 and 61538, at the subsequent RUC meeting, the specialty society extracted these codes for discussion and the RUC recommended the 25th percentile from the surveys for the work RVU.

The RUC-recommended work RVUs for these CPT codes are as follows: 61154 = 14.97 work RVUs; 61312 = 27.00 work RVUs; 61537 = 35.00 work RVUs; 61538 = 38.00 work RVUs; 61697 = 57.31 work RVUs; 61698 = 64.03 work RVUs; 61700 = 46.01 work RVUs; and 61702 = 54.28 work RVUs.

CMS Proposed Valuation

We accept the RUC-recommended work RVUs for these neurosurgery services.

4. Radiology, Pathology, and Other Miscellaneous Services

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS-RADIOLOGY, PATHOLOGY, and OTHER MISC. SERVICES” at the beginning of your comments.]

a. Pathology

The College of American Pathologists submitted four CPT codes for review using the rationale that there have been changes in cancer protocols and the content of work (see Table 25). The specialty society conducted a full RUC survey for these codes.

RUC Recommendations

The RUC reviewed the specialty's survey results for each code and believed the specialty society had presented compelling evidence to change the relative work value for each code because all were undervalued for the increased physician work now involved in the services. The RUC believed that the change in work was due to the increased number and type of slides undergoing review in the typical case, and, in particular, the number of immunohistochemical slides that must undergo review. Based on recent literature, the RUC also believed that the clinical practice of these pathology consultations had changed. In addition, the RUC agreed with the specialty society that the survey's 25th percentile reflected the true physician work for each of the codes.

The RUC-recommended work RVUs for these CPT codes are as follows: 88309 = 2.80 work RVUs, 88321 = 1.63 work RVUs, 88323 = 1.83 work RVUs, and 88325 = 2.50 work RVUs.

CMS Proposed Valuation

We are in agreement with all of these RUC-recommended work RVUs for pathology services.

b. Radiation Oncology

We submitted the radiation oncology CPT codes in Table 26 for review.

Standard RUC surveys were conducted for these services. The survey results indicated that the work RVUs for each code should be maintained at their current level, and the specialty society, the American Society for Therapeutic Radiology and Oncology (ASTRO), recommended no change in the work RVU.

RUC Recommendations

The RUC agreed with the survey results and supported the specialty society's recommendation to maintain the work RVUs. The RUC found no compelling evidence to change the work RVUs for these CPT codes, and therefore, recommended maintaining the current work values for these CPT codes as follows: 77263 = 3.14 work RVUs; 77280 = 0.70 work RVUs; 77290 = 1.56 work RVUs; 77300 = 0.62 work RVUs; 77315 = 1.56 work RVUs; 77331 = 0.87 work RVUs; 77334 = 1.24 work RVUs; and 77470 = 2.09 work RVUs.

CMS Proposed Valuation

We are in agreement with all of these RUC-recommended work RVUs for radiology oncology.

c. Radiology

We requested that the CPT codes for radiology services in Table 27 be reviewed.

In addition, the American College of Cardiology (ACC) and American College of Radiology (ACR) recommended four cardiac imaging codes be sent to the CPT Editorial Panel for review and clarification so that they may reflect current practice patterns (see Table 28). The RUC agreed with this recommendation.

The specialty societies conducted standard RUC surveys for the remaining services.

RUC Recommendations

The RUC agreed with the survey results and found there was no compelling evidence to change the work RVUs for CPT codes 70355, 71010, 71020, 71260, 72192, 72193, 73100, 73110, 73120, 73130, 73140, 74000, 74020, 74022, 74150, 74160, 76700, 76830, 78306, 78315, and 78465.

The RUC recommended a reduction in the work RVU for the DXA service, CPT code 76075, because the workgroup believed that the actual work is less intense and more mechanical than the specialty society's description of the work. In addition, the RUC believed that the survey results provided insufficient evidence to support the current work RVU associated with CPT code 78478 and also believed that the physician time was overestimated. The RUC also recommended a reduction in the work RVUs for CPT code 78480 because it was not in the correct rank order and was therefore overvalued.

The RUC-recommended work RVUs for these CPT codes are as follows: 70355 = 0.20 work RVUs; 71010 = 0.18 work RVUs; 71020 = 0.22 work RVUs; 71260 = 1.24 work RVUs; 72192 = 1.09 work RVUs; 72193 = 1.16 work RVUs; 73100 = 0.16 work RVUs; 73110 = 0.17 work RVUs; 73120 = 0.16 work RVUs; 73130 = 0.17 work RVUs; 73140 = 0.13 work RVUs; 74000 = 0.18 work RVUs; 74020 = 0.27 work RVUs; 74022 = 0.32 work RVUs; 74150 = 1.19 work RVUs; 74160 = 1.27 work RVUs; 76075 = 0.20 work RVUs; 76700 = 0.81 work RVUs; 76830 = 0.69 work RVUs; 78306 = 0.86 work RVUs; 78315 = 1.02 work RVUs; 78465 = 1.46 work RVUs; 78478 = 0.50 work RVUs; and 78480 = 0.30 work RVUs.

CMS Proposed Valuation

We are in agreement with all of these RUC-recommended work RVUs for radiology services.

d. Endoscopy Procedures

We requested the RUC to review five endoscopy CPT codes because they had never been reviewed by the RUC (see Table 29). Standard RUC surveys were conducted.

RUC Recommendations

The RUC agreed with the survey results and found no compelling evidence to change the work RVUs for any of these services. Therefore, the RUC recommended the work values for these CPT codes be maintained as follows: 43235 = 2.39 work RVUs; 43246 = 4.32 work RVUs; 43750 = 4.48 work RVUs; 45330 = 0.96 work RVUs; and 45378 = 3.69 work RVUs.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work RVUs for endoscopic procedure codes.

e. Neurology, Neuromuscular, and Nervous System

The American Academy of Neurology (AAN), American Clinical Neurophysiology Society (ACNS), American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), and the American Academy of Physical Medicine and Rehabilitation (AAPMR) submitted five neurology and neuromuscular CPT codes for this 5-Year Review and AAN and the American Academy of Pediatrics (AAP) jointly submitted CPT code 62270 (see Table 30).

In addition, we requested the RUC to review five neurological CPT codes (see Table 31).

Standard RUC surveys were conducted for these services. The specialty societies believed the survey results indicated that the current work RVUs were either correctly valued or undervalued.

RUC Recommendations

The RUC found no compelling evidence to change the work RVUs for CPT codes 95816, 95819, 95861, 95900, 95904, 95925, 95926, and 95927. However, the RUC agreed that there was compelling evidence that CPT codes 95872 and 95953 were undervalued and recommended increasing their existing RVUs.

The RUC-recommended work RVUs for these services are as follows: 95816 = 1.08 work RVUs; 95819 = 1.08 work RVUs; 95861 = 1.54 work RVUs; 95872 = 3.00 work RVUs; 95900 = 0.42 work RVUs; 95904 = 0.34 work RVUs; 95925 = 0.54 work RVUs; 95926 = 0.54 work RVUs; 95927 = 0.54 work RVUs; and 95953 = 3.30 work RVUs.

For CPT code 62270, the RUC believed that there is a bimodal distribution of physician work associated with the code because there are two different typical patient types, infants and young children. The RUC and the specialty societies believed that the infant population requires less work than in the young child population. The RUC suggested that it may be reasonable for the specialty societies to eventually consider splitting the code into the two typical patient types to capture any differences in physician work. However, for the current CPT code 62270, the RUC recommended that it should be valued higher and recommended a work RVU of 1.37.

CMS Proposed Valuation

We are in agreement with all of the RUC-recommended work RVUs for neurology, neuromuscular and nervous system services except for the recommendation for CPT code 95872. We have concerns that the work recommendation for this service, which was based on the survey's 75th percentile for work, is not the correct valuation and is inappropriate for this service. We calculated the pre-service and post-service work RVU using the surveyed physician time data. Then, we subtracted the surveyed intra-service time from the current time. Next, we multiplied this difference in time by the calculated IWPUT using the specialty recommended total work RVUs to determine an intra-service work RVU. Adding the calculated work RVUs resulted in a work RVU of slightly less than 2.0, which is close to the same value as the survey median work RVU. In accordance with this analysis and the survey median, we are recommending a work RVU of 2.00.

f. Pulmonary Medicine

We requested the RUC to review three pulmonary medicine CPT codes (see Table 32).

Standard RUC surveys were conducted. The specialty societies believed the survey results indicated that the current work RVUs were either correctly valued or undervalued.

RUC Recommendations

The RUC reviewed the survey results and recommendations from the specialty society for CPT codes 31622 and 94010 and found no compelling reason to change the work RVUs for these codes. However, the RUC agreed with the specialty society that the time data elements from the survey results reflected the typical patient encounter.

The RUC did find compelling evidence to support the specialty society's recommendation and survey work value results for CPT code 94657. However, the RUC determined that a rank order anomaly would be created with CPT code 94656 if the recommended value for CPT code 94657 was adopted. Therefore, the RUC recommended that this code be referred to the CPT Editorial Panel.

The RUC-recommended work RVUs for these codes are as follows: 31622 = 2.78 work RVUs and 94010 = 0.17 work RVUs.

CMS Proposed Valuation

We are in agreement with these RUC-recommended work RVUs for pulmonary medicine services.

g. Miscellaneous Services

(i) Anesthesia

The ASA requested that the RUC review code 00797, Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity. The ASA believed that the results of the standard RUC survey conducted by the specialty society indicated the physician work was undervalued for this code.

RUC Recommendations

The RUC reviewed the survey results and specialty society recommendation and agreed with its recommended median base unit value and physician time for the code. The RUC recommended base unit valuation for this service was 11.00.

CMS Proposed Valuation

We are in agreement with the RUC recommendation for CPT code 00797.

(ii) Allergy and Immunology

The Joint Council of Allergy, Asthma, and Immunology (JCAAI) and the American Academy of Otolaryngic Allergy (AAOA) submitted five codes without work relative values for this 5-Year Review based on the rationale that physician work was inherent in the service (see Table 33). The specialties subsequently withdrew CPT codes 95115 and 95117 from consideration.

In addition, we requested the RUC to review the immunotherapy CPT codes in Table 34 because they had never been reviewed by the RUC. Standard RUC surveys were conducted.

RUC Recommendations

The RUC reviewed the specialty society recommendations, and survey results recommended that CPT codes 95004, 95024, and 95027 be referred to the CPT Editorial Panel for clarification and possible revision. The RUC recommended that the current work RVUs be maintained for CPT codes 95144 and 95165, because there was no compelling evidence for a change. The RUC-recommended work RVUs for these CPT codes are: 95144 = 0.06 work RVUs; and 95165 = 0.06 work RVUs.

CMS Proposed Valuation

We are in agreement with these RUC-recommended work RVUs for allergy and immunology services.

(iii) Pediatric codes

The AAP requested that the RUC review eight pediatric-related CPT codes for this 5-Year Review (see Table 35). However, two of these CPT codes (90473 and 90474) were subsequently withdrawn by AAP. The remaining six codes were referred to the CPT Editorial Panel for review.

(iv) Cardiology-Related Services

We requested that the RUC review five cardiology-related CPT codes (see Table 36). The specialty societies believed that the standard RUC survey results indicated that the work RVUs for each code should be either maintained or decreased from their current level.

RUC Recommendations

The RUC reviewed the survey results and found no compelling evidence to change the work RVUs for CPT codes 33208, 93010, 93015, and 93018. However, CPT code 93325 was referred to the CPT Editorial Panel by the RUC with the recommendation that this service be bundled with CPT code 93307, Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete.

The RUC-recommended work RVUs for these CPT codes are as follows: 33208 = 8.12 work RVUs; 93010 = 0.17 work RVUs; 93015 = 0.75 work RVUs; and 93018 = 0.30 work RVUs.

CMS Proposed Valuation

We are in agreement with these RUC-recommended work RVUs for cardiology related services.

5. Evaluation and Management (E/M) Services

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—EVALUATION AND MANAGEMENT SERVICES” at the beginning of your comments.]

A consortium of 27 organizations submitted a consensus comment letter stating that the work of E/M services has changed significantly since the E/M codes were reviewed during the first 5-Year Review and requested that the E/M codes be reviewed (see Table 37).

In addition, the following specialty societies submitted requests that individual E/M CPT codes be reviewed: The American Academy of Family Physicians (AAFP), the American Medical Directors Association (AMDA), the American Geriatric Society (AGS), the American Association for Geriatric Psychiatry (AAGP), the ASA, and the American Academy of Home Care Physicians (AAHCP).

Standard RUC surveys of the E/M services were conducted by a coalition of medical specialty societies. Recommendations of the coalition, as well as comments from the coalition of surgical specialties, were considered by the RUC workgroup.

RUC Recommendations

The RUC E/M workgroup conferred via conference call throughout the summer of 2005 and reviewed previous studies and methodologies used to evaluate the physician work related to the E/M services. At the first meeting in August of 2005, the workgroup considered the recommendations of the coalition of medical specialty societies, as well as the comments of the coalition of surgical specialties that countered the arguments presented regarding increased physician work. After extensive discussion, the workgroup agreed that there was evidence that incorrect assumptions were made in the previous valuation of these services. The workgroup reviewed each E/M code extensively, reviewing the survey from the coalition of medical specialties, comparing the codes to reference codes and considering comments from the surgical coalition and other meeting attendees.

At the RUC meeting in October 2005, the RUC agreed that there was compelling evidence to review the E/M services because of evidence that incorrect assumptions were made in the previous valuation of the services. The RUC approved final recommendations for 26 of these codes, interim recommendations for six codes (CPT codes 99222, 99223, 99232, 99233, 99291, and 99292) and postponed the review of three codes (CPT codes 99213, 99214, and 99215) to the February 2006 meeting.

At the February 2006 meeting, the RUC reached consensus on the recommended work values for all the outstanding E/M codes. As an example of the RUC review process, we are including the RUC notes on the rationale used to recommend a revised work value for CPT code 99213, the mid-level office visit, which is also the most frequently billed code in the PFS:

“The RUC agreed that the compelling evidence to review CPT code 99213 is that incorrect assumptions were made in the previous valuation of CPT code 99213 (that is, the assumptions made by Harvard and CMS are flawed). The RUC extensively discussed CPT code 99213 (physician time: pre- = 3, intra- = 15, and post- = 5) and agreed that this code is slightly more work than CPT code 99202 (recommended work RVU = 0.88; physician time: pre- = 2, intra- = 15, and post- = 5). It was noted the content for CPT code 99213 represents a higher level of intensity as the medical decision making is “low” for CPT code 99213, versus “straightforward” for CPT code 99202. CMS also provided utilization data that indicated that diagnosis and number of diagnosis were more significant for CPT code 99213 than CPT code 99202. Finally, the survey respondents agreed with this relationship, as the survey median work RVU for “all” survey respondents was 1.10 for CPT code 99213 and 1.05 for CPT code 99202. Utilizing this relationship and the recommended work RVU of 0.88 for CPT code 99202, the RUC determined that a work RVU of 0.92 for CPT code 99213 is appropriate. In addition, the RUC agreed that CPT code 99213 is similar in work to CPT code 93307 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete (work RVU = 0.92, physician time: pre- = 5, intra- = 18, and post- = 5), which is a code included on the RUC's Multi-Specialty Points of Comparison (MPC). It was also noted that the 25th percentile of the ‘all’ survey respondent, weighted survey data was 0.95 RVUs. The RUC recommends a work RVU of 0.92 for CPT code 99213 (physician time: pre- = 3, intra- = 15, and post- = 5).”

The RUC also recommended that the full increase for these codes be incorporated into the surgical global periods for each CPT code with a global period of 010 and 090.

Based on a review of the survey information, the RUC recommended that the work RVUs for the following CPT codes be maintained: 99201 = 0.45 work RVUs; 99202 = 0.88 work RVUs; 99203 = 1.34 work RVUs; 99211 = 0.17 work RVUs; 99212 = 0.45 work RVUs; 99238 = 1.28 work RVUs; and 99241 = 0.64 work RVUs.

The RUC also recommended that the work RVUs for the following CPT codes be increased: 99204 = 2.30 work RVUs; 99205 = 3.00 work RVUs; 99213 = 0.92 work RVUs; 99214 = 1.42 work RVUs; 99215 = 2.00 work RVUs; 99221 = 1.88 work RVUs; 99222 = 2.56 work RVUs; 99223 = 3.78 work RVUs; 99231 = 0.76 work RVUs; 99232 = 1.39 work RVUs; 99233 = 2.00 work RVUs; 99239 = 1.90 work RVUs; 99242 = 1.34 work RVUs; 99243 = 1.88 work RVUs; 99244 = 3.02 work RVUs; 99245 = 3.77 work RVUs; 99251 = 1.00 work RVUs; 99252 = 1.50 work RVUs; 99253 = 2.27 work RVUs; 99254 = 3.29 work RVUs; 99255 = 4.00 work RVUs; 99281 = 0.45 work RVUs; 99282 = 0.88 work RVUs; 99283 = 1.34 work RVUs; 99284 = 2.56 work RVUs; 99285 = 3.80 work RVUs; 99291 = 4.50 work RVUs; and 99292 = 2.25 work RVUs.

The RUC also noted that twelve E/M codes (nursing facility and domiciliary care) originally submitted had been deleted by CPT and replaced by new CPT codes that were reviewed by the RUC last year. These new CPT codes were included in the CY 2006 PFS final rule with comment period (70 FR 70116) and the associated RVUs were considered interim and subject to comment. Therefore, these new CPT codes were not included as part of the 5-Year Review.

CMS Proposed Valuation

We are in agreement with these RUC recommended work RVUs for E/M services. We also agree with the recommendation that the full increase for these codes should be incorporated into the surgical global periods for each CPT code with a global period of 010 and 090.

6. Cardiothoracic Surgery

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—CARDIOTHORACIC SURGERY” at the beginning of your comments.]

a. Congenital Codes

The STS/ American Association for Thoracic Surgery (AATS) submitted the congenital cardiac surgical CPT codes for review (see Table 38).

The commenters stated that at the second 5-Year Review, many of the more common congenital cardiac surgical codes were reviewed, and the values were adjusted. However, at that time, these much less commonly performed congenital cardiac surgical codes were not surveyed due to resource and time constraints. The commenter believed that this has created rank order anomalies within these families of codes.

Standard RUC surveys were conducted for the services in Table 38. However, there was a low response rate that was attributable to these procedures being infrequently performed by a small number of surgeons.

RUC Recommendations

The RUC believed that the current work RVUs for the codes presented created rank order anomalies in terms of the physician work relative value, but, during the review, the RUC agreed that a number of the reference procedures had inaccurate physician times. When the reference code times were compared with the surveyed times for the codes under review, the RUC noted inconsistencies in all time segments, including intra-service time. The RUC reviewed the survey data and the data for the reference codes, and made recommendations for work RVUs to place the surveyed codes in proper rank order. Recommendations for work RVUs reflected the survey's 25th percentile, the median survey value, or the time-adjusted survey data, which was based on time adjustments for certain portions of the service when compared to the reference codes. Due to concern about the accuracy of time for some of the reference codes, the RUC also recommended that the specialty society conduct future surveys for physician time only for CPT codes 33660, 33670, 33506, 33770, and 33780. However, the RUC agreed that the new 5-Year Review values and times could not be used to justify changes in the relative values of the reference services.

The RUC-recommended work RVUs for these CPT codes are as follows: 33414 = 36.52 work RVUs; 33416 = 34.25 work RVUs; 33505 = 36.00 work RVUs; 33665 = 32.98 work RVUs; 33684 = 32.50 work RVUs; 33688 = 32.88 work RVUs; 33771 = 38.50 work RVUs; 33779 = 41.00 work RVUs; and 33781 = 41.00 work RVUs.

b. Adult Cardiac and General Thoracic Codes

The STS/ATTS submitted 46 adult cardiac CPT codes for review and 27 general thoracic CPT codes for review but subsequently withdrew two CPT codes (32095 and 35600). The specialty believed many of these CPT codes needed to be reviewed due to the rank order anomalies that exist in these families of CPT codes (see Table 39).

We submitted two CPT codes for review, 32020 and 39400; however, no specialty expressed an interest in conducting a survey for CPT code 32020 so there was no RUC recommendation forwarded for this service. (See Table 39 for all codes submitted.)

The RUC had previously approved a building-block methodology based on the STS database, which would provide a mean intra-service time for the adult cardiac and general thoracic codes, as well as the procedure-specific length of stay. Two intensity surveys were also conducted and the final recommended intensity was an average of the two survey results. The remaining pre-service and post-service inputs were derived through a panel of cardiac surgeons.

The add-on CPT codes (33141, 33517 through 33523 and 33530) were evaluated by subtracting the time data for the base code from the time data for the combined base and add-on codes, with the results weighted for frequency of occurrence.

RUC Recommendations

The RUC workgroup reviewed the data elements for each code on a code-by-code basis. Most of the discussion focused on the number and level of post-operative visits, as well as the pre-service time. For the adult cardiac and general thoracic codes, the RUC agreed that the pre-service time was overstated and needed to reflect previously approved RUC pre-service times. Also, the RUC questioned the total times allocated to the codes when compared to a normal surgical work week. The workgroup developed a pre-service time standard that was used for a majority of the codes. This standard consisted of 60 minutes for evaluation, 15 minutes for positioning, and 20 minutes for scrub dress and wait time. For emergent procedures, the pre-service times were set at 10 minutes for evaluation, 12 minutes for positioning, and 15 minutes for scrub dress and wait time. The immediate post-service time was examined in conjunction with other visits on the same day of surgery. For most of the codes, the immediate post-service time was standardized at 40 minutes.

The intra-service times were derived from the STS database with mean times used for the adult cardiac codes and median times for the general thoracic codes. Because the general thoracic codes have a much lower number of cases in the database, the STS believed that the median was more appropriate. The RUC agreed with the specialty society that critical care visits should be used in the STS building-block methodology for all of the adult cardiac codes and for 13 of the general thoracic codes.

The assignment of the level of critical care services was recommended for each code based on the STS panel's knowledge and experience in caring for these patients, within the framework of the duration of mechanical ventilation and the length of intensive care unit (ICU) stay provided by appropriate data in the STS database. The RUC also made changes to the hospital visits on a line-by-line basis, but used the STS length of stay data as a guide. Generally, the level of hospital visits was reduced so that the total number of visits equaled the length of stay. On the day of discharge, the RUC assigned a discharge day management code as the only service provided on that day.

During the review of various cardiothoracic surgery procedures, the RUC determined that several of the reference service codes used in the analysis of surveyed codes (specifically, CPT codes 33506, 33660, 33670, 33770 and 33780) had inaccurate physician times associated with them. The RUC instructed the specialty society to conduct a survey of time for these reference codes; however, these times could not be used to justify new relative values.

The RUC recommended work RVUs for these CPT codes were as follows:

General Thoracic codes: 32141 = 23.90 work RVUs; 32442 = 51.45 work RVUs; 32445 = 57.74 work RVUs; 32484= 23.25 work RVUs; 32486 = 39.44 work RVUs; 32488 = 38.95 work RVUs; 32540 = 26.42 work RVUs; 32651 = 16.64 work RVUs; 32652 = 26.35 work RVUs; 32653 = 16.24 work RVUs; 32654 = 17.73 work RVUs; 32655 = 14.69 work RVUs; 32657 = 11.90 work RVUs; 32662 = 14.29 work RVUs; 32663 = 23.00 work RVUs; 32665 = 19.56 work RVUs; 32815 = 42.94 work RVUs; 39220 = 18.40 work RVUs; 39400 = 7.61 work RVUs; 43108 = 76.55 work RVUs; 43113 = 73.23 work RVUs; 43116 = 87.16 work RVUs; 43118 = 61.08 work RVUs; 43121 = 46.59 work RVUs; 43123 = 76.14 work RVUs; 43124 = 60.61 work RVUs; 43135 = 24.20 work RVUs. As noted above in this section, there was no RUC recommendation forwarded for CPT code 32020.

Adult Cardiac codes: 33140 = 25.49 work RVUs; 33141 = 2.43 work RVUs; 33300 = 40.03 work RVUs; 33305 = 70.21 work RVUs; 33400 = 38.33 work RVUs; 33405 = 37.82 work RVUs; 33406 = 49.18 work RVUs; 33410 = 42.91 work RVUs; 33411 = 56.91 work RVUs; 33413 = 56.19 work RVUs; 33415 = 34.58 work RVUs; 33425 = 45.97 work RVUs; 33426 = 39.78 work RVUs; 33427 = 41.82 work RVUs; 33430 = 46.45 work RVUs; 33460 = 40.19 work RVUs; 33463 = 50.93 work RVUs; 33464 = 40.30 work RVUs; 33465 = 45.72 work RVUs; 33474 = 36.39 work RVUs; 33475 = 39.39 work RVUs; 33510 = 31.75 work RVUs; 33511 = 35.22 work RVUs; 33512 = 40.26 work RVUs; 33513 = 41.65 work RVUs; 33514 = 44.36 work RVUs; 33516 = 46.04 work RVUs; 33517 = 3.36 work RVUs; 33518 = 7.41 work RVUs; 33519 = 9.91 work RVUs; 33521 = 12.01 work RVUs; 33522 = 13.53 work RVUs; 33523 = 15.39 work RVUs; 33530 = 9.78 work RVUs; 33533 = 30.85 work RVUs; 33534 = 36.98 work RVUs; 33535 = 41.85 work RVUs; 33536 = 45.53 work RVUs; 33542 = 44.20 work RVUs; 33545 = 52.49 work RVUs; 33641 = 27.71 work RVUs; 33860 = 55.45 work RVUs; 33863 = 55.10 work RVUs; 33945 = 80.84 work RVUs; and 35820 = 32.24 work RVUs.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work RVUs for the congenital cardiac surgery services.

As mentioned above, the general thoracic and adult cardiac surgery codes submitted to the RUC for review did not undergo the standard RUC survey methodology. Rather, the data pertaining to these codes were derived from the STS database, a voluntary registry developed by the STS that has reportedly captured data on approximately 70 percent of all cardiac surgical procedures in the United States.

We believe that the STS database, which also captures outcomes data, is a significant tool in the effort to improve the quality of patient care and we hope that this kind of data collection will be emulated by other specialties. We also believe that the time and visit data contained in this database could be a useful adjunct to the RUC's validation of the standard RUC survey results. However, we have significant concerns with its use as a tool to derive work RVUs without reference to a standard RUC survey. We have questions regarding the representativeness of the data in the STS database because it is unclear what percentage of the patients in the database is derived from academic medical centers versus community hospitals or whether the cases are selectively reported (for example, does the case mix contain a disproportionate number of complex cases?) We also would like information regarding the type of hospitals that chose not to participate in the database. Additionally, while we recognize this database has collected large numbers of cases for cardiac services, the database was not robust for the non-cardiac thoracic service.

In addition, we would also want to know the median values, as well as the mean values, for the intra-service time for the adult cardiac services because the RUC's standard methodology is based on median values. Therefore, we are concerned about maintaining the relativity between these services and those where the median values were used to recommend the work RVUs. We also believe the median is a better estimate of central tendency when more extreme cases occur in either direction.

However, our main concern is not with the time data itself, but rather with how these data were translated into work RVUs because work RVUs are not calculated solely on the basis of the time it takes to perform a given procedure. The other equally important variable is the intensity of the procedure, which is a measure of the technical skill, mental effort, and psychological stress involved in performing the procedure. The standard RUC survey captures these data by comparisons to the key reference procedure, asking the responders to rate both the surveyed and reference codes on the specific intensity measures, using a scale of one to five.

The presenting specialties used an entirely different methodology to arrive at their intensity measures by estimating the IWPUT of each service. The presenters stated that the IWPUT was estimated using two methods: IWPUT magnitude estimation and RASCH paired analysis for each code. According to the presenters, the IWPUT magnitude estimation produced direct IWPUT values and the RASCH analysis produced arbitrary scalar values as estimates of CPT code intensity rank and dispersion. These values were converted to IWPUT values by regression of the results to obtain slope, and offset of the results was based on the median value of the magnitude estimation survey. Each RASCH scalar was then converted to IWPUT with the formula y = mx + b where m is the slope and b is the y-intercept.

Though we appreciate the effort that went into such a method, we have several concerns with this approach: (1) We do not believe that the RASCH paired analysis methodology has been approved by the RUC, and has certainly not yet been accepted by CMS as a method for calculating the intensity of a service; (2) we also would want to know more about the surveys themselves, as well as the instructions to the surveyees, before agreeing to any work RVUs based on this method; and (3) we are concerned that the relativity of the fee schedule could be compromised by using such a different method to determine the work relative values of a small number of codes because current work RVUs for other services are not based on this methodology. In addition, we have a further concern regarding the appropriate relativity of the RUC recommendations for these thoracic and cardiac procedures. If we assume the times in the STS database are accurate, by comparing the intra-service times in the STS database to the median times from the surveys done in 2000 for these codes, it appears that surgeons might often underestimate the time spent in the intra-service period. If this is actually the case here, then this could also be true for other services that would not have the benefit of this database. The acceptance of the work RVUs derived by this methodology could then produce rank order anomalies with codes done by other specialties and the relativity of the fee schedule could be compromised by the selective use of this database.

We would not want to see the RUC abandon its survey methodology, unless a better approach can be found that can be applied to all services. We understand that the standard RUC survey process is not perfect, but it does provide an even playing field for all specialties and we would be concerned if each specialty was allowed to develop its own unique method for estimating work RVUs. Therefore, we would recommend that the RUC review this issue again to determine the appropriate use of data sources other than the RUC survey.

It is our responsibility to assure all medical specialties that we will review and evaluate their services using an approach that is accepted by the AMA and CMS. However, we do not know how to use this STS data to compare the relativity of these thoracic and cardiac surgery services to services of similar intensity in other clinical areas. Therefore, we are proposing not to accept the RUC work RVU recommendations for these codes. Because the RUC did approve the use of the STS database and the specialty societies put forth a substantial effort to present their data to the RUC, based on that approval, we also do not think it would be appropriate to propose maintaining the current values.

We believe the standard RUC survey process used to evaluate the cardiac surgery codes during the second 5-Year Review had the correct incremental increase in work RVUs between codes, as well as the appropriate intensity for each code. We have calculated the IWPUT for the current values for all of the cardiac codes submitted for review (excluding the add-on codes discussed below) and multiplied the IWPUT of each code with the time proposed for that code to yield a new RVU for that service. We also calculated an IWPUT for the thoracic codes using the current values. Because we do not have survey data, we believe this is a fair way to value the proposed codes while maintaining the incremental increase between codes. We look forward to comments on this issue and would be willing to consider future RUC recommendations if the specialty societies wish to submit standard RUC surveys for these codes.

CPT codes 33517, 33518, 33519, 33521, 33522, and 33523 are coronary surgery bypass codes using venous grafts and arterial grafts. These are add-on codes used in conjunction with the primary code, a coronary arterial graft. Add-on codes reflect the additional intra-service time required to perform the additional venous anastomoses. These codes do not contain post-service time, critical care time, or hospital care. When presented to the RUC, this series of codes had critical care time and inpatient hospital care time added to the total value of the code. We will maintain the current RVU valuation for CPT codes 33517, 33518, 33519, 33521, 33522, and 33523.

Therefore, the proposed work RVUs for these CPT codes are as follows: 32141 = 13.98 work RVUs; 32442 = 32.86 work RVUs; 32445 = 34.95 work RVUs; 32484 = 20.66 work RVUs; 32486 = 28.40 work RVUs; 32488 = 28.87 work RVUs; 32540 = 19.94 work RVUs; 32651 = 14.26 work RVUs; 32652 = 20.75 work RVUs; 32653 = 18.05 work RVUs; 32654 = 15.82 work RVUs; 32655 = 13.59 work RVUs; 32657 = 13.63 work RVUs; 32662 = 16.42 work RVUs; 32663 = 18.44 work RVUs; 32665 = 15.52 work RVUs; 32815 = 31.17 work RVUs; 33140 = 19.97 work RVUs; 33141 = 4.83 work RVUs; 33300 = 25.09 work RVUs; 33305 = 27.05 work RVUs; 33400 = 36.23 work RVUs; 33405 = 36.64 work RVUs; 33406 = 45.54 work RVUs; 33410 = 35.36 work RVUs; 33411 = 52.12 work RVUs; 33413 = 51.76 work RVUs; 33414 = 36.52 work RVUs; 33415 = 27.11 work RVUs; 33416 = 34.25 work RVUs; 33425 = 34.55 work RVUs; 33426 = 37.95 work RVUs; 33427 = 39.94 work RVUs; 33430 = 45.57 work RVUs; 33460 = 23.56 work RVUs; 33463 = 36.59 work RVUs; 33464 = 26.78 work RVUs; 33465 = 28.75 work RVUs; 33474 = 23.01 work RVUs; 33475 = 41.97 work RVUs; 33505 = 36.00 work RVUs; 33510 = 30.37 work RVUs; 33511 = 31.51 work RVUs; 33512 = 35.16 work RVUs; 33513 = 36.12 work RVUs; 33514 = 36.93 work RVUs; 33516 = 38.39 work RVUs; 33517 = 2.57 work RVUs; 33518 = 4.84 work RVUs; 33519 = 7.11 work RVUs; 33521 = 9.39 work RVUs; 33522 = 11.65 work RVUs; 33523 = 13.93 work RVUs; 33530 = 5.85 work RVUs; 33533 = 34.63 work RVUs; 33534 = 36.06 work RVUs; 33535 = 38.73 work RVUs; 33536 = 38.04 work RVUs; 33542 = 28.81 work RVUs; 33545 = 36.72 work RVUs; 33641 = 26.70 work RVUs; 33665 = 32.98 work RVUs; 33684 = 32.50 work RVUs; 33688 = 32.88 work RVUs; 33771 = 38.50 work RVUs; 33779 = 41.00 work RVUs; 33781 = 41.00 work RVUs; 33860= 39.29 work RVUs; 33863 = 44.93 work RVUs; 33945 = 42.04 work RVUs; 35820 = 25.53 work RVUs; 39220 = 17.39 work RVUs; 39400 = 5.60 work RVUs; 43108 = 57.20 work RVUs; 43113 = 40.41 work RVUs; 43116 = 65.85 work RVUs; 43118 = 46.37 work RVUs; 43121 = 41.80 work RVUs; 43123 = 57.14 work RVUs; 43124 = 56.51 work RVUs; and 43135 = 20.52 work RVUs.

For CPT code 32020, Tube thoracostomy with or without water seal (e.g., for abscess, hemothorax, empyema)(separate procedure), although there was no RUC recommendation provided due to the lack of a level interest for surveying this code, we continue to believe that this service is misvalued. This code was presented to the RUC during the two previous 5-Year Reviews. Based on a lack of compelling evidence, the RUC recommended maintaining the work RVUs, and we accepted this recommendation. However, we believe that since valuation of this CPT code continues to be based on Harvard time data, changes in practice and technology have not been incorporated, leading to an overvaluation of this service. The Harvard time data for this service includes: Pre-service time of 46 minutes, intra-service time of 24 minutes, post-service time of 25 minutes, 9 minutes for ICU time, 15 minutes for hospital days, and 2 minutes for office visits for a total time of 121 minutes. We believe that CPT code 32020 is comparable to CPT code 38300, Drainage of lymph node abscess or lymphadenitis; simple, or CPT code 38500, Biopsy or excision of lymph node(s); open, superficial. Both of these CPT codes were reviewed by the RUC during the second 5-Year Review. The RUC times for CPT code 38500 are: pre-service time of 35 minutes, intra-service time of 30 minutes and post-service time of 15 minutes, for a total time of 80 minutes, this includes one outpatient visit resulting in a work RVU of 3.74. If the value of the outpatient visit is removed from CPT code 38500, this results in an RVU of 3.29. We believe CPT code 32020 compares favorably to 38500 and propose a work RVU of 3.29 for CPT code 32020.

7. General, Colorectal and Vascular Surgery

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—GENERAL, COLORECTAL AND VASCULAR SURGERY” at the beginning of your comments.]

a. General Surgery

The American College of Surgeons (ACS) submitted the following CPT codes in Table 40 for review.

In addition, the American Society of Colon and Rectal Surgeons (ASCRS) submitted six CPT codes for review (see Table 41).

We submitted the CPT codes in Table 42 for review.

However, the following CPT codes were subsequently withdrawn from the 5-Year Review: 44604, 44605, 47480, 47490, 47510, 47511, 47525 and 47530. ASCRS also withdrew CPT codes 44152 and 44153, and is referring them to the CPT Editorial Panel.

For most codes, a standard RUC survey with over 30 responses was used. However, the surveys for CPT code 43622 had 29 responses and CPT code 43634 had 26 responses. Minisurveys, with over 30 responses, were used for CPT codes 44151 and 44156. Where NSQIP data was available, the specialty society also used an alternative methodology based on a building-block approach that used intra-service times and length of stay data from the NSQIP database to develop the recommendations. A specialty society consensus panel then assigned pre-service times, immediate post-service times, as well as IWPUT estimates, with the number and level of office visits determined based on comparisons to codes requiring similar physician work.

RUC Recommendations

The RUC recommended maintaining the existing RVUs for CPT codes 44140 and 49505 because the RUC believed there was a lack of compelling evidence that the work had changed.

For those services without NSQIP data, where only survey data was used as a basis for review, the RUC recommended the survey median for CPT codes 38100, 38101, 38115, 43620, 43632, 43634, 44156, 47765. For CPT code 49010, the RUC recommended use of the survey's 25th percentile because the RUC recommended deleting one hospital visit. For CPT code 47760, the RUC recommended the 25th percentile because the RUC believed that the 25th percentile was closer to the reference code. The RUC recommended use of the surveyed 75th percentile (25 work RVUs) for: CPT code 44603, which represents the suturing of multiple small intestinal perforations, to keep the correct rank order with CPT code 44602 (22.00 recommended work RVUs) that is used for the repair of a single perforation; CPT code 43622 because the RUC believed that the use of the median value would create a rank order anomaly; and CPT code 44151 because the RUC believed that the survey underestimated the physician time required for the service.

For CPT codes 47780 and 47785, the RUC used a building-block method to arrive at a recommendation which added 4.00 work RVUs to the recommended work RVUs for the respective base CPT codes 47760 and 47765 to account for the Roux-en-Y procedure. This resulted in recommended RVUs that were lower than the survey median for CPT code 47780 and higher for CPT code 47785.

For services for which NSQIP data were presented along with survey data, the RUC recommended the use of the surveys 25th percentile for CPT codes 19180, 47562, and 49002. The RUC used the NSQIP data to validate the recommendation to use the surveyed median work RVUs for CPT codes 43632, 43633, 43820, 43840, 44143, 44150, 44155 and 44602. Other RUC recommendations used the NSQIP data to increase the work RVUs above the survey median and, in one instance, beyond the survey's 75th percentile. For CPT codes 44120, 44130 and 47600, the RUC believed the physicians responding to the survey underestimated their intra-service time. Therefore, the RUC applied what was believed to be an appropriate IWPUT to the additional NSQIP time and added the resulting work RVUs to the survey median.

The RUC recommended that CPT code 49000 be referred to the CPT Editorial Panel because this code is currently used for two distinct patient populations and needs to be separated into two codes to be appropriately valued.

The 5-Year Review process allows specialty societies to request that the RUC review the work RVUs of additional codes where a rank order anomaly might have been caused by a RUC 5-Year Review recommendation for codes in the same family. Upon reviewing the workgroup recommendations for the partial colectomy procedures, CPT codes 44140 and 44143, the RUC determined that other codes in the family, CPT codes 44141, 44144, 44145, 44146 and 44147, needed to be reviewed to avoid rank order anomalies.

The RUC considered these CPT codes at their February 2006 meeting. The specialty society presented standard RUC surveys for all these services. For CPT codes 44141, 44144, 44146 and 44147, the RUC recommended the survey median. However, for CPT code 44145, the RUC recommended to maintain the current value of 26.38 work RVUs because the post-operative work is slightly less than the CPT code 44144 for which 27.00 work RVUs are recommended.

The RUC-recommended work RVUs for these CPT codes were as follows: 19180 = 14.67 work RVUs; 38100 = 18.00 work RVUs; 38101 = 18.00 work RVUs; 38115 = 20.00 work RVUs; 43620 = 31.00 work RVUs; 43621 = 36.00 work RVUs; 43622 = 36.50 work RVUs; 43632 = 32.00 work RVUs; 43633 = 30.00 work RVUs; 43634 = 33.50 work RVUs; 43820 = 20.00 work RVUs; 43840 = 20.00 work RVUs; 44120 = 20.11 work RVUs; 44130 = 20.87 work RVUs; 44140 = 20.97 work RVUs; 44141 = 27.00 work RVUs; 44143 = 25.00 work RVUs; 44144 = 27.00 work RVUs; 44145 = 26.38 work RVUs; 44146 = 33.00 work RVUs; 44147 = 31.00 work RVUs; 44150 = 27.50 work RVUs; 44151 = 32.00 work RVUs; 44155 = 31.50 work RVUs; 44156 = 34.50 work RVUs; 44602 = 22.00 work RVUs; 44603 = 25.00 work RVUs; 47562 = 11.07 work RVUs; 47600 = 15.88 work RVUs; 47760 = 34.75 work RVUs; 47765 = 48.50 work RVUs; 47780 = 38.75 work RVUs; 47785 = 52.50 work RVUs; 49002 = 15.75 work RVUs; 49010 = 15.00 work RVUs; and 49505 = 7.59 work RVUs.

CMS Proposed Valuation

We agree with the RUC-recommended work RVUs for CPT codes 19180, 38100, 38101, 38115, 43620, 43621, 43622, 43632, 43633, 43634, 43820, 43840, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44602, 44603, 47562, 47760, 47765, 47780, 47785, 49002, 49010 and 49505.

We have concerns with the RUC recommendations to use the NSQIP data to increase the work RVUs for CPT codes 44120, 44130 and 47600 above the median, and, for 47600 above the 75th percentile, from the survey. While we support the use of such a database as validation for survey results, we believe that the application of the NSQIP IWPUT to the 25-minute difference in intra-time between the survey and NSQIP is questionable. First, it is still not clear whether the NSQIP data is truly representative. Second, the IWPUT applied to the additional 25 minutes is higher than the IWPUT for the rest of the intra-time. Third, such a methodology assumes, without evidence, that there is a linear relationship between the survey respondents' estimate of time and estimate of work RVUs; however, even if the survey time estimates had matched the NSQIP data, it is not clear whether or by how much the respondents would have increased their work value estimate. Fourth, until we have available valid and representative data such as the NSQIP for all procedures, there is the risk that applying the data randomly could distort the relativity between services. Therefore, we are proposing to use the median survey values of 18.00, 20.00 and 14.00 as the work RVUs for CPT codes 44120, 44130 and 47600, respectively.

b. Colon and Rectal Surgery

The ASCRS submitted several colorectal surgery CPT codes (see Table 43).

ASCRS subsequently withdrew CPT codes 46760, 46761 and 46762 from the 5-Year Review.

For most codes, a standard RUC survey with over 30 responses was used. A minisurvey was used for a few codes.

RUC Recommendations

The RUC agreed with the specialty society's recommendations to maintain the current work RVUs for CPT codes 46040, 46060 and 46280 because the survey data supported the existing work associated with the code.

The RUC recommended the increased work RVUs at the surveys' median work values, as requested by the specialty society, for CPT codes 45020, 46045, 46270, 46275 and 46285.

For the proctoscopy-anoscopy family of codes, the RUC agreed that the surveyed median work RVUs, and often even the 25th percentile, were inconsistent with the reference code. Therefore, the RUC did not reference the surveyed RVUs in arriving at the recommendations. Rather, the RUC used the surveyed times for each service and applied what the workgroup considered an appropriate IWPUT to these times to arrive at the recommended work RVUs for this family.

The specific RUC work RVU recommendations for these colon and rectal surgery CPT codes were as follows: 45020 = 7.75 work RVUs; 45300 = 0.91 work RVUs; 45303 = 2.22 work RVUs; 45305 = 2.01 work RVUs; 45307 = 2.22 work RVUs; 45308 = 2.01 work RVUs; 45309 = 2.22 work RVUs; 45315 = 2.22 work RVUs; 45317 = 1.08 work RVUs; 45320 = 2.43 work RVUs; 45321 = 2.76 work RVUs; 45327 = 3.63 work RVUs; 46040 = 4.95 work RVUs; 46045 = 5.50 work RVUs; 46060 = 5.68 work RVUs; 46270 = 4.50 work RVUs; 46275 = 5.00 work RVUs; 46280 = 5.97 work RVUs; 46285 = 5.00 work RVUs; 46600 = 0.49 work RVUs; 46604 = 1.08 work RVUs; 46606 = 1.76 work RVUs; 46608 = 1.95 work RVUs; 46610 = 1.95 work RVUs; 46611 = 1.08 work RVUs; 46612 = 2.14 work RVUs; 46614 = 1.08 work RVUs; and 46615 = 1.18 work RVUs.

CMS Proposed Valuation

We agree with the RUC-recommended work RVUs for CPT codes 45020, 46040, 46045, 46060, 46270, 46275, 46280, and 46285.

We are proposing not to accept the RUC recommendations for all the presented codes in the proctoscopy-anoscopy family. We are proposing to maintain the current work RVUs for CPT codes 45300, 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327, 46600, 46604, 46606, 46608, 46610, 46611, 46612, 46614 and 46615.

We believe that the method used by the RUC to obtain work values for these services was flawed. The calculation of the recommended work RVUs depended solely on applying a workgroup-derived IWPUT to the surveyed physician time from surveys that were considered otherwise unusable. We do not believe that the use of IWPUT, in the absence of other supporting data, has been previously accepted by the RUC. We believe the RUC has established rules that state that IWPUT cannot be the sole rationale for valuation and it appears that this workgroup might not have adhered to that standard. We believe that this use of IWPUT differs from that used by workgroup one, as described above. There were acceptable surveys that were used as anchors to create the correct rank order for the dermatology codes without adequate surveys. In addition, for the dermatology codes, the calculation was generally used to validate the current or lower work RVUs for the services, while for these scope codes, the calculation was not used to validate but to support significant increases for many of the services. However, if the specialty society wishes to resurvey these codes and the RUC submits work RVU recommendations to CMS, we would certainly be willing to consider them.

c. Vascular Surgery

The Society for Vascular Surgery (SVS) submitted the CPT codes in Table 44 for review. However, the specialty society subsequently withdrew CPT codes 27603, 35612 and 35642 from review.

For all codes, a standard RUC survey was used. All but the following CPT codes had 30 or more responses: 34471 (28 responses), 35508 (23 responses), 35515 (18 responses), 35516 (29 responses), 35616 (29 responses), 60600 (19 responses). The specialty society also used the intra-service times and length of stay data from the NSQIP database to develop some of its recommendations. A specialty society consensus panel then assigned pre-service times, and immediate post-service times, as well as IWPUT estimates.

RUC Recommendations

The RUC agreed with the specialty society that the following CPT codes cannot undergo the RUC evaluation process before having their descriptors revised and recommended referring these CPT codes to the CPT Editorial panel: 35381, 35501, 35507, 35509, 35541, 35546, 35601, 35641 and 37720. (Note that CPT code 37720 was subsequently deleted by CPT for CY 2006.) For the remaining codes, the RUC reviewed both the survey data and the NSQIP data, where provided, for each procedure. In many instances, where the NSQIP time and length of stay data were available, the RUC believed that the physicians responding to the survey underestimated their intra-service time and that the NSQIP data more accurately reflected the actual intra-service times for these procedures.

The RUC accepted the specialty society's requested increase in work RVUs for 12 CPT codes, agreeing with the specialty society that these procedures were undervalued due to compelling evidence such as changes in length of stay, changes in patient populations, and incorrect assumptions made in the previous valuation of the service. For CPT codes 27880, 28805, 34001, 34471, 35506, 35508, 35515, 35516, 35606, 60600 and 60605, the RUC-recommended work RVUs were at the survey median or lower. However, for CPT code 33877, the RUC accepted a work value greater than the survey's 75th percentile that was derived from a building-block approach using the NSQIP data for the service. The RUC increased the work RVUs for nine codes. For eight of the codes, the increases were at levels below those requested by the specialty society, and for one code the increase was slightly higher than the requested work RVUs. For CPT codes 35081, 35216, 35583 and 35616, the recommended increase was no higher than the surveyed median work RVUs. For CPT codes 34201, 35102, 35556, 35566, and 35585, the RUC accepted work values greater than the survey's median percentile that were derived from a building-block approach using the NSQIP data for the service.

The specific RUC-recommended work RVUs for these CPT codes are as follows: 27880 = 13.75 work RVUs; 28805 = 11.25 work RVUs; 33877 = 64.04 work RVUs; 34001 = 16.25 work RVUs; 34201 = 18.31 work RVUs; 34471 = 20.00 work RVUs; 35081 = 31.00 work RVUs; 35102 = 36.28 work RVUs; 35216 = 34.00 work RVUs; 35506 = 23.75 work RVUs; 35508 = 25.00 work RVUs; 35515 = 25.00 work RVUs; 35516 = 23.00 work RVUs; 35556 = 27.25 work RVUs; 35566 = 32.00 work RVUs; 35583 = 26.00 work RVUs; 35585 = 32.00 work RVUs; 35606 = 21.00 work RVUs; 35616 = 21.00 work RVUs; 60600 = 24.00 work RVUs; and 60605 = 30.50 work RVUs.

CMS Proposed Valuation

We accept the RUC-recommended work RVUs for CPT codes 27880, 28805, 34001, 34471, 35216, 35506, 35508, 35515, 35516, 35606, 60600, 60605, 35081, 35583, and 35616.

We disagree with the RUC recommendations for CPT codes 33877, 34201, 35102, 35556, 35566, and 35585. For these services, the RUC used the NSQIP time data to increase the work values above the survey median, and even for above several codes the 75th percentile. For the reasons discussed above, we reject such a use of the NSQIP data at this time. Therefore, we are proposing to use the survey median work RVUs for these CPT codes: 33877 = 53.00 work RVUs; 34201 = 17.00 work RVUs; 35102 = 34.00 work RVUs; 35556 = 25.00 work RVUs; 35566 = 30.00 work RVUs; and 35585 = 30.00 work RVUs.

8. Otolaryngology and Ophthalmology

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS-OTOLARYNGOLOGY AND OPTHALMOLOGY” at the beginning of your comments.]

a. Otolaryngology Procedures

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) submitted the CPT codes in Table 45 for review.

We initially requested that the RUC review five CPT codes but then withdrew CPT code 31255 from the 5-Year Review (see Table 46).

RUC Recommendations

For one CPT code 42120, palate resection procedure, the RUC, based on the data presented by the specialty society, agreed that there was increased work and intensity involved in comparison to other codes with similar intensity. The RUC believed the survey results reflected the complexity of the patient, physician time and work necessary in performing this procedure, and recommended work RVUs of 11.00 for CPT code 42120.

The specialty society presented data on two maxillectomy procedures, CPT codes 31225 and 31230, which the RUC also viewed as undervalued. The RUC believed that the re-evaluation of these two codes corrects rank order anomalies and accounts for the appropriate intensity for each procedure. The RUC recommended work RVUs of 24.00 for CPT code 31225 and 28.00 for CPT code 31230.

For three lymphadendectomy procedures, CPT codes 38700, 38720, and 38724, the specialty society presented data with the rationale that the previous valuation was flawed because the procedures were not evaluated by otolaryngologists. The RUC believed that the survey results reflected the appropriate complexity of the patient, physician time and work necessary in performing the procedure, and justified an increase in physician work. The RUC-recommended work RVUs for these CPT codes are as follows: 38700 = 12.00 work RVUs; 38720 = 20.00 work RVUs; and 38724 = 22.00 work RVUs.

The specialty society presented survey data on three pharyngectomy procedures, CPT codes 42890, 42892, and 42894, which had never been reviewed by the RUC. The RUC agreed that there was a change in the patient population and that the increased intensity involved in these procedures was comparable to other codes with similar intensity. The RUC recommended the increase demonstrated by the survey median which was 17.00 work RVUs for CPT code 42890, 23.09 work RVUs for CPT code 42892, and 30.00 work RVUs for CPT code 42894.

The specialty society presented survey data on three tonsillectomy procedures, CPT codes 42842, 42844, and 42845, which the RUC agreed were undervalued due to a previous flawed methodology. The RUC believed that the survey results reflected the appropriate physician work and time necessary in performing this procedure and recommended the following work RVUs for these CPT codes: 42842 = 11.00 work RVUs; 42844 = 16.10 work RVUs; and 42845 = 32.00 work RVUs.

For the partial glossectomy procedures, CPT codes 41120, 41130, and 41135, the RUC believed that there was not compelling evidence to increase the work for CPT code 41120, and, therefore, recommended maintaining the current value for this service. The RUC also agreed that increasing the values for the two remaining procedures would correct the existing rank order anomalies and that these increases were justified by survey results. The recommendation for the work RVUs for these CPT codes is as follows: 41120 = 9.76 work RVUs; 41130 = 14.00 work RVUs; and 41135 = 27.00 work RVUs.

For complete glossectomy procedures, CPT codes 41140 and 41145, the specialty society presented survey data on these procedures and suggested decreasing the work RVU of CPT code 41140. The RUC believed that the survey results did not justify decreasing the work RVUs for this service, particularly because over half of the survey respondents indicated that the work of performing CPT code 41140 has not changed in the past 5 years. Therefore, the RUC recommended maintaining the value for this code. The RUC believed that the flawed methodology previously used for valuing CPT code 41145 caused this procedure to be misvalued and that an increase in work was validated by the survey median results. The RUC recommended the following work RVUs for these CPT codes: 41140 = 25.46 work RVUs; and 41145 = 34.00 work RVUs.

For the composite glossectomy procedures, CPT codes 41150, 41153, and 41155, the specialty society presented survey data on each of these procedures, noting that the current work RVUs for each of these services create a rank order anomaly. The RUC agreed that increasing the RVUs would correct these rank order anomalies and that these increases were justified by the survey results. The RUC-recommended work RVUs for these CPT codes are as follows: 41150 = 26.50 work RVUs; 41153 = 34.00 work RVUs; and 41155 = 40.00 work RVUs.

For the laryngopharyngectomy procedures, CPT codes 31360, 31365, 31390 and 31395, the specialty society presented as compelling evidence the rationale that the current work RVUs create rank order anomalies, and that there also has been a change in the patient population. The RUC agreed that increasing the RVUs of these procedures by accepting the 75th percentile of survey results corrected the specific rank order anomalies and also accounted for the change in the patient population. The RUC-recommended work RVUs for these CPT codes are as follows: 31360 = 28.00 work RVUs; 31365 = 37.00 work RVUs; 31390 = 40.00 work RVUs; and 31395 = 44.00 work RVUs.

For the laryngectomy procedures, CPT codes 31367, 31368, 31370, 31375, 31380 and 31382, the specialty society presented survey data with the rationale that the current work values are based on a flawed methodology that creates rank order anomalies, and that there also has been a change in patient population. The RUC agreed with the specialty society and recommended increasing the work RVUs for these services to maintain rank order between the codes in the family and to establish the correct intensity of the procedure based on the change in patient population. The RUC-recommended work RVUs for these CPT codes are: 31367 = 27.36 work RVUs; 31368 = 36.00 work RVUs; 31370 = 25.00 work RVUs; 31375 = 25.00 work RVUs; 31380 = 25.00 work RVUs; and 31382 = 28.00 work RVUs.

For CPT code 30520, based on the increase in physician time in the current survey data, the RUC believed that the service was misvalued and that there was additional work involved which was not previously captured. Using the building-block methodology, the RUC recommended a work RVU of 6.27 for CPT code 30520.

For CPT codes 31575 and 31579, the RUC agreed with the specialty society that the surveys validate the current values. The RUC also believed that the survey validated the current work value for CPT code 41100, particularly because 98 percent of survey respondents indicated that the work in performing this service has not changed in the past 5 years. The RUC recommended maintaining the original work values of 1.10 work RVUs for CPT code 31575, 2.26 work RVUs for CPT code 31579, and 1.63 work RVUs for CPT code 41100.

The specialty society provided survey data for CPT code 69210 using the rationale that the patient population had become more complex. The RUC did not agree with the specialty society that the patient population had changed because 94 percent of the survey respondents indicated that the work in performing this service has not changed in the past 5 years. The RUC recommended maintaining the current work value of 0.61 for this service.

CMS Proposed Valuation

We are in agreement with the RUC-recommended work RVUs for the following otolaryngology CPT codes: 38700, 38720, 38724, 41120, 41130, 41135, 41140, 41145, 42120, 42890, 42892, and 42894.

For the tonsillectomy procedures, CPT codes 42842, 42844, and 42845, the number of hospital days decreased by at least two days (including critical care visits for one code), but the outpatient post-operative visits increased by one. The median values for intra-service times were accepted by the RUC for these services, which is an indication that a value other than the 75th percentile for work also may be appropriate. CPT codes 42842 and 42844 were valued at the median work RVU obtained from the surveys. However, CPT code 42845 was valued by the RUC at the 75th percentile for work. Therefore, we are accepting the median recommended work values for CPT codes 42842 of 11.00 work RVUs and 42844 of 16.10 work RVUs and, consistent with use of the median, proposing work RVUs for CPT code 42845 of 29.00.

For the composite glossectomy procedures, CPT codes 41150, 41153, and 41155, the number of hospital days decreased by at least 2 days (including, in some instances, critical care visits). CPT codes 41153 and 41155 were valued by the RUC at the 75th percentile for work, but CPT code 41150 was valued based on the median work value. The median values for intra-service times were accepted by the RUC for these services, which is an indication that a value other than the 75th percentile for work also may be appropriate. Therefore, we are accepting the RUC-recommended work RVUs of 26.50 for CPT code 41150 which were based on the median work value, and consistent with use of the median proposing work RVUs of 30.00 for CPT code 41153 and 36.00 for CPT code 41155.

For the laryngopharyngectomy procedures, CPT codes 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390 and 31395, the number of hospital days decreased by at least two days and the post-operative outpatient visits increased by one day. However, in one instance the number of outpatient visits decreased (CPT code 31395). The median values for intra-service times were accepted by the RUC for these services, which is an indication that a value other than the 75th percentile for work also may be appropriate. Therefore, we are proposing using median values for these services resulting in the following work RVUs for these CPT codes: 31360 = 24.00 work RVUs; 31365 = 31.50 work RVUs; 31367 = 24.00 work RVUs; 31368 = 30.50 work RVUs; 31370 = 24.00 work RVUs; 31375 = 22.50 work RVUs; 31380 = 22.00 work RVUs; 31382 = 25.00 work RVUs; 31390 = 35.00 work RVUs; and 31395 = 39.50 work RVUs.

For CPT codes 30520, 31575, 31579, 41100 and 69210, we are in agreement with the RUC-recommended work RVUs for these services, except for CPT code 41100. The RUC recommended maintaining the current work RVUs of 1.63 for this service, which is even greater than the 75th percentile for work, which is what the specialty society had recommended. We believe the more appropriate work RVUs for this service is represented by the median, which is 1.37, and, therefore, we are recommending 1.37 work RVUs for CPT code 41100.

We would note that although we accepted the RUC's recommendation of a work RVU of 0.61 for CPT code 69210, we are concerned with this valuation for the use of this code for routine removal of ear wax during a physical examination of a patient. This code is listed with a “separate procedure” designation in the CPT code book, meaning that it is billed most properly when it is the only service provided for a particular date of service. However, Medicare data used for evaluation of codes in the current 5-Year Review indicate that CPT code 69210 was billed with an E/M service 63 percent of the time. It is our understanding that CPT code 69210 is to be used when there is a substantial amount of cerumen in the external ear canal that is very difficult to remove and that impairs the patient's auditory function. We will continue to monitor the use of this code for the appropriate circumstances.

b. Ophthalmology Services

The American Academy of Ophthalmology (AAO), the American Optometric Association (AOA) and the American Society of Cataract and Refractive Surgery submitted 15 codes for the 5-Year Review (see Table 47). However, the specialty societies subsequently withdrew five of these codes (CPT codes 65420, 65900, 67917, 67924 and 68750) from the 5-Year Review.

We submitted the following ophthalmology CPT codes for review (see Table 48).

RUC Recommendations

The RUC questioned the survey results for CPT codes 67038 and 67228 and indicated that the survey data may be flawed because respondents may have based their answers on a different number of membranes stripped or sessions conducted. The RUC recommended that these two CPT codes be referred to the CPT Editorial Panel for clarification.

Based on a review of the survey data, the RUC agreed with the specialty society that the survey results demonstrated that the work had not changed and, thus, that the current work RVUs should be retained for the following CPT codes: 66761 = 4.06 work RVUs; 67840 = 2.04 work RVUs; 68840 = 1.25 work RVUs; 76519 = 0.54 work RVUs; 92226 = 0.33 work RVUs; 92235 = 0.81 work RVUs; and 92250 = 0.44 work RVUs. In addition, the RUC recommended retaining the work RVU of 0.50 for CPT code 92083 because the specialty society had not presented compelling evidence that the physician work had changed.

For CPT codes 67221, 67820, and 66984, the RUC recommended reductions in the work RVUs. The RUC used a building-block approach based on the work RVU of 3.24 for the reference CPT code 67141, Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, one or more sessions; cryotherapy, diathermy, and the work RVUs of 0.21 for the infusion code G0347, which contain comparable work. The RUC recommended work RVUs of 3.45 for CPT code 67221.

The RUC supported the specialty society's recommendation to decrease the work value for CPT code 67820 based on evidence that the previous Harvard survey data was flawed. The RUC agreed with assigning work RVUs of 0.71 to CPT code 67820 based on a comparison/crosswalk to the key reference service, CPT code 65205, Removal of foreign body, external eye; conjunctival superficial, which has work RVUs of 0.71.

For CPT code 66984, the RUC did not agree with the specialty society recommendation that the current work RVU of 10.21 should be maintained, because changes in technology and technique in the last 10 years have led to increased efficiencies. The RUC concluded that these efficiencies resulted in a lower overall time for the procedure. The RUC used the previous survey pre-service time of 44 minutes and subtracted the current survey pre-service time of 25 minutes for a difference of 19 minutes. These 19 minutes were then multiplied by an IWPUT of 0.0224, resulting in an RVU of 0.43, which was subtracted from the current value. The RUC agreed that although the intra-service physician time has decreased from the historical 50 minutes to the current survey time of 30 minutes as indicated by the survey respondents, the decrease in time reflects a decrease of only low intensity work (that is, suturing) and no further decrease in work RVUs was recommended. Therefore, the RUC recommended work RVUs of 9.78 for CPT code 66984.

The RUC agreed with the specialty society that there was compelling evidence to support the increases for CPT codes 67414, 67445, 67500, 67515, 67904, 67911, and 67966, either because the current work RVUs caused rank order anomalies, the previous Harvard survey data was misvalued when compared to codes with similar values, or there was a change in the technique of performing the procedures (specifically for CPT codes 67911 and 67966, in which skin-grafting is bundled into these codes). However, for two CPT codes, 65426 and 65850, while the RUC recognized that there was compelling evidence to support increases, the RUC did not agree with the specific increases recommended by the specialty society.

For CPT code 65426, the RUC believed that evidence suggested a change in technique for this procedure, and believed that a value close to the survey's 25th percentile was justified by using a building-block approach. For CPT code 65850, the RUC agreed that there is a rank order anomaly between CPT codes 65850 and 66170, Fistualization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery, as well as a change in the patient population. The RUC believed an increase in value was justified by using a building-block approach. The RUC recommended 5.85 work RVUs for CPT code 65426 and 11.14 work RVUs for CPT code 65850.

For CPT code 66821, the RUC agreed that the intensity of this procedure was misvalued and that an increase in the relative value would be appropriate. The RUC disagreed with our previous intensity crosswalk to CPT code 66984, Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), specified in the Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule proposed notice (May 3, 1996; 61 FR 20027). The RUC believed that the previous survey from 1995 should stand on its own as an acceptable survey due to the inappropriate selection by HCFA in 1995 of intensity for this code. The RUC-recommended work RVU for this service is 2.78, the same value recommended by the RUC in 1995.

CMS Proposed Valuation

We are in agreement with the RUC recommended work values for these ophthalmology services.

c. Additional Codes

The American Speech-Language-Hearing Association (ASHA) submitted the following speech and audiology CPT codes (see Table 49) but subsequently withdrew them from the 5-Year Review.

9. HCPAC Codes

a. Podiatric Services

[If you choose to comment on issues in this section, please include the caption “DISCUSSION OF COMMENTS—HCPAC CODES” at the beginning of your comments.]

We submitted the podiatric services in Table 50 for review.

HCPAC Recommendation

The HCPAC agreed with the specialty society that there was compelling evidence that the valuation of these services was incorrect due to a flawed methodology used in the previous Harvard valuation for all six podiatric codes. Based on the survey data, the specialty society requested that the work RVU increase for four codes and decrease for two codes.

For CPT codes 10060 and 29580, the HCPAC supported an increase in the existing work values for these codes and recommended a work RVU of 1.50 for CPT code 10060 and 0.60 for CPT code 29580, which represent the survey median of the survey data for these services.

For CPT code 11040, the HCPAC did not support the work RVU increase recommended by the specialty society, but instead recommended a work RVU of 0.55, which represented the 25th percentile work RVU from the survey data.

For CPT codes 11041 and 11730, the HCPAC recommended a decrease in the work RVUs and, based on the median from the survey data, recommended a work RVU of 0.80 for CPT code 11041 and 1.10 for CPT code 11730.

For CPT code 11042, the HCPAC did not agree with the specialty society that the work RVU should be increased to 1.20 work RVUs. The HCPAC recommended maintaining the current work RVU of 1.12 for this CPT code, which was slightly higher than the survey's 25th percentile work value of 1.10 work RVUs.

The HCPAC-recommended work values for these services are as follows: 10060 = 1.50 work RVUs; 11040 = 0.55 work RVUs; 11041 = 0.80 work RVUs; 11042 = 1.12 work RVUs; 11730 = 1.10 work RVUs; and 29580 = 0.60 work RVUs.

CMS Proposed Valuation

For CPT code 10060, we compared the survey times them with the current Harvard-based times used to value this service. These times are comparable and, therefore, we are recommending maintaining the current work RVUs of 1.17 for this code.

For CPT code 29580, we compared the current Harvard-based times with the survey times. Due to the small reduction in time, the recommended increase in work RVUs is not supported. Therefore, we are proposing to assign 0.55 work RVUs to this service, which represents the 25th percentile of the survey and more accurately represents the time associated with this service.

For CPT code 11730, the current work RVUs are slightly more (0.03) than the recommended value and the survey time is approximately 30 percent greater than the current Harvard-based time. For these reasons, we agree with the HCPAC's recommendation of 1.10 work RVUs for 11730 which represents the median survey value.

For CPT codes 11040, 11041 and 11042, the survey times all reflect significant reductions from current Harvard-based times used to value these services. Based on this comparison which shows decreases in time ranging from 47 percent to 68 percent, we believe that the low values from the surveys more accurately represent the valuation of these services. Therefore, we are proposing to assign work RVUs as follows: 11040 = 0.48 work RVUs; 11041 = 0.60 work RVUs; and 11042 = 0.80 work RVUs. In addition, to ensure that the other codes in this family are properly valued, we recommend the RUC should review the valuation of CPT codes 11043 and 11044.

b. Other HCPAC Codes

The American Dietetic Association submitted five CPT and HCPCS codes related to medical nutrition services that were referred to the CPT Editorial Panel (see Table 51).

Additionally, the ASHA submitted CPT code 96105, Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour, for review but subsequently withdrew this code.

C. Other Issues Under the 5-Year Review

[If you choose to comment on issues in this section, please include the caption “OTHER ISSUES” at the beginning of your comments.]

1. Anesthesia Services

Although anesthesia services are paid under the PFS, they are paid on the basis of an anesthesia code-specific base unit and time units that vary based on the anesthesia time of the case. Since anesthesia services do not have a work value per code as do other medical and surgical services, a work value must be imputed for each anesthesia code. For the last 5-Year Review, this imputed work value was compared to an actual work value determined by the RUC and the ASA through a building-block approach. Under the building-block approach, each anesthesia code was uniformly divided into five components: pre-anesthesia, equipment and supply preparation, induction period, post-induction anesthesia period, and post-anesthesia. The work was determined for each of the five components and summed to calculate total anesthesia work for the anesthesia code.

Although the ASA submitted one anesthesia code and several other codes for this 5-Year Review, they continue to believe the work of anesthesia services remain seriously undervalued. The last 5-Year Review of anesthesia services proved to be a very laborious and exhaustive process involving several different RUC workgroups. The valuation of anesthesia work is a very complex process as it involves relating components of anesthesia services to other medical and surgical services of similar time and work. The ASA was dissatisfied with the recommendations made by the RUC for the last 5-Year Review for anesthesia work. The major points of disagreement were the use and extent of extrapolation and the work value for the post-induction anesthesia period, which is the longest period of the anesthesia service.

For the last 5-Year Review, the ASA requested the RUC to extrapolate from 19 high volume anesthesia services, which were studied and accounted for over 50 percent of Medicare payments for anesthesia services, to all anesthesia services. The RUC thought that extrapolation should be limited. That is, an analysis of a single anesthesia code based on a single surgical code was insufficient when the anesthesia code covers a large number of surgical codes. For the last 5-Year Review, the building-block approach used a value of 0.025 for the IWPUT for the post-induction anesthesia period. This was a value that the RUC agreed to, which we approved, although the ASA thought it was too low.

As a result of its relationship with the RUC and the past recommendations, the ASA requested that we address the valuation of anesthesia services reported under CPT codes 00100 through 01999. The ASA furnished an analysis that builds on the methodology used in the last 5-Year Review for the valuation of work for anesthesia services.

Based on comparable physicians' services, the ASA believes that the more appropriate IWPUT for the post-induction period is 0.043. Using this IWPUT, the ASA calculated a scaling factor and used this to recalculate the post-induction work value and an adjusted total work RVU for each of the 19 codes. Based on an extrapolation from the 19 surveyed services used in the last 5-Year Review, the ASA proposed that the anesthesia work value should be increased by 37.5 percent. The extrapolation proposed by the ASA is more far reaching than the extrapolation used by the RUC in the last 5-Year Review. We do not favor using extrapolation other than on the limited basis it was used in the last 5-Year Review.

Since the ASA believes that the RUC process does not work well for their codes, they requested that we directly evaluate their recommendations independent of any RUC review of input. Although there may be some merit to the ASA approach, we believe this analysis is more appropriately done by a multispecialty workgroup within the RUC itself. Thus, we are recommending the valuation of anesthesia services, namely the proposed valuation of the post-induction time period, be referred to the RUC for their review and consideration. For example, the ASA and the RUC could review the IWPUT for post-induction time, as currently proposed by the ASA and compare this to the corresponding IWPUT recognized in the last 5-Year Review of anesthesia work for the 19 surveyed codes.

A second issue concerning anesthesia services pertains to the impact of the revised work values for E/M services and their relationship to the valuation of pre- and post-anesthesia services, components of the building-block approach. The pre- and post-anesthesia services derive their work values from the lower level E/M codes for new patients, the subsequent hospital care codes and the initial inpatient consultation codes. We are proposing to substitute the proposed revised work values for E/M codes where applicable and recompute the anesthesia work values and their impact on the increase in total anesthesia work. While this results in a very minor adjustment to anesthesia work (that is, less than 1 percent), we believe this approach provides for the consistent application of the proposed work RVUs changes.

2. Discussion of Post-Operative Visits Included in the Global Surgical Packages

We have established a national definition for a global surgical package so that payment is made consistently for the same set of services across all contractor jurisdictions. In constructing the RVUs for a global surgery service, all services that are believed to be typically included in the defined global period are built into the final resource-based RVUs and are not separately billable within the defined global period; this is reflected in the proposed work RVUs in Addenda B and C. This would include pre-surgery work, the intra-service time of actually performing the surgical procedure, and the post-operative (follow-up) visits associated with the monitoring and recovery of the patient.

As stated above in this section, we are proposing to apply the RUC-recommended new values for the E/M services to all surgical services with a 10 or 90-day global period. However, because of variations in the patient population and in practice patterns, there is some question whether the assumptions about the number and level of visits within the global period reflect the actual post-operative work performed. Some surgeons have commented to us that they perform more visits than are included in the global period for their services. It is also likely that some patients require fewer than the “typical” number of follow-up visits included in the global period.

Although we are not proposing any changes to our global policy at this time, we would be interested in receiving comments concerning our current policy of including these post-operative visits in the global surgical packages and what advantages or disadvantages might be associated with proposing a change to this policy in the future.

3. Codes Referred to CPT Editorial Panel From Five-Year Review of Work Relative Value Units

4. Budget Neutrality

Section 1848(c)(2)(B)(ii) of the Act requires that increases or decreases in RVUs for a year may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we must make adjustments to preserve budget neutrality. This year, we expect that budget-neutrality adjustments will be required as a result of changes in RVUs resulting from the 5-Year Review. Revisions in payment policies, including the establishment of interim and final RVUs for coding changes that will be announced later this year, may result in additional budget-neutrality adjustments.

We considered making the statutorily required budget-neutrality adjustments (under section 1848(c)(2)(B)(ii) of the Act) to account for the 5-Year Review of physician work by reducing all work RVUs. We currently estimate that all work RVUs would have to be reduced by 10 percent under this option. Alternatively, we considered making an adjustment to the PFS CF to meet the provisions of section 1848(c)(2)(B)(ii). This option would require an estimated 5 percent reduction in the CF. We note that the application of the budget neutrality adjustment to the CF would negatively impact all PFS services; whereas the application of the budget neutrality adjustment to the work RVUs would impact only those services that have physician work RVUs. Because the need for a budget neutrality adjustment would be largely due to changes proposed as a result of the 5-Year Review of work RVUs, we believe it is more equitable to apply the adjustment across services that have work RVUs. For this third 5-Year Review, we are proposing to establish a budget neutrality adjustor that would reduce all work RVUs by an estimated 10 percent to meet the budget neutrality provisions of section 1848(c)(2)(B)(ii).

As we noted in the CY 2005 Physician Fee Schedule final rule with comment period (69 FR 66371), PE and malpractice expense RVUs were not subject to comment and will not be recalculated (other than changes to PE RVUs that result from changes in PE inputs due to changes in physician time or in the number of post procedure visits as part of the 5-Year Review of work RVUs).

5. Effect on Practice Expense Inputs Stemming From the 5-Year Review

The proposed changes for work RVUs reflect, in part, the physician's time needed to perform each service, as well as the number and level of assumed post-operative visits. To the extent that the RUC recommended changes in the times associated with the intra-service portion of the procedure, we are also proposing to adjust the clinical labor time assigned for assisting the physician in the nonfacility setting. In addition, if an accepted new work RVU reflects a change in the number or level of post-operative visits, we are proposing to modify the clinical staff time to reflect the change. This adjusted time is also applied to the equipment used in the post-operative visits. Where the number of post-operative visits has changed, the number of minimum multi-specialty visit (MMSV) packs will also be adjusted accordingly. A MMSV pack consists of the following supplies: exam table paper, 2 pairs of non-sterile gloves, a patient gown, a pillow case, and a thermometer probe cover. These changes in clinical labor and equipment time and in the quantity of supplies will have a minimal impact on the PE component.

6. Nature and Format of Comments on Work RVUs

We will accept comments on the proposed work RVUs for the codes identified in the Addendum C of this notice. We will also accept comments on the anesthesia code, CPT code 00797. Comments should discuss how the work associated with a given CPT or HCPCS code is analogous to the work in other services, or discuss the rationale for agreeing or disagreeing with the proposed work RVU. We are especially interested in information or discussions that were not presented in earlier comments.

D. Resource-Based Practice Expense (PE) RVUs

[If you choose to comment on issues in this section, please include the caption “PRACTICE EXPENSE” at the beginning of your comments.]

Based on section 1848(c)(1)(B) of the Act, practice expense (PE) is the portion of the resources used in furnishing the service that reflects the general categories of physician and practitioner expenses, such as office rent and wages of personnel, but excluding malpractice expenses.

Section 121 of the Social Security Amendments of 1994 (Pub. L. 103-432), enacted on October 31, 1994, required CMS to develop a methodology for a resource-based system for determining PE RVUs for each physician's service. Until that time, physicians' PEs were based on historical allowed charges. This legislation stated that the revised PE methodology must consider the staff, equipment, and supplies used in the provision of various medical and surgical services in various settings beginning in 1998. The Secretary has interpreted this to mean that Medicare payments for each service would be based on the relative PE resources typically involved with performing the service.

The initial implementation of resource-based PE RVUs was delayed from January 1, 1998, until January 1, 1999, by section 4505(a) of the Balanced Budget Act of 1997 (BBA 97) (Pub. L. 105-33). In addition, section 4505(b) of the BBA 97 required that the new payment methodology be phased-in over 4 years, effective for services furnished in CY 1999, and fully effective in CY 2002. The first step toward implementation of the statute was to adjust the PE values for certain services for CY 1998. Section 4505(d) of BBA 97 required that, in developing the resource-based PE RVUs, the Secretary must:

• Use, to the maximum extent possible, generally accepted cost accounting principles that recognize all staff, equipment, supplies, and expenses, not solely those that can be linked to specific procedures.
• Develop a refinement method to be used during the transition.
• Consider, in the course of notice and comment rulemaking, impact projections that compare new proposed payment amounts to data on actual physician PEs.

Beginning in CY 1999, we began the four year transition to resource-based PE RVUs. In CY 2002, the resource-based PE RVUs were fully transitioned.

1. Current Methodology

The following sections discuss the current PE methodology.

a. Data Sources

There are two primary data sources used to calculate PE. The AMA's Socioeconomic Monitoring System (SMS) survey data are used to develop the PE per hour (PE/HR) for each specialty. The second source of data used to calculate PE was originally developed by the Clinical Practice Expert Panels (CPEP). The CPEP data include the supplies, equipment and staff times specific to each procedure.

The AMA developed the SMS survey in 1981 and discontinued it in 1999. Beginning in 2002, we incorporated the 1999 SMS survey data into our calculation of the PE RVUs, using a 5-year average of SMS survey data. (See Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Value Units Under the Physician Fee Schedule for CY 2002 final rule, published November 1, 2001 (66 FR 55246).) The SMS PE survey data are adjusted to a common year, 1995. The SMS data provide the following six categories of PE costs:

• Clinical payroll expenses, which are payroll expenses (including fringe benefits) for nonphysician personnel.
• Administrative payroll expenses, which are payroll expenses (including fringe benefits) for nonphysician personnel involved in administrative, secretarial or clerical activities.
• Office expenses, which include expenses for rent, mortgage interest, depreciation on medical buildings, utilities and telephones.
• Medical material and supply expenses, which include expenses for drugs, x-ray films, and disposable medical products.
• Medical equipment expenses, which include expenses depreciation, leases, and rent of medical equipment used in the diagnosis or treatment of patients.
• All other expenses, which include expenses for legal services, accounting, office management, professional association memberships, and any professional expenses not mentioned above.

In accordance with section 212 of the Medicare, Medicaid and State Child Health Insurance Program Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), we established a process to supplement the SMS data for a specialty with data collected by entities and organizations other than the AMA (that is, the specialty itself). (See the Criteria for Submitting Supplemental Practice Expense Survey Data interim final rule with comment period, published on May 3, 2000 (65 FR 25664).) Originally, the deadline to submit supplementary survey data was through August 1, 2001. In the Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Value Units Under the Physician Fee Schedule for CY 2002 final rule (November 1, 2001; 66 FR 55246), the deadline was extended through August 1, 2003. To ensure maximum opportunity for specialties to submit supplementary survey data, we extended the deadline to submit surveys until March 1, 2005 in the Revisions to Payment Policies Under the Physician Fee Schedule for CY 2004 final rule, (November 7, 2003; 68 FR 63196) (hereinafter referred to as CY 2004 PFS final rule).

The CPEPs consisted of panels of physicians, practice administrators, and nonphysicians (registered nurses (RNs), for example) who were nominated by physician specialty societies and other groups. There were 15 CPEPs consisting of 180 members from more than 61 specialties and subspecialties. Approximately 50 percent of the panelists were physicians.

The CPEPs identified specific inputs involved in each physician service provided in an office or facility setting. The inputs identified were the quantity and type of nonphysician labor, medical supplies, and medical equipment.

In 1999, the AMA's RUC established the Practice Expense Advisory Committee (PEAC). Since 1999, and until March 2004, the PEAC, a multi-specialty committee, reviewed the original CPEP inputs and provided us with recommendations for refining these direct PE inputs for existing CPT codes. Through its last meeting in March 2004, the PEAC provided recommendations, which we have reviewed and accepted, for over 7,600 codes. As a result, the current CPEP inputs differ markedly from those originally recommended by the CPEPs. The PEAC has now been replaced by the Practice Expense Review Committee (PERC), which acts to assist the RUC in recommending PE inputs.

b. Allocation of PEs to Services

To establish PE RVUs for specific services, it is necessary to establish the direct and indirect PE associated with each service. Our current approach allocates aggregate specialty practice costs to specific procedures and, thus, is often referred to as a “top-down” approach. The specialty PEs are derived from the AMA's SMS survey and supplementary survey data. The PEs for a given specialty are allocated to the services performed by that specialty on the basis of the CPEP data and work RVUs assigned to each CPT code. The specific process is detailed as follows:

Step 1—Calculation of the SMS Cost Pool for Each Specialty

The six SMS cost categories can be described as either direct or indirect expenses. The three direct expense categories include clinical labor, medical supplies and medical equipment. Indirect expenses include administrative labor, office expense, and all other expenses. We combine these indirect expenses into a single category. The SMS cost pool for each specialty is calculated as follows:

• The specialty PE/HR for each of the three direct and one indirect cost categories from the SMS is calculated by dividing the aggregate PE per specialty by the specialty's total hours spent in patient care activities (also determined by the SMS survey). The PE/HR is divided by 60 to obtain the PE per minute (PE/MIN).
• Each specialty's PE pools (for each of the three direct and one indirect cost categories) are created by multiplying the PE/MIN for the specialty by the total time the specialty spent treating Medicare patients for all procedures (determined using Medicare utilization data). Physician time on a procedure-specific level is available through RUC surveys of new or revised codes and through surveys conducted as part of the 5-Year Review process. For codes that the RUC has not yet reviewed, the original data from the Harvard resource-based RVU system survey are used. Physician time includes time spent on the case prior to, during, and after the procedure. The physician procedure time is multiplied by the frequency that each procedure is performed on Medicare patients by the specialty.
• The total specialty-specific SMS PE for each cost category is the sum, for each direct and indirect cost category, of all of the procedure-specific total PEs.

Step 2—Calculation of CPEP Cost Pool

CPEP data provide expenditure amounts for the direct expense categories (clinical labor, supplies and equipment cost) at the procedure level. Multiplying the CPEP procedure-level PEs for each of these three categories by the number of times the specialty provided the procedure, produces a total category cost, per procedure, for that specialty. The sum of the total expenses from each procedure results in the total CPEP category cost for the specialty.

Step 3—Calculation and Application of Scaling Factors

This step ensures that the total of the CPEP costs across all procedures performed by the specialty equates with the total direct costs for the specialty as reflected by the SMS data. To accomplish this, the CPEP data are scaled to SMS data by a scaling factor so that the total CPEP costs for each specialty equals the total SMS cost for the specialty. (The scaling factor is calculated by dividing the specialty's SMS pool by the specialty's CPEP pool.)

The unscaled CPEP cost per procedure value, at the direct cost level, is then multiplied by the respective specialty scalar to yield the scaled CPEP procedure value. The sum of the scaled CPEP direct cost pool expenditures equals the total scaled direct expense for the specific procedure at the specialty level.

Step 4—Calculation of Indirect Expenses

Indirect PEs cannot be directly attributed to a specific service because they are incurred by the practice as a whole. Indirect costs include rent, utilities, office equipment and supplies, and accounting and legal fees. There is not a single, universally accepted approach for allocating indirect practice costs to individual procedure codes. Rather allocation involves judgment in identifying the base or bases that are the best measures of a practice's indirect costs.

To allocate the indirect PEs to a specific service, we use the following methodology:

• The scaled direct expenses and the converted work RVU (the work RVU for the service is multiplied by $34.5030, the 1995 CF) are added together, and then multiplied by the number of services provided by the specialty to Medicare patients;
• The total indirect PEs per specialty are calculated by summing the indirect expenses for all other procedures provided by that specialty.

Step 5—Calculation and Application of Indirect Scaling Factors

Similar to the direct costs, the indirect costs are scaled to ensure that the total across all procedures performed by the specialty equates with the total indirect costs for the specialty as reflected by the SMS data. To accomplish this, the indirect costs calculated in Step 4 are scaled to SMS data. The calculation of the indirect scaling factors is as follows:

• The specialty's total SMS indirect expense pool is divided by the specialty's total indirect expense pool calculated in Step 4, to yield the indirect expense scaling factor.
• The unscaled indirect expense amount, at the procedure level, is multiplied by the specialty's scaling factor to calculate the procedure's scaled indirect expenses.
• The sum of the scaled indirect expense amount and the procedure's direct expenses yields the total PEs for the specialty for this procedure.

Step 6—Weighted Average of RVUs for Procedures Performed by More Than One Specialty

For codes that are performed by more than one specialty, a weighted average PE is calculated based on Medicare frequency data of all specialties performing the procedure.

Step 7—Budget Neutrality and Final RVU Calculation

Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs may not cause total PFS payments to differ by more than $20 million from what they would have been if the adjustments were not made. If the aggregate adjustments to PE RVUs would cause PFS expenditures to exceed the $20 million threshold, the total scaled direct and indirect inputs are then adjusted by a budget neutrality factor (BNF) to calculate RVUs. Budget neutrality for the upcoming year is determined relative to the sum of PE RVUs for the current year. Although the PE RVUs for any particular code may vary from year-to-year, the sum of PE RVUs across all codes is set equal to the current year. The BNF is equal to the sum of the current year's PE RVUs, divided by the sum of the direct and indirect inputs across all codes for the upcoming year. The BNF is applied to (multiplied by) the scaled direct and indirect expenses for each code to set the PE RVU for the upcoming year.

c. Other Methodological Issues: Non-Physician Work Pool (NPWP)

As an interim measure, until we could further analyze the effect of the top-down methodology on the Medicare payment for services with no physician work (including the technical components (TCs) of radiation oncology, radiology and other diagnostic tests), we created a separate PE pool for these services. However, any specialty society could request that its services be removed from the non-physician work pool (NPWP). We will remove services from the NPWP if we find that the requesting specialty provides the service the majority of the time.

NPWP Step 1—Calculation of the SMS Cost Pool for Each Specialty

This step parallels the calculations described above for the standard “top-down” PE allocation methodology. For codes in the NPWP, the direct and indirect SMS costs are set equal to the weighted average of the PE/HR for the specialties that provide the services in the pool. Clinical staff time is substituted for physician time in the calculation. The clinical staff time for the code is from CPEP data. Otherwise, the calculation is similar to the method described previously for codes with physician time.

NPWP Step 2—Calculation of Charge-based PE RVU Cost Pool

The NPWP calculation uses the 1998 (charge-based) PE RVU value for the code, multiplied by the 1995 CF (25.74 × $34.503 = $888.11). The percentage of clinical labor, supplies and equipment are the percentage that each PE category represents for all physicians relative to the total PE for all physicians (calculated from the SMS data).

NPWP Step 3—Calculation and Application of Scaling Factors

After the total cost pools for each specialty and code performed by the specialty are calculated, the steps to ensure the total costs for all of the procedures performed by a specialty do not exceed the total costs for the specialty (scaling) are the same as those described previously for codes with physician work.

NPWP Step 4—Calculation of Indirect Expenses

Because codes in the NPWP do not have work RVUs, indirect expenses are set equal to direct expenses (for codes with physician work, indirect expenses equal the sum of the scaled direct expenses and the converted work RVU). This amount is then multiplied by the number of times the procedure is performed.

NPWP Step 5—Calculation and Application of Indirect Scaling Factors

Similar to the direct costs, the indirect costs are scaled to ensure that the total of the charge-based PE RVU costs across all procedures equates with the total indirect costs as reflected by the SMS data for the NPWP. To accomplish this, the charge-based data are scaled to SMS data so the total charge-based costs equal the total SMS costs.

NPWP Step 6—Budget Neutrality and Final RVU Calculation

Similar to the calculation for codes with physician work, when a budget neutrality adjustment is necessary, the BNF is applied to (multiplied by) the scaled direct and indirect expenses for each code to set the PE RVU for the upcoming year.

d. Facility/Non-facility Costs

Procedures that can be performed in a physician's office, as well as in a hospital have two PE RVUs: Facility and non-facility. The non-facility setting includes physicians' offices, patients' homes, freestanding imaging centers, and independent pathology labs. Facility settings include hospitals, ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs). The methodology for calculating the PE RVU is the same for both facility and non-facility RVUs, but is applied independently to yield two separate PE RVUs. Because the PEs for services provided in a facility setting are generally included in the payment to the facility (rather than the payment to the physician under the fee schedule), the PE RVUs are generally lower for services provided in the facility setting.

2. PE Proposals Methodology for CY 2006

The following discussions outline the specific PE related proposals for CY 2007.

We have three major goals for our resource-based PE methodology:

• To ensure that the PE portion of PFS payments reflect, to the greatest extent possible, the relative resources required for each of the services on the PFS. This could only be accomplished by using the best available data to calculate the PE RVUs.
• To develop a payment system for PE that is understandable and at least somewhat intuitive, so that specialties could better predict the impacts of changes in the PE data.
• To stabilize the PE portion of PFS payments so that changes in PE RVUs do not produce large fluctuations in the payment for given procedures from year-to-year.

These goals have also been supported in numerous comments we have received from the medical community.

In the CY 2006 PFS proposed rule (70 FR 45764), we proposed the following changes to the PE methodology that we believed would help in achieving our three major goals (stated above in this section):

• Using the PE/HR data from seven specialty-specific supplementary surveys.
• Calculating the direct PE using a bottom-up methodology.
• Eliminating the NPWP.

We also proposed an indirect PE methodology that was to assign to each service the higher of the current indirect PE RVUs or the indirect PE RVUs calculated using the supplementary survey data.

In the CY 2006 PFS final rule with comment period (70 FR 70116), we withdrew these proposals primarily because a programming error for the indirect PE RVU calculation had led to the publication of inaccurate proposed PE RVUs. On February 15, 2006, we sponsored a PE Town Hall Meeting and invited the public, including all specialty representatives to attend. At this meeting, we supplied a detailed description of the bottom-up approach to the calculation of resource-based PE RVUs. Three examples were examined in detail that illustrated the impact of the various assumptions that could be used under a bottom-up approach. We specifically requested input from all interested parties on possible changes to our PE methodology, including the move to a bottom-up approach and the various methods of calculating indirect PE.

We have reviewed the approximately 35 comments that we received in response to our solicitation. Many of the comments were combined efforts from related specialty organizations. Additionally, the AMA RUC also supplied a letter that captured the comments of nearly 30 specialty organizations. The following is a summary of some of the comments we received.

• Delaying Implementation of Changes to the Current PE Methodology: There were mixed opinions from commenters on whether we should proceed with a proposal to use a bottom-up approach. Some commenters emphasized that the CPEP data has been refined and is now the best available source of data, and asserted that it should be used for the calculation of resource-based PE RVUs. Other comments suggested a delay in changing to a bottom-up approach because of the other issues that are affecting PFS payments this year (such as, the effect of imaging payment provisions in the Deficit Reduction Act (DRA), the impact of the negative update, and the uncertainty regarding the impact of the 5-Year Review of work RVUs).
• Transition to a Bottom-Up Approach: The majority of commenters requested a minimum one-year transition to a maximum 3-year transition period to fully implement any change to a bottom-up approach. All of the commenters supported a transition period whether or not they supported the implementation of a bottom-up approach.
• Use of Supplemental Survey Data: A large number of commenters stated that, irrespective of what we propose for 2007, the supplemental survey data that has already been accepted should be used. Other commenters believed that the supplemental survey data grossly overstated PEs and should not be utilized in the development of resource based PE RVUs.
• Multi-Specialty PE Survey: The majority of commenters supported the construction and use of a multi-specialty survey to collect PE data. Commenters believed that the supplemental survey data is inflated and that the SMS survey data are outdated.
• Review Equipment Utilization Assumptions and Interest Rates: Many commenters supported the review and revision of both the current utilization assumptions and the interest rates associated with high cost equipment. Commenters had mixed reactions as to whether the utilization rates should be higher or lower, and some suggested that we review the possibility of equipment-specific utilization assumptions for the future. Most commenters believed that the current 11 percent interest rate is significantly higher then the actual interest rates and many commenters suggested a rate of approximately prime plus 2 percent.
• Proxy Work RVUs for No Physician Work Services: Commenters were divided on the assignment of a proxy work RVU to services that contain no physician work. Some commenters believed that no physician work services are unfairly penalized under any bottom-up approach, while other comments stated that the inclusion of a proxy work RVU would double count the clinical labor associated with the no physician work services.

After considering the comments we received on the CY 2006 PFS proposed rule (70 FR 45764) and in response to comments received during and following the Town Hall meeting, we believe that the use of a bottom-up methodology for direct costs, use of the supplementary survey data and elimination of the NPWP would assist us in meeting our goal of a PE methodology that is equitable, understandable and stable. Therefore, we are again proposing these changes to our PE methodology. We are also proposing a change in the methodology used to calculate the indirect PE for each service that is different than previously proposed. The following is a summary of our proposals.

a. Use a Bottom-Up Method to Calculate the Direct PEs

We believe that we have consistently made a good faith effort to ensure fairness in our PE RVU-setting system by using the best data available at any one time. The reason we did not adopt the bottom-up methodology originally proposed in 1997 and instead adopted the top-down methodology finalized in 1998 was because we recognized the concerns among the physician community that the resource input data developed in 1995 by the CPEP were less reliable than the aggregate specialty cost data derived from the SMS process.

However, the situation has now changed. The PEAC/PERC/RUC has completed the refinement of the original CPEP data and we believe that the refined PE inputs now, in general, accurately capture the relative direct costs of performing PFS services. Conversely, although we have now accepted supplementary survey data from 13 specialties, we have not received updated aggregate cost data from most specialties. Thus, we believe that, in the aggregate, the refined CPEP data represent more reliably the relative direct cost PE inputs for physicians' services.

Therefore, instead of using the top-down approach to calculate the direct PE RVUs, where the aggregate CPEP/RUC costs for each specialty are scaled to match the aggregate SMS costs, we propose to adopt a bottom-up method of determining the relative direct costs for each service. Under this method, the direct costs would be determined by adding the costs of the resources (that is, the clinical staff, equipment and supplies) typically required to provide the service. The costs of the resources, in turn, would be calculated from the refined CPEP/RUC inputs in our PE database.

We believe that this proposed change, which was welcomed by most commenters in the CY 2006 PFS proposed rule, will lead to greater stability and accuracy in the PE portion of our payment system. Currently, under the top-down methodology, the need to scale the CPEP costs to equal the SMS costs meant that any changes in the direct PE inputs for one service often leads to unexpected results for other services where the inputs had not been altered. In addition, the current PE RVUs for a procedure do not necessarily change proportionately with changes in the direct inputs, creating possible anomalous values. We believe that our proposed bottom-up methodology would resolve these issues, so that changes in the PE RVUs would be more intuitive and would result in fewer surprises.

b. Use the PE/HR Data From the Seven Surveys We Have Previously Accepted and, in Addition, Use the PE/HR Data From the Survey Submitted by the National Coalition of Quality Diagnostic Imaging Services (NCQDIS)

As explained in the CY 2005 PFS final rule with comment period (69 FR 66242), we received surveys from the ACC, the ACR, and the ASTRO by March 1, 2004. The data submitted by the ACC and the ACR met our criteria. However, as requested by the ACC and the ACR, we deferred using their data until issues related to the NPWP could be addressed. (The survey data from ASTRO did not meet the precision criteria established for supplemental surveys; therefore, we did not accept or use it in the calculation of PE RVUs for 2005.)

In March 2005, we also received surveys from the Association of Freestanding Radiation Oncology Centers (AFROC), the AUA, the AAD, the JCAAI, the NCQDIS, and a joint survey from the American Gastroenterological Association (AGA), the American Society of Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG).

All the surveys, with the exception of the survey from NCQDIS, met our criteria. Therefore, we proposed in the CY 2006 PFS proposed rule (70 FR 45775) to use the survey data from all the surveys meeting our criteria in the calculation of PE RVUs for 2006; but, as discussed in the CY 2006 PFS final rule with comment period (70 FR 70116) and above in this section, this proposal was not finalized.

We contracted with the Lewin Group (Lewin) to evaluate whether the supplemental survey data that were submitted met our criteria and to make recommendations to us regarding their suitability for use in calculating PE RVUs. As described in the CY 2006 PFS proposed rule (70 FR 45775), Lewin recommended blending the radiation oncology data from the AFROC survey data with the ASTRO survey data submitted in 2004 to calculate the PE/HR. According to Lewin, the goal of the AFROC survey was to represent the population of freestanding radiation oncology centers only. To develop an overall average for the radiation oncology PE pool, the Lewin Group recommended we use the AFROC survey for freestanding radiation oncology centers, and the hospital-based subset of last year's ASTRO survey. We agreed that this blending of the AFROC and ASTRO data was a reasonable way to calculate an average PE/HR that fully reflects the practice of radiation oncology in all settings. Blending the survey data overcame the initial problem that the ASTRO data do not meet the precision criteria as discussed in the CY 2005 PFS final rule (69 FR 66242). In addition, as discussed in the CY 2006 PFS proposed rule (70 FR 45776), blending of the data allowed for a broader base of radiation oncology providers to be represented.

Also, as discussed in the CY 2006 PFS proposed rule (70 FR 45764), Lewin indicated that the survey data submitted by the NCQDIS on independent diagnostic testing facilities (IDTFs) did not meet our precision criterion. However, upon further analysis, Lewin agreed with NCQDIS' determination that the inclusion of one inaccurate record skewed the findings outside the acceptable precision range. Lewin recalculated the precision level at 8.1 percent of the mean PE/HR (weighted by the number of physicians in the practice). Lewin indicated that the level of precision for the total PE/HR satisfies the level of precision requirement, and recommended acceptance of the survey.

We are now proposing to use the PE/HR data from all of the above surveys, including the NCQDIS survey, in the calculation of the PE RVUs for 2007. We are again proposing for radiation oncology to use the new PE/HR derived from combining the AFROC and ASTRO survey data, as recommended by Lewin.

We propose to use the PE per physician hour figures in Table 52. It should be noted that the relatively high PE per physician hour values for IDTFs result from the fact that there are far fewer hours for this specialty than most others. IDTFs use relatively few physician hours, so the same practice expenses in the numerator divided by the smaller denominator results in considerably higher values for practice expenses per hour. Although these values of PE/HR appear to be outliers, they actually contribute little to the overall value for practice expenses per hour, because the volume of each of the services performed by the IDTFs represents a relatively small percentage of the total services.

Section 303(a)(1)(B) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) added section 1848(c)(2)(I) of the Act to require CMS to use survey data submitted by a specialty group where at least 40 percent of the specialty's payments for Part B services are attributable to the administration of drugs in 2002 to adjust PE RVUs for drug administration services. The statute applies to surveys that include expenses for the administration of drugs and biologicals, and were received by March 1, 2005 for determining the CY 2006 PE RVUs. Section 303(a)(1)(A)(ii) of the MMA also added section 1848(c)(2)(B)(iv)(II) of the Act to provide an exemption from budget neutrality in 2005 and 2006 for any additional expenditures resulting from the use of these surveys. In the Changes to Medicare Payment for Drugs and Physician Fee Schedule Payments for CY 2004 interim final rule published January 7, 2004 (69 FR 1084), we stated that the specialties of urology, gynecology, and rheumatology meet the above criteria. As described in the CY 2006 PFS final rule with comment period (70 FR 70116), we accepted for the purposes of calculating the 2006 PE RVUs for drug administration services the new survey data from the AUA and exempted from the budget neutrality adjustment any impacts of accepting these data for purposes of calculating PE RVUs for drug administration services. (Note: Rheumatology and gynecology did not submit supplemental survey data.)

c. Eliminate the NPWP and Calculate the PE RVUs for All Services Using the Same Methodology

Primarily because of the lack of representative SMS data or accurate direct cost inputs for specialties such as radiology and radiation oncology, the adoption of the top-down approach necessitated the creation of the NPWP. This separate work pool was created to allocate PE RVUs for TC codes and codes that are not performed by physicians and, thus, have no work RVUs. In the CY 2000 Physician Fee Schedule; Payment Policies and Relative Value Unit Adjustment final rule, we indicated that “the purpose of this pool was only to protect the (TC) services from the substantial decreases” caused by inaccurate CPEP data and the lack of physician work RVU in the allocation of the indirect costs (64 FR 59406). Unfortunately, the services priced by the NPWP methodology have proven to be especially vulnerable to any change in the work pool's composition. This has led to significant fluctuations from year to year in the PE RVUs calculated for these services.

The major specialties comprising the NPWP (radiology, radiation oncology and cardiology) have now submitted supplemental survey data that we have accepted and are proposing to use in their PE calculations. (See the discussion on supplementary surveys above in this section.) Now that we have representative aggregate PE data for these specialties, and with the completion of the refinement of the direct cost inputs, the continued necessity and equity of treating these technical services outside the PE methodology applied to other services is questionable.

Therefore, we are proposing to eliminate the NPWP and to calculate the PE RVUs for the services currently in the work pool by the same methodology used for all other services. This would also allow the use of the refined CPEP/RUC data to price the direct costs of individual services, rather than utilizing the pre-1998 charge-based PE RVUs. In addition, this proposal would lead to greater stability for the PE RVUs for these services and would lead to more intuitive results than have occurred with the NPWP methodology.

d. Modify the Current Indirect PE RVUs Methodology

As described previously, the SMS and supplementary survey data are the source for the specialty-specific aggregate indirect costs used in our PE calculations. We then allocate the indirect costs to particular codes on the basis of the direct costs allocated to a code and the work RVUs. In the CY 2006 PFS proposed rule (70 FR 45764), we stated that we had no information that would indicate that the current indirect PE methodology is inaccurate. At that time, we also were not aware of any alternative approaches or data sources that we could use to calculate more appropriately the indirect PE, other than the new supplementary survey data, which we propose to incorporate into our PE calculations. Therefore, we proposed to use the current indirect PEs in our calculation, incorporating the new survey data into the codes performed by the specialties submitting the surveys. We also indicated in that same proposed rule that we would welcome any suggestions that would assist us in further refinement of this indirect PE methodology. For example, we were considering whether we should continue to accept supplementary survey data or whether it would be preferable and feasible to have an SMS-type survey of only indirect costs for all specialties, or whether a more formula-based methodology independent of the SMS data should be adopted, perhaps using the specialty-specific indirect-to-total cost percentage as a basis of the calculation. For a prior discussion of many of the issues associated with allocating indirect costs, please refer to the CY 2000 Physician Fee Schedule; Payment Policies and Relative Value Unit Adjustment proposed rule (63 FR 30823).

3. Modifications to PE Proposals

As a result of collaboration with the PFS community and public comments on this issue, we are now in a position to propose modifications to the indirect PE methodology.

a. Indirect Percentage Factor: Use of the Specialty-Specific Percentage That Indirect PEs Represent of Total PEs Based on the Survey Data

We currently allocate indirect expenses on the sum of the direct expenses and the work RVUs (converted to dollars by multiplying by the CF). We are proposing to allocate indirect expenses by applying a specialty-specific indirect percentage factor to the direct expenses in order to recognize the varying proportion that indirect costs represent of total costs by specialty. This would have the effect of relatively increasing the indirect expense allocation for services that are on average performed by specialties with higher indirect PE percentages, and relatively decreasing the indirect expense allocation for services that are performed by specialties with lower indirect PE percentages. For a given service, the specific indirect percentage factor to apply to the direct costs for the purpose of the indirect allocation would be calculated as the weighted average of the ratio of the indirect to direct costs (based on the survey data) for the specialties that perform the code. For example, if a service is performed by a single specialty with indirect PEs that were 75 percent of total PEs, the indirect percentage factor to apply to the direct costs for the purposes of the indirect allocation would be (0.75/0.25) = 3.0.

b. Continued Use of the Specialty-Specific Indirect Scaling Factors

As described earlier, we incorporate the indirect PE/HR surveys into the methodology through the use of specialty-specific indirect scaling factors. We would continue to use the specialty-specific indirect scaling factors; however, to apply them in a simpler manner we propose to create an index. This index would reflect the relationship between each specialty's indirect scaling factor and the overall indirect scaling factor for the entire PFS. For example, if a specialty had an indirect practice cost index of 2.00, this specialty would have an indirect scaling factor that was twice the overall average indirect scaling factor. If a specialty had an indirect practice cost index of 0.50, this specialty would have an indirect scaling factor that was half the overall average indirect scaling factor. The calculation and application of the indirect practice cost index is described in more detail below in this section.

c. Use of the Clinical Labor Costs in the Indirect Allocation for a Service When the Clinical Labor Costs are Greater Than the Physician Work RVU

We have received numerous comments that services with little or no physician work RVUs are disadvantaged under our current indirect allocation methodology based on the direct costs and the work RVUs. In response to these comments, when the clinical labor portion of the direct PE RVU is greater than the physician work RVU for a particular service, we are proposing to allocate on the direct costs and the clinical labor costs. For example, if a service has no physician work, the direct PE RVU is 1.10 and the clinical labor portion of the direct PE RVU is 0.65 RVUs, we would use the 1.10 direct PE RVUs and the 0.65 clinical labor portion of the direct PE RVUs for the indirect PE allocation for that service. As another example, if the physician work RVUs for a service are 0.25, the direct PE RVU is 1.10 and the clinical labor portion of the direct PE RVU is 0.65 RVUs, we would use the 1.10 direct PE RVUs and the 0.65 clinical labor RVUs for the indirect allocation for that service. We would not use the 0.25 physician work RVUs for the indirect PE allocation since the 0.65 clinical labor RVUs are greater than the 0.25 physician work RVUs.

d. Use of 2005 Utilization Data in the Indirect PE RVU Calculation

Under the current PE methodology, we predominately use the 1997-2000 utilization data in the calculation of the indirect PE RVUs when the service existed during 1997-2000 or the first year of utilization data if the service did not exist during that time period. We used those years of utilization data primarily to increase the year to year stability of the PE RVUs. With the changes we are proposing to make to PE RVUs, in particular the elimination of the NPWP, we will increase the year-to-year stability of the PE RVUs. We believe it is now appropriate to use updated utilization data in the calculation of the indirect PEs. We believe the other proposed changes in the PE methodology will help obtain the year-to-year stability we were attempting to achieve by continuing to use the older utilization data. Additionally, the use of more current utilization data would reflect the more current practice patterns. We are proposing to use the 2005 utilization data in the calculation of the 2007 indirect PE RVUs. We are also seeking comments on whether the utilization data should be updated yearly, which would increase the accuracy of the PE calculations, or less often, which would increase the stability of the PE RVUs.

e. Elimination of the Special Methodologies for Services With Technical and Professional Components

Under the PFS, when services have technical, professional, and global components that can be billed separately, the payment for the global component equals the sum of the payment for the technical and professional components. Under the current PE methodology, the different mix of specialties that perform the global, technical and professional components can cause the PE RVUs, otherwise created by the methodology, to fail to add together properly; that is, the global component does not equal the sum of the professional and technical components. The global component might exceed the sum of the technical and professional components or it might be less than the sum of the technical and professional components. We ensure that the technical and professional components add to the global component in one of two ways. For services in the NPWP, we set the PE RVUs for the global component equal to the sum of the professional component PE RVU and the technical component PE RVU. For services outside the NPWP, we set the PE RVUs for the technical component equal to the difference between the global PE RVUs and the professional component RVUs.

With our proposed change to a bottom-up methodology for the direct PEs, there would be no weighted averaging of the direct costs inputs necessary to create the direct PE RVUs and, therefore, the direct PE RVUs for the professional and technical components would sum to the global component. Under the current methodology, as a result of the process used to ensure the professional and technical components sum to the global, RVUs for a service with a global component can be either more or less than the RVUs that would have been calculated for the service if the professional and technical components did not have to sum to the global.

Given the proposed change to bottom-up methodology and the elimination of the NPWP, we believe it is inappropriate to have codes for which the global, and the technical and professional components are assigned RVUs that are either less than or greater than the methodology would otherwise produce, and thus, are paid at a rate that is either less than or greater than the methodology would otherwise specify. (See section II.D.1. of this proposed notice for the discussion of the current methodology.) Therefore, we are proposing that in the calculation of the indirect percentage factor described earlier in section II.D.3.a., we would use a weighted average of the ratio of indirect to direct costs across all the specialties that perform the global, technical, and professional components; that is, we would apply the same weighted average indirect percentage factor to allocate indirect expenses to the global, professional, and technical components for a service. We also propose to utilize a similar weighted averaging approach across all the specialties that perform the components when calculating the indirect PE scaling factor. Because the direct PE RVUs for the technical and professional components sum to the global under the bottom-up methodology, and we are proposing to calculate the indirect percentage factor and the indirect scaling factor so that they do not vary between the technical, professional, and global components, our proposed methodology would create technical and professional components that sum to the global, and no other special methodology would need to be employed.

(i) Proposed PE RVU Methodology

Below is a description of the proposed PE RVU methodology.

(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 survey PE per physician hour data. Information specific to the creation of the setup file can be found at the end of section II.D.

(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. The direct costs consist of the costs of the direct inputs for clinical labor, medical supplies, and medical equipment. The clinical labor cost is the sum of the cost of all the staff types associated with the service; it is the product of the time for each staff type and the wage rate for that staff type. The medical supplies cost is the sum of the supplies associated with the service; it is the product of the quantity of each supply and the cost of the supply. The medical equipment cost is the sum of the cost of the equipment associated with the service; it is the product of the number of minutes each piece of equipment is used in the service and the equipment cost per minute. The equipment cost per minute is calculated as described at the end of this section.

Apply a budget neutrality adjustment to the direct inputs.

Step 2: Calculate the current aggregate pool of direct PE costs. To do this, multiply the current aggregate pool of total direct and indirect PE costs (that is, the current aggregate PE RVUs multiplied by the CF) by the average direct PE percentage from the SMS and supplementary specialty survey data.

Step 3: Calculate the aggregate pool of proposed direct costs. To do this, for all PFS services, sum the product of the direct costs for each service from Step 1 and the utilization data for that service.

Step 4: Using the results of Step 2 and Step 3 calculate a direct PE budget neutrality adjustment so that the proposed aggregate direct cost pool does not exceed the current aggregate direct cost pool and apply it to the direct costs from Step 1 for each service.

Step 5: Convert the results of Step 4 to an RVU scale for each service. To do this, divide the results of Step 4 by the Medicare PFS CF.

(c) Create the Indirect PE RVUs

Create indirect allocators.

Step 6: Based on the SMS and supplementary specialty 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 perform the service. Note that for services with technical and professional components we are calculating the direct and indirect percentages across the global, professional and technical components. That is, the direct and indirect percentages for a given service (for example, echocardiogram) do not vary by the professional, technical and global components.

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 RVU, the clinical PE RVU and the work RVU. (Note that the work RVU used in the calculation includes the separate work budget neutrality adjustment from the 5-Year Review of the work RVUs discussed elsewhere in this proposed notice.)

For most services the indirect allocator is: Indirect percentage * (direct PE RVU/direct percentage) + work RVU.

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 allocator is: indirect percentage * (direct PERVU/direct percentage) + clinical PE RVU + work RVU.
• If the clinical labor PE RVU exceeds the work RVU (and the service is not a global service), then the indirect allocator is: indirect percentage * (direct PERVU/direct percentage) + clinical PE RVU.

Note

that for global services the indirect allocator is based on both the work RVU and the clinical labor PE RVU. We do this to recognize that, for the professional service, indirect PEs will be allocated using the work RVUs, and for the technical component service, indirect PEs will be allocated using the direct PE RVU and the clinical labor PE RVU. This also allows the global component RVUs to equal the sum of the professional and technical component RVUs.)

For presentation purposes in the examples in the Table 53, the formulas are divided into two parts for each service. The first part does not vary by service and is the indirect percentage * (direct PE RVU/direct percentage). The second part is either the work RVU, clinical PE RVU, or both depending on whether the service is a global service and whether the clinical PE RVU exceeds the work RVU (as described earlier in this step.)

Apply a budget neutrality adjustment to the indirect allocators.

Step 9: Calculate the current aggregate pool of indirect PE RVUs by multiplying the current aggregate pool of PE RVUs by the average indirect PE percentage from the physician specialty survey data. This is similar to the Step 2 calculation for the direct PE RVUs.

Step 10: Calculate an aggregate pool of proposed 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. This is similar to the Step 3 calculation for the direct PE RVUs.

Step 11: Using the results of Step 9 and Step 10, calculate an indirect PE adjustment so that the proposed aggregate indirect allocation does not exceed the available aggregate indirect PE RVUs and apply it to indirect allocators calculated in Step 8. This is similar to the Step 4 calculation for the direct PE RVUs.

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 physician time for the service, and the specialty's utilization for the service.

Step 14: Using the results of Step 12 and Step 13, calculate the specialty-specific indirect PE scaling factors as under the current methodology.

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 perform the service. Note that for services with technical and professional components, we calculate the indirect practice cost index across the global, professional and technical components. Under this method, the indirect practice cost index for a given service (for example, echocardiogram) does not vary by the professional, technical and global components.

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 RVU.

(d) Calculate the Final PE RVUs

Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs from Step 17.

Step 19: Calculate and apply the final PE budget neutrality adjustment by comparing the results of Step 18 to the current pool of PE RVUs. This final budget neutrality adjustment is primarily required because certain specialties are excluded from the PE RVU calculation for ratesetting purposes, but all specialties are included for purposes of calculating the final budget neutrality adjustment. (See “Specialties excluded from rate-setting calculation” below in this section.)

(e) Setup File Information

• Specialties excluded from rate-setting calculation: For the purposes of calculating the PE RVUs, we exclude certain specialties such as midlevel practitioners paid at a percentage of the PFS, audiology, and low volume specialties from the calculation. This is the same approach used under the current methodology. These specialties are included for the purposes of calculating the budget neutrality adjustment.
• Crosswalk certain low volume physician specialties: Crosswalk the utilization of certain specialties with relatively low PFS utilization to the associated specialties. This is the same approach used under the current methodology.
• Physical therapy utilization: Crosswalk physical therapy utilization to the specialty of physical therapy. This is the same approach used under the current methodology.
• Identify professional and technical services not identified under the usual TC and 26 modifier: Flag the services that are professional and technical component services, but do not use TC and 26 modifiers (for example, electrocardiograms). This flag associates the professional and technical component with the associated global code for use in creating the indirect PE RVU. For example, the professional service code 93010 is associated with the global code 93000.
• Payment modifiers: Payment modifiers are accounted for in the creation of the file. 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.
• Proposed work RVUs from the 5-Year Review: The setup file contains the proposed work RVUs from the 5-Year Review.

The equipment cost per minute is calculated as:

(f) Equipment Cost Per Minute =

(1/(minutes per year * usage)) * price * ((interest rate/(1−(1/((1 + interest rate) * life of equipment))) + maintenance)

Where:

Minutes per year = maximum minutes per year if usage were continuous (that is, usage = 1); 150,000 minutes.

Usage = equipment utilization assumption; 0.5.

Price = price of the particular piece of equipment.

Interest rate = 0.11.

Life of equipment = useful life of the particular piece of equipment.

Maintenance = factor for maintenance; 0.05.

(ii) Transition the Resulting Revised PE RVUs over a Four-Year Period

A complete analysis of the impacts of these changes is contained in the impact analysis in section V. of this proposed rule. We are concerned that, when combined with a proposed negative update factor for CY 2007 and the proposed changes to the work RVUs under the 5-Year Review, the shifts in some of the PE RVUs resulting from the immediate implementation of our proposals could potentially cause some disruption for medical practices. Therefore, we are proposing to transition the proposed PE changes over a 4-year period. This would also give ample opportunity for us, as well as the medical specialties and the RUC, to identify any anomalies in the PE data, to make any further appropriate revisions, and to collect additional data as needed prior to the full implementation of the proposed PE changes.

During the transition period, the PE RVUs would be calculated on the basis of a blend of RVUs calculated using our proposed methodology described above (weighted by 25 percent during CY 2007, 50 percent during CY 2008, 75 percent during CY 2009, and 100 percent thereinafter), and the current CY 2006 PE RVUs for each existing code. PE RVUs for codes that are new during this period would be calculated using only the proposed methodology, and paid at the fully transitioned rate. We believe that implementing all of these proposed changes would further our goal of producing a more accurate, more intuitive and more stable PE methodology.

For example, as stated above in this section, now that the direct PE inputs have been refined, we believe that the proposed CPEP/RUC direct input data are superior to the specialty-specific SMS PE/HR data for the purposes of determining the typical direct PE resources required to perform each service on the PFS. First, we have received recommendations on the procedure-specific inputs from the multi-specialty PEAC that were based on presentations from the relevant specialties, after the inputs were closely scrutinized by the PEAC using standards and packages that were agreed upon by all involved specialties. Second, the refined CPEP/RUC data are more current than the aggregate specialty-specific data for the majority of specialties. Third, for direct costs, we believe that it is reasonable to assume that the costs of the clinical staff, supplies and equipment are the same for a given service, regardless of the specialty that is performing it. This does not happen under the top-down direct cost methodology, where the specialty-specific scaling factors can create differing direct costs for the same service.

We also believe the proposed methodology is less confusing and more intuitive than the current approach. First, the NPWP would be eliminated and all services would be priced using one methodology, eliminating the complicated calculations needed to price NPWP services. Second, any revisions made to the direct inputs for one or more services would now have predictable results. Changes in the direct practice inputs for a service would proportionately change the PE RVUs for that service without significantly affecting the PE RVUs for unrelated services (except, of course, to the extent that a budget neutrality adjustment is required to be applied by the statute).

The proposed methodology would also create a system that would be significantly more stable from year-to-year than the current approach. Specialties should no longer experience the wide fluctuations in payment for a given service due to an aberrant direct cost scaling factor. Direct PEs should only change for a service if the service is further refined or when prices are updated, while indirect PEs should change only when there are changes in the mix of specialties furnishing the service or if any future new survey data for indirect costs are utilized.

We recognize that there may be some outstanding issues that need further consideration, and we welcome input from the medical community regarding those issues. We also believe the proposed transition period would give us the opportunity to work with the affected specialties to collect any needed data or to determine whether further revisions to our PE methodology are needed before payment is based entirely on the proposed methodology. As we gain experience with the new methodology, we will reexamine this policy beginning next year and propose necessary revisions through future rulemaking.

Therefore, we welcome all comments on these proposed changes, particularly those concerning additional modifications to the indirect PE methodology that might help us further our intended goals.

III. Collection of Information Requirements

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.)

IV. Response to Comments

Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments received by the date and time specified in the DATES section of this preamble, and, we will respond to the comments in the CY 2007 Physician Fee Schedule final rule with comment period.

V. Regulatory Impact Analysis

[If you choose to comment on issues in this section, please include the caption “REGULATORY IMPACT ANALYSIS” at the beginning of your comments.]

A. Overall Impact

We have examined the impacts of this proposed notice as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibilities of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). As indicated in more detail below, we estimate that the PFS work RVU provisions included in this proposed notice will redistribute more than $100 million in one year. We are considering this proposed notice to be economically significant because its provisions are estimated to result in an increase, decrease or aggregate redistribution of Medicare spending that will exceed $100 million. Therefore, this proposed notice is a major rule and we have prepared a regulatory impact analysis.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any one year. We prepare a regulatory flexibility analysis unless we certify that a rule would not have a significant economic impact on a substantial number of small entities. The analysis must include a justification concerning the reason action is being taken, the kinds and number of small entities the rule affects, and an explanation of any meaningful options that achieve the objectives with less significant adverse economic impact on the small entities.

Section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside a Metropolitan Statistical Area and has fewer than 100 beds. For purposes of the RFA, physicians, nonphysician practitioners, and suppliers are considered small businesses if they generate revenues of $6 million or less. Approximately 95 percent of physicians are considered to be small entities. There are over 980,000 physicians, other practitioners and medical suppliers that receive Medicare payment under the PFS. The analysis and discussion provided in this section, as well as elsewhere in this proposed notice, complies with the RFA requirements.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any one year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $120 million. Medicare beneficiaries are considered to be part of the private sector for this purpose. A discussion concerning the impact of this proposed notice on beneficiaries is found later in this section.

Executive Order 13132 establishes certain requirements that an agency must meet when it issues a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications.

We have examined this proposed notice in accordance with Executive Order 13132 and have determined that this regulation would not have any significant impact on the rights, roles, or responsibilities of State, local, or tribal governments. A discussion concerning the impact of this proposed notice on beneficiaries is found later in this section.

B. Anticipated Effects

We have prepared the following analysis, which, together with the information provided in the rest of this preamble, meets all assessment requirements. It explains the rationale for and purposes of the proposed notice; details the costs and benefits of the rule; analyzes alternatives; and presents the measures we propose to use to minimize the burden on small entities.

Section 1848(c)(2)(B)(ii) of the Act requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustments to preserve budget neutrality. This year, the estimated $4 billion impact of proposed changes in work RVUs resulting from the 5-year refinement will require that a budget-neutrality adjustment be made. Revisions in payment policies, including the establishment of interim and final RVUs for coding changes that will be announced later this year, may result in additional budget-neutrality adjustments.

We considered making the statutorily required budget-neutrality adjustment to account for the 5-Year Review of physician work by reducing all work RVUs. We estimate that all work RVUs would have to be reduced by 10 percent under this option. Alternatively, we considered making the budget neutrality adjustment to the PFS CF. This option would require an estimated 5 percent reduction in the CF and would also affect services that do not have work RVUs, and were thus not part of the 5-Year Review. Therefore, to confine the impact to services that have physician work RVUs, we are proposing to establish a budget neutrality adjustor that would reduce the work RVUs by an estimated 10 percent to meet the provisions of section 1848(c)(2)(B)(ii) of the Act.

Table 54 shows the specialty-level impact on payment of the work and PE changes discussed in this proposed notice for the CY 2007 Medicare PFS, including the effect of the separate work budget neutrality adjustor discussed above. Because we have proposed a four-year transition for the new PE changes, we also show the impact of the fully implemented PE changes in 2010. Our estimates of changes in Medicare revenues for PFS services compare payment rates for 2006 with proposed payment rates for 2007 and 2010 using 2005 Medicare utilization for all years. These impacts do not include estimates of the annual updates to the Medicare PFS CF for 2007 through 2010. We are using 2005 Medicare claims processed and paid through March 30, 2005, that we estimate are 98 percent complete. Using a single year of utilization, as opposed to multiple years, limits the estimated changes to the proposed work and PE. This approach is consistent with the methodology outlined in section II.D.3.d. of this proposed notice, “Use of 2005 utilization data in the indirect PE RVU calculation.” To the extent that there are year-to-year changes in the volume and mix of services provided by physicians, the actual impact on total Medicare revenues will be different than those shown here. The payment impacts reflect averages for each specialty based on Medicare utilization. The payment impact for an individual physician would be different from the average, based on the mix of services the physician provides. The average change in total revenues would be less than the impact displayed here because physicians furnish services to both Medicare and non-Medicare patients and specialties may receive substantial Medicare revenues for services that are not paid under the PFS. For instance, independent laboratories receive approximately 80 percent of their Medicare revenues from clinical laboratory services that are not paid under the PFS.

Table 54 shows only the payment impact on PFS services. The following is an explanation of the information represented in Table 54:

• Specialty: The physician specialty or type of practitioner/supplier.
• Allowed Charges: Allowed charges are the Medicare Fee Schedule amounts for covered services and include co-payments and deductibles (which are the financial responsibility of the beneficiary). These amounts have been summed across all services provided by physicians, practitioners or suppliers with a specialty to arrive at the total allowed charges for the specialty.
• Impact of Work RVU Changes: The percentage increase or decrease in allowed charges attributed to changes in the valuation of physician/clinical work for the given specialty.
• Impact of PE RVU Changes: The percentage increase or decrease in allowed charges attributed to changes in the valuation of practice expense for the services provided by physicians, practitioners or suppliers within each specialty (shown in the first year of phase-in (2007) and at full implementation (2010)).
• Combined impact of Work and PE RVU changes: The percentage increase or decrease in allowed charges attributed to the sum of changes to the valuation of physician/clinical work and the valuation of practice expense for services provided by physicians, practitioners or suppliers within each specialty (shown in the first year of phase-in of PE changes (2007) and at full implementation of PE changes (2010)).

This is the third 5-Year Review of physician work RVUs. The first 5-Year Review occurred as part of the 1996 regulatory process and was effective for services furnished on or after January 1, 1997. The second 5-Year Review of physician work RVUs occurred as part of the 2001 regulatory process and was effective for services furnished on or after January 1, 2002. Table 55 compares some basic data points from the three 5-Year Reviews.

We are currently developing the CY 2007 PFS proposed rule that will contain our estimate of all other proposed policies and changes that will affect payment for PFS services in CY 2007. We will show the combined impact of all policy and other changes affecting PFS payments in the final CY 2007 PFS rule.

C. Alternatives Considered

This proposed notice discusses the proposed revisions to the work RVUs under the PFS. The preamble provides descriptions of the statutory provisions that are addressed, identifies those areas when discretion has been exercised, presents rationale for our decisions and, where relevant, alternatives that were considered.

D. Impact on Beneficiaries

Overall, we believe these changes would improve beneficiary access to reasonable and necessary services since services would now be more appropriately valued. The payment changes would also affect beneficiary liability. Any changes in aggregate beneficiary liability from a particular work RVU change will be a function of the coinsurance (20 percent if applicable for the particular service after the beneficiary has met the deductible) and the effect of the aggregate impact of the work RVU changes on the calculation of the Medicare Part B premium rate (generally, 25 percent of the aggregate payment change).

E. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf ), in Table 56, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed notice.

Expenditures are classified as transfers between Medicare providers/suppliers (that is physicians, other practitioners medical suppliers, and providers that receive payment under or based on the PFS) and the Federal government. The −$40 million shown in Table 56 represents the net impact of an increase in FY 2007 payments for mammography and a decrease in FY 2007 payments for physical therapy.

In accordance with the provisions of Executive Order 12866, this proposed notice was reviewed by the Office of Management and Budget.

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

Note:

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

Addendum A: Explanation and Use of Addenda B

The addenda on the following pages provide various data pertaining to the Medicare fee schedule for physicians' services furnished in 2007. Addendum B contains the RVUs for work, non-facility PE, facility PE, and malpractice expense, and other information for all services included in the PFS.

In previous years, we have listed many services in Addendum B that are not paid under the PFS. To avoid publishing as many pages of codes for these services, we are not including clinical laboratory codes and most alphanumeric codes (Healthcare Common Procedure Coding System (HCPCS) codes not included in CPT) in Addendum B.

Addendum B—2007 Relative Value Units and Related Information Used in Determining Medicare Payments for 2007

This addendum contains the following information for each CPT code and alphanumeric HCPCS code, except for: alphanumeric codes beginning with B (enteral and parenteral therapy), E (durable medical equipment), K (temporary codes for nonphysicians' services or items), or L (orthotics); and codes for anesthesiology. The Addendum B included in this proposed notice does not include codes which are carrier priced since the RVUs for these services are set at 0.00.

Please also note the following:

• An “NA” in the “Non-facility PE RVUs” column of Addendum B means that CMS has not developed a PE RVU in the non-facility setting for the service because it is typically performed in the hospital (for example, an open heart surgery is generally performed in the hospital setting and not a physician's office).
• Services that have an “NA” in the “Facility PE RVUs” column of Addendum B are typically not paid using the PFS when provided in a facility setting. These services (which include “incident to” services and the technical portion of diagnostic tests) are generally paid under either the outpatient hospital prospective payment system or bundled into the hospital inpatient prospective payment system payment.

1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number for the service. Alphanumeric HCPCS codes are included at the end of this addendum.

2. Modifier. A modifier is shown if there is a technical component (modifier TC) and a professional component (PC) (modifier -26) for the service. If there is a PC and a TC for the service, Addendum B contains three entries for the code. A code for: the global values (both professional and technical); modifier -26 (PC); and, modifier TC. The global service is not designated by a modifier, and physicians must bill using the code without a modifier if the physician furnishes both the PC and the TC of the service.

Modifier-53 is shown for a discontinued procedure. There will be RVUs for the code (CPT code 45378) with this modifier.

3. Status indicator. This indicator shows whether the CPT/HCPCS code is in the PFS and whether it is separately payable if the service is covered.

A = Active code. These codes are separately payable under the PFS if covered. There will be RVUs for codes with this status. The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service. Carriers remain responsible for coverage decisions in the absence of a national Medicare policy.

B = Bundled code. Payments for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient).

C = Carrier-priced code. Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation, such as an operative report.

D = Deleted/discontinued code. These codes are deleted effective with the beginning of the CY and are always subject to a 90-day grace period.

E = Excluded from the PFS by regulation. These codes are for items and services that CMS excludes from payment under the PFS by regulation. No RVUs are shown, and no payment may be made under the PFS for these codes. Payment for them, when covered, continues under reasonable charge procedures.

F = Deleted/discontinued codes. (Code not subject to a 90-day grace period.) These codes are deleted effective with the beginning of the CY and are never subject to a grace period. This indicator is no longer effective as of January 1, 2006.

G = Code not valid for Medicare purposes. Medicare does not recognize codes assigned this status. Medicare uses another code for reporting of, and payment for, these services. (Codes subject to a 90-day grace period.) This indicator is no longer effective with the 2006 PFS as of January 1, 2006.

H = Deleted modifier. For 2000 and later years, either the TC or PC component shown for the code has been deleted or the deleted component is shown in the database with the H status indicator.

I = Not valid for Medicare purposes. Medicare uses another code for the reporting of, and the payment for these services. (Codes not subject to a 90-day grace period.)

N = Noncovered service. These codes are noncovered services. Medicare payment may not be made for these codes. If RVUs are shown, they are not used for Medicare payment.

P = Bundled or excluded code. There are no RVUs for these services. No separate payment is made for them under the PFS.

—If the item or service is covered as incident to a physician's service and is furnished on the same day as a physician's service, payment for it is bundled into the payment for the physician's service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician's service).

—If the item or service is covered as other than incident to a physician's service, it is excluded from the PFS (for example, colostomy supplies) and is paid under the other payment provisions of the Act.

R = Restricted coverage. Special coverage instructions apply. If the service is covered and no RVUs are shown, it is carrier-priced.

T = There are RVUs for these services, but they are only paid if there are no other services payable under the PFS billed on the same date by the same provider. If any other services payable under the PFS are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made.

X = Exclusion by law. These codes represent an item or service that is not within the definition of “physicians’ services” for PFS payment purposes. No RVUs are shown for these codes, and no payment may be made under the PFS. (Examples are ambulance services and clinical diagnostic laboratory services.)

4. Description of code. This is an abbreviated version of the narrative description of the code.

5. Physician work RVUs. These are the RVUs for the physician work for this service in 2007. The RVUs for codes with a 10- or 90-day global period reflect the application of the RUC-recommended values for the E/M services that are included as part of the global period for the service. Codes that are not used for Medicare payment are identified with a “+.” Note: The separate budget neutrality adjustor is not reflected in these physician work RVUs.

6. Fully implemented non-facility practice expense RVUs. These are the fully implemented resource-based PE RVUs for non-facility settings.

7. Transitional Non-facility practice expense RVUs. These are the 2007 resource-based PE RVUs for non-facility settings.

8. Fully implemented facility practice expense RVUs. These are the fully implemented resource-based PE RVUs for facility settings.

9. Transitional facility practice expense RVUs. These are the 2007 resource-based PE RVUs for facility settings.

10. Malpractice expense RVUs. These are the RVUs for the malpractice expense for the service for 2006.

11. Non-facility total. This is the sum of the work, fully implemented non-facility PE, and malpractice expense RVUs.

12. Transitional non-facility total. This is the sum of the work, 2007 transitional non-facility PE, and malpractice expense RVUs.

13. Facility total. This is the sum of the work, fully implemented facility PE, and malpractice expense RVUs.

14. Transitional facility total. This is the sum of the work, 2007 transitional facility PE, and malpractice expense RVUs.

15. Global period. This indicator shows the number of days in the global period for the code (0, 10, or 90 days). An explanation of the alpha codes follows:

MMM = Code describes a service furnished in uncomplicated maternity cases including antepartum care, delivery, and postpartum care. The usual global surgical concept does not apply. See the 1999 Physicians' CPT for specific definitions.

XXX = The global concept does not apply.

YYY = The global period is to be set by the carrier (for example, unlisted surgery codes).

ZZZ = Code related to another service that is always included in the global period of the other service. (Note: Physician work and PE are associated with intra service time and in some instances the post service time.)