[Federal Register: November 2, 1999 (Volume 64, Number 211)]
[Rules and Regulations]
[Page 59429-59478]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr02no99-17]
[[pp. 59429-59478]] Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule for Calendar Year 2000
[[Continued from page 59428]]
[[Page 59429]]
service work based on a small-group panel comparison of codes within
clinical families. This method could be used to identify statistical
outliers that appear to be either misaligned or compressed in terms of
overall physician work effort employing a simpler approach than
magnitude estimation.
3. Clinical Profile. Use a physician-level-clinical profile
database that includes estimates of total available clinical time, as
well as estimates of total volume of services provided during that time
period at the CPT code level. This method would use objectively
collected volume of service estimates and current work RVU time
estimates to evaluate the reasonableness of total service time
estimates relative to estimates of available service time.
4. Alternative Data Sources. Four alternative objective data
sources could be used in the direct identification of services whose
intra-service times may be misvalued: Anesthesia time estimates from
Medicare claims data, operative times obtained from a data vendor,
operative times collected from a panel of hospitals, and intra-service
times collected through direct observation.
5. Claims Data: Focused Review. Use Medicare claims data to
identify services whose number of pre- and post-operative hospital
visits provided during the global surgical period may be misvalued
given current lengths of stay and proportion of same day surgery cases.
6. Claims Data: Over Time. Use Medicare claims data to identify
services with potentially misvalued work RVUs by analyzing changes over
time in site of service, frequency, and specialty mix.
7. Direct Comparison. Identify services with potentially misvalued
work RVUs through a direct comparison of work per unit of time (WPUT).
This method would use statistical analysis to identify those services
with a WPUT estimate that differs significantly from the typical value
for a group of services expected to have similar levels of WPUT.
In their report, HER also suggested that we: establish a set of
standard data collection methods and review procedures and review and
correct flaws in the annual review process.
(Note: The contents of this report can be accessed through our
homepage, as discussed earlier.)
We are incorporating some of the approaches identified by our
contractor, and are also considering other means of identifying
misvalued services.
We recently awarded a contract to HER to examine in more detail
secondary databases that will enable us to validate RUC and Harvard
physician time data. Three databases will be examined: D.J. Sullivan
intraoperative time data, outpatient and ambulatory care survey data
obtained by the National Center for Health Statistics, and MGMA group
practice data on total clinical time and services.
We are also attempting to identify other primary and secondary
databases that have the potential for identifying misvalued services.
We would welcome any comments on the existence and usefulness of such
databases, as well as comments on other methodologies that might assist
us in determining how to identify misvalued services.
V. Physician Fee Schedule Update and Conversion Factor for Calendar
Year 2000
The 2000 physician fee schedule conversion factor is $36.6137. The
2000 anesthesia conversion factor is $17.77.
The specific calculations to determine the conversion factor for
physicians' services for calendar year 2000 are explained below.
Detail on Calculation of the Calendar Year 2000 Physician Fee
Schedule Update and the 2000 Conversion Factor
Physician Fee Schedule Update and Conversion Factor
The conversion factor is affected by section 1848(c)(2)(B)(ii)(II)
of the Act, which requires that changes to the relative value units of
the Medicare physician fee schedule not cause expenditures to increase
or decrease by more than $20 million from the amount of expenditures
that would have been made if such adjustments had not been made. We
implement this requirement through a uniform budget-neutrality
adjustment to the conversion factor.
Taking this factor into account, as well as the percent change in
the MEI and Sustainable Growth Rate (SGR) adjustments described below,
the 2000 conversion factor is calculated as follows:
1999 Conversion Factor....................................... 34.7315
2000 Update.................................................. 1.05472
Volume and Intensity Adjustment.............................. 0.9988
Other Factors................................................ 1.0007
2000 Conversion Factor....................................... 36.6137
The 5.5 (1.05472) percent 2000 update is calculated as follows:
MEI.......................................................... 2.4%
SGR adjustment............................................... 3.0%
2000 Update.................................................. 5.5%
Under section 1848(d)(3) of the Act, the update is equal to the
product of the MEI and the performance adjustment factor (or SGR
adjustment). Thus, the MEI of 2.4 percent (or 1.024) and the SGR
adjustment of 3.0 percent (1.03) are multiplied together to produce the
2000 update of 5.5 percent (1.05472).
There is another adjustment of 1.0007 to the conversion factor to
reflect that Medicare will no longer provide separate payment for pulse
oximetry, temperature gradient studies and venous pressure
determinations. Payment for these codes is bundled into payment for
other services. Consistent with our proposed rule (64 FR 39638),
savings from this provision are recognized in the budget neutrality
calculation on the physician fee schedule conversion factor.
The MEI and the SGR adjustments are described below.
The Percentage Change in the Medicare Economic Index
The MEI measures the weighted-average annual price change for
various inputs needed to produce physicians' services. The MEI is a
fixed-weight input price index, with an adjustment for the change in
economy-wide labor productivity. This index, which has 1996 base
weights, is comprised of two broad categories: physician's own time and
physician's practice expense.
The physician's own time component represents the net income
portion of business receipts and primarily reflects the input of the
physician's own time into the production of physicians' services in
physicians' offices. This category consists of two subcomponents: wages
and salaries and fringe benefits. These components are adjusted by the
10-year moving average annual percent change in output per man-hour for
the nonfarm business sector to eliminate double counting for
productivity growth in physicians' offices and the general economy.
The physician's practice expense category represents the rate of
price growth in nonphysician inputs to the production of services in
physicians' offices. This category consists of wages and salaries and
fringe benefits for nonphysician staff and other nonlabor inputs. Like
physician's own time, the nonphysician staff categories are adjusted
for productivity using the 10-year moving average annual percent change
in output per man-hour for the nonfarm business sector. The physician's
practice expense component also includes the following categories of
nonlabor inputs: office expense, medical materials and supplies,
professional liability insurance, medical equipment, professional car,
and other expense. The table below presents a listing of the MEI
[[Page 59430]]
cost categories with associated weights and percent changes for price
proxies for the 2000 update. The calendar year 2000 MEI is 2.4 percent.
Increase in the Medicare Economic Index Update for Calendar Year 2000
\1\
------------------------------------------------------------------------
CY 2000
Cost Categories and Price Measures 1996 Percent
Weights \2\ Changes
------------------------------------------------------------------------
Medicare Economic Index Total................. 100.0 2.4
1. Physician's Own Time 3 4............... 54.5 2.3
a. Wages and Salaries: Average hourly 44.2 2.5
earnings private nonfarm, net of
productivity.........................
b. Fringe Benefits: Employment Cost 10.3 1.2
Index, benefits, private nonfarm, net
of productivity......................
2. Physician's Practice Expense \3\....... 45.5 2.5
a. Nonphysician Employee Compensation. 16.8 2.2
1. Wages and Salaries: Employment 12.4 2.5
Cost Index, wages and salaries,
weighted by occupation, net of
productivity.....................
2. Fringe Benefits: Employment 4.4 1.5
Cost Index, fringe benefits,
white collar, net of productivity
b. Office Expense: Consumer Price 11.6 2.3
Index for Urban Consumers (CPI-U),
housing..............................
c. Medical Materials and Supplies: 4.5 5.5
Producer Price Index (PPI), ethical
drugs/PPI, surgical appliances and
supplies/CPI-U, medical equipment and
supplies (equally weighted)..........
d. Professional Liability Insurance: 3.2 3.9
HCFA professional liability insurance
survey \5\...........................
e. Medical Equipment: PPI, medical 1.9 -0.5
instruments and equipment............
f. Other Professional Expense......... 7.6 1.7
1. Professional Car: CPI-U, 1.3 -1.1
private transportation...........
2. Other: CPI-U, all items less 6.3 2.3
food and energy..................
Addendum:
Productivity: 10-year moving average of n/a 1.2
output per man-hour, nonfarm business
sector...................................
Physician's Own Time, not productivity 54.5 3.5
adjusted.................................
Wages and salaries, not productivity 44.2 3.8
adjusted.............................
Fringe benefits, not productivity 10.3 2.4
adjusted.............................
Nonphysician Employee Compensation, not 16.8 3.5
productivity adjusted....................
Wages and salaries, not productivity 12.4 3.7
adjusted.............................
Fringe benefits, not productivity 4.4 2.7
adjusted.............................
------------------------------------------------------------------------
\1\ The rates of historical change are for the 12-month period ending
June 30, 1999, which is the period used for computing the calendar
year 2000 update. The price proxy values are based upon the latest
available Bureau of Labor Statistics data as of September 21, 1999.
\2\ The weights shown for the MEI components are the 1996 base-year
weights, which may not sum to subtotals or totals because of rounding.
The MEI is a fixed-weight, Laspeyres-type input price index whose
category weights indicate the distribution of expenditures among the
inputs to physicians' services for calendar year 1996. To determine
the MEI level for a given year, the price proxy level for each
component is multiplied by its 1996 weight. The sum of these products
(weights multiplied by the price index levels) over all cost
categories yields the composite MEI level for a given year. The annual
percent change in the MEI levels is an estimate of price change over
time for a fixed market basket of inputs to physicians' services.
\3\ The Physician's Own Time and Nonphysician Employee Compensation
category price measures include an adjustment for productivity. The
price measure for each category is divided by the 10-year moving
average of output per man-hour in the nonfarm business sector. For
example, the fringe benefit component of Physician's Own Time is
calculated by dividing the rate of growth in the employment cost index
for benefits of private nonfarm workers by the 10-year moving average
rate of growth of output per man-hour for the nonfarm business sector.
Dividing one plus the decimal form of the percent change in the
average hourly earnings (1+.024=1.024) by one plus the decimal form of
the percent change in the 10-year moving average of labor productivity
(1+.012=1.012) equals one plus the change in average hourly earnings
net of the change in output per man hour (1.024/1.012=1.012). All
Physician's Own Time and Nonphysician Employee Compensation categories
are adjusted in this way. Due to a higher level of precision the
computer calculated quotient may differ from the quotient calculated
from rounded individual percent changes.
\4\ The average hourly earnings proxy, the Employment Cost Index
proxies, as well as the CPI-U, housing and CPI-U, private
transportation are published in the Current Labor Statistics Section
of the Bureau of Labor Statistics' Monthly Labor Review. The remaining
CPIs and PPIs in the revised index can be obtained from the Bureau of
Labor Statistics' CPI Detailed Report or Producer Price Indexes.
\5\ Derived from a HCFA survey of several major insurers (the latest
available historical percent change data are for the period ending
second quarter of 1999).
n/a Productivity is factored into the MEI compensation categories as an
adjustment to the price variables; therefore, no explicit weight
exists for productivity in the MEI.
Medicare Performance Relative to the SGR
Medicare Sustainable Growth Rate
Section 1848(f) of the Act, as amended by section 4503 of the BBA,
replaces the volume performance standard with a sustainable growth rate
(SGR) standard. It specifies the formula for establishing yearly SGR
targets for physicians' services under Medicare. The use of SGR targets
is intended to control the actual growth in Medicare expenditures for
physicians' services.
The SGR targets are not limits on expenditures. Payments for
services are not withheld if the SGR target is exceeded. Rather, the
appropriate fee schedule update, as specified in section 1848(d)(3)(A)
of the Act, is adjusted to reflect the success or failure in meeting
the SGR target.
As provided in section 4502 of the BBA, the update to the
conversion factor is adjusted based on a comparison of actual
expenditure to the SGR. The law refers to this update as the update
adjustment factor. The amended section 1848(d)(3) of the Act now states
that ``the `update adjustment factor' for a year is equal (as estimated
by the Secretary) to--
(i) the difference between (I) the sum of the allowed expenditures
for physicians' services (as determined under subparagraph (C)) for the
period beginning April 1, 1997, and ending on March 31 of the year
involved, and (II) the amount of actual expenditures for physicians'
services furnished during the period beginning April 1, 1997, and
ending on March 31 of the preceding year; divided by
(ii) the actual expenditures for physicians' services for the 12-
month period ending on March 31 of the preceding year, increased by the
sustainable growth rate under
[[Page 59431]]
subsection (f) for the fiscal year which begins during such 12-month
period.''
The result is a 3.0 percent adjustment for 2000.
VI. Provisions of the Final Rule
The provisions of this final rule restate the provisions of the
July 22, 1999, proposed rule except as noted elsewhere in this
preamble. Following is a highlight of the changes made:
For our proposal relating to physician pathology services and
independent laboratories (Sec. 415.130(c)), we have decided to adopt
our proposal to pay only hospitals for the TC services furnished to its
inpatients, but delay implementation until January 1, 2001, to allow
independent laboratories and hospitals sufficient time to negotiate
arrangements.
For our proposal relating to optometrist services, we are revising
the regulations at Sec. 410.23 (Limitations on services of an
optometrist) to specify that Medicare Part B pays for services of a
doctor of optometry, acting within the scope of his or her license,
with respect to the provision of items or services described in section
1861(s) of the Act.
For our proposal relating to CPT modifier -25, we are making the
following changes:
We are proceeding to include procedures with a global
period indicator of ``XXX'' in the application of the global surgery
payment policy relating to the use of modifier -25.
We will not, however, require the routine use of modifier
-25 with all procedures having a global indicator of ``XXX''. Instead,
we will identify specific codes if an E/M service is furnished with a
specified code. To be billed for, it would need to be documented as
being significant and separately identifiable and be reported with
modifier -25.
We will seek review of these codes from physician
specialty societies, as well as those nonphysician practitioners who
are authorized to bill Medicare on their own.
Specific procedure codes for which the use of modifier -25
is required when a significant, separately identifiable E/M service is
furnished and reported by the same physician or nonphysician
practitioner will be included as edits in the Correct Coding Initiative
edits.
These edits will be implemented no earlier than October 1,
2000, and will continue to be added as appropriate on an ongoing basis.
In the meantime, however, since modifiers are an inherent
part of HCPCS, we urge all practitioners to familiarize themselves with
them and to make it a practice to use them when applicable.
For our proposal relating to coverage of prostate cancer screening
tests (Sec. 410.39) we are implementing the requirements as stated in
the proposed rule. However, we are revising Sec. 410.39(e)(1) to
provide that payment ``may not be made for a screening PSA blood test
performed for a man age 50 or younger''.
For our proposal to discontinue separate payment for pulse
oximetry, temperature gradient studies, venous pressure determinations,
and to list them in the physician fee schedule with a status code of
``B'' for ``payment always bundled into payment for other services,''
we will bundle payment for these services starting in 2000 with the
exception of 94762, which we will continue to pay separately when
continuous overnight monitoring is medically necessary as a separate
procedure.
VII. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).
VIII. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will respond to the comments in the preamble to that
document.
IX. Regulatory Impact Analysis
We have examined the impacts of this final rule as required by
Executive Order (EO) 12866, the Unfunded Mandates Reform Act (UMRA)
(Public Law 104-4), the Regulatory Flexibility Act (RFA) (Public Law
96-354), and the Federalism Executive Order (EO) 13132.
Executive Order 12866 directs agencies to assess costs and benefits
of available regulatory alternatives and, when regulation is necessary,
to select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety effects,
distributive impacts, and equity). A regulatory impact analysis (RIA)
must be prepared for major rules with economically significant effects
($100 million or more annually). The changes in the Medicare physician
fee schedule are, for the most part, budget neutral. This final rule
conforms the regulations to new statutory benefits that exceed $100
million in Medicare spending. (See the estimated costs tables in
sections IX. M. and IX. N.) Therefore, this final rule is considered to
be a major rule as defined in Title 5, United States Code, Section
804(2).
The UMRA also requires (in section 202) that agencies prepare an
assessment of anticipated costs and benefits before developing any rule
that may result in an expenditure by State, local, or tribal
governments, in the aggregate, or by the private sector, of $100
million or more in any given year. This final rule will have no
consequential effect on State, local, or tribal governments. We believe
the private sector cost of this rule falls below these thresholds as
well.
The RFA requires that we analyze regulatory options for small
businesses and other small entities. 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 of why 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 and
lessen significant adverse economic impact on the small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 50 beds.
For purposes of the RFA, all physicians are considered to be small
entities. There are about 700,000 physicians and other practitioners
who receive Medicare payment under the physician fee schedule. We have
prepared the following analysis which, together with the rest of this
preamble, meets all four assessment requirements. It explains the
rationale for and purpose of the rule, details the costs and benefits
of the rule, analyzes alternatives, and presents the measures we
considered to minimize the burden on small entities.
[[Page 59432]]
A. Resource-Based Malpractice Relative Value Units
As explained earlier in this preamble, the resource-based
malpractice RVUs must be implemented in a budget-neutral manner. That
is, the total fee schedule malpractice RVUs must be the same under the
resource-based method as would have existed had the prior charge-based
malpractice RVUs been retained. This means that increases in RVUs for
some services will necessarily be offset by corresponding decreases in
values for other services. Table 3 shows, by specialty, the estimated
percentage changes in allowed charges for our proposed resource-based
malpractice RVUs.
As Table 3 shows, the effects on payments are very modest and, in
most cases, negligible. Of the 35 major payment specialties, 15 are
estimated to experience payment increases, 19 are estimated to
experience payment decreases, and 1 experiences no change. Only two
specialties are estimated to experience increases of more than 1
percent, emergency medicine (2.6 percent) and nephrology (1.1 percent),
with an estimated median payment increase of 0.3 percent among the
specialties that receive an increase. Only three specialties are
estimated to experience payment decreases of 1 percent or more cardiac
surgery (-1.2 percent), orthopedic surgery (-1.1 percent), and thoracic
surgery (-1.0 percent) with an estimated median payment decrease of -
0.5 percent among the specialties which receive a decrease. These
impacts are slightly different than those shown in the July 22 proposed
rule because they reflect different case mix using 1998 rather than
1997 service frequencies; incorporate RVU changes made as a result of
comments received on the NPRM; and reflect the final budget-neutrality
adjustment calculated by our actuaries.
The impact of the changes on the total revenue (Medicare and non-
Medicare) for a given specialty is less than the impact displayed in
Table 3 since physicians furnish services to both Medicare and non-
Medicare patients. The magnitude of the impact on Medicare payment for
a specialty depends generally on the mix of services a physician in the
specialty furnishes.
Table 3.--Impact on Total Allowed Charges by Specialty of the Resource
Based Malpractice Expense Relative Value Units
[Percent change]
------------------------------------------------------------------------
Allowed Impact by
Specialty charges (in specialty
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................... 0.2 -0.6
CARDIAC SURGERY......................... 0.3 -1.2
CARDIOLOGY.............................. 3.7 -0.1
CLINICS................................. 1.4 0.2
DERMATOLOGY............................. 1.2 0.0
EMERGENCY MEDICINE...................... 0.8 2.6
FAMILY PRACTICE......................... 3.0 0.3
GASTROENTEROLOGY........................ 1.1 -0.4
GENERAL PRACTICE........................ 1.0 0.4
GENERAL SURGERY......................... 1.7 -0.2
HEMATOLOGY ONCOLOGY..................... 0.6 0.2
INTERNAL MEDICINE....................... 6.3 0.3
NEPHROLOGY.............................. 0.9 1.1
NEUROLOGY............................... 0.8 0.3
NEUROSURGERY............................ 0.3 0.5
OBSTETRICS/GYNECOLOGY................... 0.4 -0.6
OPHTHALMOLOGY........................... 3.5 -0.5
ORTHOPEDIC SURGERY...................... 2.0 -1.1
OTOLARYNGOLOGY.......................... 0.6 -0.3
PATHOLOGY............................... 0.5 -0.6
PLASTIC SURGERY......................... 0.2 -0.3
PSYCHIATRY.............................. 1.1 -0.2
PULMONARY............................... 1.0 0.2
RADIATION ONCOLOGY...................... 0.4 -0.5
RADIOLOGY............................... 2.7 -0.6
RHEUMATOLOGY............................ 0.3 0.3
THORACIC SURGERY........................ 0.5 -1.0
UROLOGY................................. 1.2 -0.1
VASCULAR SURGERY........................ 0.3 -0.5
ALL OTHER PHYSICIAN..................... 1.2 0.1
OTHERS:
CHIROPRACTOR........................ 0.4 0.6
NONPHYSICIAN PRACTITIONER........... 0.9 -0.4
OPTOMETRIST......................... 0.4 0.4
PODIATRY............................ 1.0 0.4
SUPPLIERS........................... 0.4 -0.4
------------------------------------------------------------------------
B. Resource-Based Practice Expense Relative Value Units
Revisions in resource-based practice expense RVUs for physicians'
services are calculated to be budget neutral, that is, the total
practice expense RVUs for calendar year 2000 are calculated to be the
same as the total practice expense RVUs that we estimate would have
occurred without the changes proposed in this regulation. This means
that increases in practice expense RVUs for
[[Page 59433]]
some services will necessarily be offset by corresponding decreases in
values for other services.
Table 4, ``Impact on Total Allowed Charges by Specialty of the
Final Rule Practice Expense Changes'' shows, by specialty, the
estimated percent changes in allowed charges resulting from the
practice expense proposals discussed earlier in this rule. This table
shows the impact of changes in the year 2000, as well as 3-year impact
from 2000 to 2002 on the fully implemented practice expense RVUs. In
the year 2000, the practice expense RVUs are a blend of 50 percent of
the charged-based RVU and 50 percent of the resource-based RVU. The
year 2000 impact column shows the impact of changes in this rule
relative to what payments would have been in 2000 had there been no
changes from this rule. The column labeled 2000-2002 impact compares
payments using the fully implemented RVUs published in the November 2,
1998 final rule (63 FR 58816) to the fully implemented RVUs reflecting
changes included in this rule.
Table 4.--Impact on Total Allowed Charges by Specialty of Final Rule Practice Expense Changes
[Percent change]
----------------------------------------------------------------------------------------------------------------
Allowed Year 2000 2000-2002
Specialty charges (in impact impact
billions) (percent) (percent)
----------------------------------------------------------------------------------------------------------------
ANESTHESIOLOGY.................................................. 1.6 -3 -9
CARDIAC SURGERY................................................. 0.3 -2 -6
CARDIOLOGY...................................................... 3.7 -1 -3
CLINICS......................................................... 1.4 0 -1
DERMATOLOGY..................................................... 1.2 0 0
EMERGENCY MEDICINE.............................................. 0.8 -1 -2
FAMILY PRACTICE................................................. 3.0 0 1
GASTROENTEROLOGY................................................ 1.1 -1 -4
GENERAL PRACTICE................................................ 1.0 0 1
GENERAL SURGERY................................................. 1.8 0 -1
HEMATOLOGY ONCOLOGY............................................. 0.6 0 0
INTERNAL MEDICINE............................................... 6.3 0 0
NEPHROLOGY...................................................... 0.9 0 1
NEUROLOGY....................................................... 0.8 0 0
NEUROSURGERY.................................................... 0.3 0 -1
OBSTETRICS/GYNECOLOGY........................................... 0.4 1 2
OPHTHALMOLOGY................................................... 3.5 1 2
ORTHOPEDIC SURGERY.............................................. 2.0 0 1
OTHER PHYSICIAN................................................. 1.2 -1 -2
OTOLARYNGOLOGY.................................................. 0.6 1 2
PATHOLOGY....................................................... 0.5 3 9
PLASTIC SURGERY................................................. 0.2 1 2
PSYCHIATRY...................................................... 1.1 0 -1
PULMONARY....................................................... 1.0 -1 -2
RADIATION ONCOLOGY.............................................. 0.6 0 0
RADIOLOGY....................................................... 2.8 -1 -2
RHEUMATOLOGY.................................................... 0.3 1 4
THORACIC SURGERY................................................ 0.5 -2 -5
UROLOGY......................................................... 1.2 0 1
VASCULAR SURGERY................................................ 0.3 0 -1
OTHERS: .............. 0 0
CHIROPRACTOR................................................ 0.4 0 0
NONPHYSICIAN PRACTITIONER................................... 0.9 0 0
OPTOMETRIST................................................. 0.4 2 5
PODIATRY.................................................... 1.0 1 2
SUPPLIERS................................................... 0.4 6 18
----------------------------------------------------------------------------------------------------------------
Table 5 shows the impacts we displayed in the proposed rule
published on July 22, 1999 for practice expense only and the
corresponding impacts which result from this final rule. This table
shows only the fully implemented fee schedule impact, not the year 2000
impact incorporating the transition. There are two factors that explain
the difference between the proposed rule and final rule impact
statements. In the proposed rule, we indicated that we were considering
removing some services from the zero physician work RVU pool. We did
not include the effect of that policy change in the proposed rule
impact statement. That change is now included in the ``Final Rule''
column. The zero work RVU change affects specialties which perform the
technical portion of diagnostic tests. We are also using a higher
practice expense per hour for thoracic and cardiac surgery in order to
establish the SMS specialty practice expense pools. This change affects
only these two specialties. Both of these changes are discussed in more
detail earlier in the preamble to this final rule.
[[Page 59434]]
Table 5.--Impact on Total Allowed Charges by Specialty of Practice Expense Changes Only 7/22/1999 Proposed Rule
and This Final Rule
----------------------------------------------------------------------------------------------------------------
Allowed Proposed rule Final rule
Specialty charges impact impact
(billions) (percent) (percent)
----------------------------------------------------------------------------------------------------------------
ANESTHESIOLOGY.................................................. 1.6 -8 -9
CARDIAC SURGERY................................................. 0.3 -8 -6
CARDIOLOGY...................................................... 3.7 -2 -3
CLINICS......................................................... 1.4 -1 -1
DERMATOLOGY..................................................... 1.2 2 0
EMERGENCY MEDICINE.............................................. 0.8 -1 -2
FAMILY PRACTICE................................................. 3.0 2 1
GASTROENTEROLOGY................................................ 1.1 -2 -4
GENERAL PRACTICE................................................ 1.0 2 1
GENERAL SURGERY................................................. 1.8 0 -1
HEMATOLOGY ONCOLOGY............................................. 0.6 1 0
INTERNAL MEDICINE............................................... 6.3 0 0
NEPHROLOGY...................................................... 0.9 0 1
NEUROLOGY....................................................... 0.8 1 0
NEUROSURGERY.................................................... 0.3 1 -1
OBSTETRICS/GYNECOLOGY........................................... 0.4 3 2
OPHTHALMOLOGY................................................... 3.5 1 2
ORTHOPEDIC SURGERY.............................................. 2.0 3 1
OTHER PHYSICIAN................................................. 1.2 0 -2
OTOLARYNGOLOGY.................................................. 0.6 2 2
PATHOLOGY....................................................... 0.5 2 9
PLASTIC SURGERY................................................. 0.2 1 2
PSYCHIATRY...................................................... 1.1 -1 -1
PULMONARY....................................................... 1.0 -2 -2
RADIATION ONCOLOGY.............................................. 0.6 0 0
RADIOLOGY....................................................... 2.8 0 -2
RHEUMATOLOGY.................................................... 0.3 5 4
THORACIC SURGERY................................................ 0.5 -6 -5
UROLOGY......................................................... 1.2 2 1
VASCULAR SURGERY................................................ 0.3 0 -1
OTHERS:
CHIROPRACTOR................................................ 0.4 0 0
NONPHYSICIAN PRACTITIONER................................... 0.9 2 0
OPTOMETRIST................................................. 0.4 2 5
PODIATRY.................................................... 1.0 2 2
SUPPLIERS................................................... 0.4 1 18
----------------------------------------------------------------------------------------------------------------
Table 6 shows the percentage change in total payment (in 2000
physician fee schedule dollars) for selected high-volume procedures
that result from the change in payment related to the changes in
practice expense and malpractice RVUs contained in this final rule.
These tables reflect the impact of this final rule only on the fully
implemented fee schedule amount. The payments in these columns are
determined using a conversion factor of $36.6137. The RVUs used for
calculating payments in the ``old'' columns are from the Federal
Register published on November 2, 1998. The RVUs used in calculating
payments in the ``new'' columns are from this final rule. By using the
conversion factor of $36.6137 to calculate payments in both the ``old''
and ``new'' columns, the impact of changes in practice expense and
malpractice expense RVU are illustrated. These tables do not show the
actual impact on payment from 1999 to 2000 because they do not
incorporate the effect of the transition or physician fee schedule
update. In general, payments for services in the facility setting,
including evaluation and management services, are declining due to our
policy to exclude costs associated with bringing clinical staff to the
facility setting. Payment for a tissue exam by a pathologist (CPT
88305) is increasing due to our proposal to remove the service from the
zero work pool. The increase in value for the technical portion of the
services causes a corresponding increase in the global service.
Table 6.--Total Payment For Selected Procedures
----------------------------------------------------------------------------------------------------------------
Old non- New non- Percent Old New Percent
Code Mod Description facility facility change facility facility change
----------------------------------------------------------------------------------------------------------------
11721.... ...... Debride nail, 6 $ 39.18 $ 39.18 0% 34.43 $ 28.56 -17
or more.
17000.... ...... Destroy benign/ 49.43 60.41 22 32.24 32.95 2
premal lesion.
27130.... ...... Total hip NA NA NA 1,435.23 1,395.71 -3
replacement.
27236.... ...... Treat thigh NA NA NA 1,118.73 1,065.82 -5
fracture.
27244.... ...... Treat thigh NA NA NA 1,133.38 1,085.96 -4
fracture.
27447.... ...... Total knee NA NA NA 1,500.43 1,460.52 -3
replacement.
33533.... ...... CABG, arterial, NA NA NA 1,940.01 1,829.59 -6
single.
35301.... ...... Rechanneling of NA NA NA 1,124.23 1,133.93 1
artery.
43239.... ...... Upper GI 272.41 247.14 -9 147.63 139.13 -6
endoscopy,
biopsy.
45385.... ...... Lesion removal 413.00 462.80 12 292.69 275.70 -6
colonoscopy.
[[Page 59435]]
66821.... ...... After cataract 201.74 196.98 -2 191.58 170.99 -11
laser surgery.
66984.... ...... Remove cataract/ NA NA NA 700.03 654.65 -6
insert lens.
67210.... ...... Treatment of 593.87 602.66 1 545.08 550.67 1
retinal lesion.
71010.... 26.... Chest x-ray.... 8.79 8.79 0 8.79 8.79 0
71020.... ...... Chest x-ray.... 35.15 34.42 -2 35.17 34.42 -2
71020.... 26.... Chest x-ray.... 10.62 10.62 0 10.62 10.62 0
77430.... ...... Weekly 180.14 187.83 4 180.23 187.83 4
radiation
therapy.
78465.... ...... Heart image 542.25 527.24 -3 542.52 527.24 -3
(3d), multiple.
88305.... ...... Tissue exam by 61.51 82.01 33 61.54 82.01 33
pathologist.
88305.... 26.... Tissue exam by 40.28 40.64 1 40.29 40.64 1
pathologist.
90801.... ...... Psy dx 143.53 146.09 2 142.86 138.77 -3
interview.
90806.... ...... Psytx, off, 45- 97.76 97.76 0 95.98 93.73 -2
50 min.
90807.... ...... Psytx, off, 45- 101.79 103.62 2 102.94 99.22 -4
50 min w/e&m.
90862.... ...... Medication 49.79 50.89 2 49.09 46.50 -5
management.
90921.... ...... ESRD related 245.31 263.25 7 245.43 237.26 -3
services,
month.
90935.... ...... Hemodialysis, NA NA NA 69.97 61.51 -12
one evaluation.
92004.... ...... Eye exam, new 120.83 124.49 3 86.82 88.61 2
patient.
92012.... ...... Eye exam 75.79 63.71 -16 36.27 36.61 1
established
pat.
92014.... ...... Eye exam & 87.87 91.53 4 58.98 59.68 1
treatment.
92980.... ...... Insert NA NA NA 949.13 851.63 -10
intracoronary
stent.
92982.... ...... Coronary artery NA NA NA 716.15 630.12 -12
dilation.
93000.... ...... Electrocardiogr 26.36 26.36 0 26.37 26.36 0
am, complete.
93010.... ...... Electrocardiogr 8.79 8.79 0 8.79 8.79 0
am report.
93015.... ...... Cardiovascular 106.55 104.35 -2 106.60 104.35 -2
stress test.
93307.... ...... Echo exam of 204.30 198.08 -3 204.40 198.08 -3
heart.
93307.... 26.... Echo exam of 49.79 48.70 -2 49.82 48.70 -2
heart.
93510.... 26.... Left heart 231.03 247.87 7 231.15 247.87 7
catheterizatio
n.
98941.... ...... Chiropractic 34.78 35.15 1 30.40 30.76 1
manipulation.
99202.... ...... Office/ 68.47 72.50 6 53.48 45.40 -15
outpatient
visit, new.
99203.... ...... Office/ 97.03 102.52 6 78.03 69.57 -11
outpatient
visit, new.
99204.... ...... Office/ 136.94 145.36 6 112.09 102.88 -8
outpatient
visit, new.
99205.... ...... Office/ 169.89 179.41 6 145.43 135.84 -7
outpatient
visit, new.
99211.... ...... Office/ 23.07 25.63 11 14.29 8.79 -38
outpatient
visit, est.
99212.... ...... Office/ 36.61 39.18 7 28.21 23.07 -18
outpatient
visit, est.
99213.... ...... Office/ 48.33 51.63 7 38.46 33.68 -12
outpatient
visit, est.
99214.... ...... Office/ 76.16 80.92 6 62.27 56.02 -10
outpatient
visit, est.
99215.... ...... Office/ 110.94 116.07 5 96.71 90.44 -6
outpatient
visit, est.
99221.... ...... Initial NA NA NA 72.53 65.17 -10
hospital care.
99222.... ...... Initial NA NA NA 115.02 108.38 -6
hospital care.
99223.... ...... Initial NA NA NA 157.52 151.21 -4
hospital care.
99231.... ...... Subsequent NA NA NA 34.07 32.59 -4
hospital care.
99232.... ...... Subsequent NA NA NA 54.95 53.82 -2
hospital care.
99233.... ...... Subsequent NA NA NA 78.39 76.16 -3
hospital care.
99236.... ...... Observ/hosp NA NA NA 220.52 215.29 -2
same date.
99238.... ...... Hospital NA NA NA 68.87 64.44 -6
discharge day.
99239.... ...... Hospital NA NA NA 91.58 88.24 -4
discharge day.
99241.... ...... Office 57.12 61.14 7 40.66 32.95 -19
consultation.
99242.... ...... Office 95.93 101.79 6 74.36 67.37 -9
consultation.
99243.... ...... Office 121.92 128.51 5 98.54 89.70 -9
consultation.
99244.... ...... Office 168.06 176.48 5 142.13 132.54 -7
consultation.
99245.... ...... Office 213.09 222.25 4 186.09 176.11 -5
consultation.
99251.... ...... Initial NA NA NA 42.13 36.61 -13
inpatient
consult.
99252.... ...... Initial NA NA NA 77.29 71.76 -7
inpatient
consult.
99253.... ...... Initial NA NA NA 104.40 97.39 -7
inpatient
consult.
99254.... ...... Initial NA NA NA 146.16 138.77 -5
inpatient
consult.
99255.... ...... Initial NA NA NA 198.18 191.12 -4
inpatient
consult.
99261.... ...... Follow-up NA NA NA 28.21 23.80 -16
inpatient
consult.
99262.... ...... Follow-up NA NA NA 50.92 45.77 -10
inpatient
consult.
99263.... ...... Follow-up NA NA NA 72.16 67.37 -7
inpatient
consult.
99282.... ...... Emergency dept NA NA NA 27.84 26.73 -4
visit.
99283.... ...... Emergency dept NA NA NA 59.34 60.05 1
visit.
99284.... ...... Emergency dept NA NA NA 92.31 94.10 2
visit.
99285.... ...... Emergency dept NA NA NA 142.50 146.09 3
visit.
99291.... ...... Critical care, 187.10 187.83 0 185.72 179.41 -3
first hour.
99292.... ...... Critical care, 94.46 96.66 2 93.41 89.70 -4
addl 30 min.
99301.... ...... Nursing NA NA NA 65.57 60.41 -8
facility care.
99302.... ...... Nursing NA NA NA 86.82 80.92 -7
facility care.
99303.... ...... Nursing NA NA NA 107.70 100.32 -7
facility care.
99311.... ...... Nursing fac NA NA NA 33.70 30.02 -11
care, subseq.
99312.... ...... Nursing fac NA NA NA 53.12 49.79 -6
care, subseq.
99313.... ...... Nursing fac NA NA NA 74.73 71.03 -5
care, subseq.
99348.... ...... Home visit, est 70.30 72.50 3 70.70 66.64 -6
patient.
99350.... ...... Home visit, est 158.17 164.40 4 154.95 154.88 0
patient.
----------------------------------------------------------------------------------------------------------------
Table 7 shows the combined impact of the proposed changes in the
malpractice RVUs and the fully implemented practice expense RVUs.
Comment: One commenter indicated that specialty level impacts
displayed in the proposed rule were misleading and
[[Page 59436]]
caused a great deal of confusion in the physician community. Although
the commenter indicated that it is appropriate for us to display
specialty level impacts that result from the new rule relative to prior
policy, the commenter also requested that we show the total impact of
adopting resource-based methodologies.
Response: In general, we show the impact of changes that result
from a new rule, not the cumulative impact of changes in policy
contained in prior rules as well as the new one. However, we
acknowledge that it can be difficult to understand changes that result
from adoption of the resource-based practice expense methodology
because those changes may result from policy changes contained in the
final rule published on November 2, 1998 (63 FR 58814), from changes
due to this final rule, and because all of these changes are occurring
over the 4-year transition period. Impacts of the final rule published
on November 2, 1998 are shown on page 58895 of the physician fee
schedule final rule published on November 2, 1998. The percentage
increase for a particular specialty can be combined with the impacts
shown in table 7 (which shows the impacts in addition to those
presented in the November 2, 1998 final rule) to determine the impact
of moving to resource based methodologies for practice expense and
malpractice expense.
The impact of the changes on the total revenue (Medicare and non-
Medicare) for a given specialty is less than the impact displayed in
these tables since physicians furnish services to both Medicare and
non-Medicare patients. The magnitude of the impact that Medicare
payment has on a specialty depends generally on the mix of services a
physician in the specialty provides and the sites in which the services
are performed. As we indicated in the proposed rule, each year since
the fee schedule has been implemented, our actuaries have determined
any adjustments needed to meet the requirements of budget neutrality. A
key component of the actuarial determination of budget neutrality
involves estimating any impact of changes in the volume and intensity
of physicians' services furnished to Medicare beneficiaries as a result
of the proposed changes.
In estimating the impacts of proposed changes under the physician
fee schedule on the volume and intensity of services, the actuaries
have historically used a model that assumes that 50 percent of the
change in net revenue for a procedure would be recouped. This does not
mean that the payments are reduced by 50 percent. In fact, payments
have typically been reduced only by a few percent or less. In 1999, the
actuary revised the assumption about response to payment changes and
will use a model that assumes a 30 percent volume-and-intensity
response to price reductions. The actuary is continuing to assume no
reduction in volume and intensity response to a price increase. Our
actuary's analysis of the volume-and-intensity response is available on
our homepage (www.hcfa.gov).
Comment: We again received comments in response to our assumption
that physicians respond to payment reductions so as to offset revenue
reductions. One commenter indicated that a 30 percent volume-and-
intensity response seems extreme.
Response: We provide a response to this and similar comments in the
final rule published November 2, 1998 (63 FR 588894). We reiterate that
our assumption that physicians respond to payment reductions so as to
offset 30 percent of revenue reduction in physician fees. Most
physicians, even those in specialties with a negative payment impact
shown in table 7, will experience an increase in physician fees in
2000. This is largely due to an update of 5.4 percent. Since there are
few specialties that will actually experience a decline in payment in
2000, the adjustment to the conversion factor for behavioral responses
to fee reductions will be only 0.12 percent (or approximately $0.04).
To the extent that the volume-and-intensity response does not occur,
the SGR system enacted as part of the BBA will return the volume-and-
intensity adjustment in the form of higher future updates to the
Medicare physician fee schedule CF. The volume-and-intensity adjustment
should not affect aggregate payments because our actuaries assume an
offsetting increase in the volume and intensity of services provided in
2000.
Table 7.--Impact on Total Allowed Charges by Specialty of Fully
Implemented Practice Expense and Malpractice Expense Relative Value
Units
------------------------------------------------------------------------
Changes
Allowed Resulting from
Specialty Charges (in this Final
billions) Rule (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................... 1.6 -9
CARDIAC SURGERY......................... 0.3 -8
CARDIOLOGY.............................. 3.7 -3
CLINICS................................. 1.4 -1
DERMATOLOGY............................. 1.2 0
EMERGENCY MEDICINE...................... 0.8 1
FAMILY PRACTICE......................... 3.0 1
GASTROENTEROLOGY........................ 1.1 -4
GENERAL PRACTICE........................ 1.0 2
GENERAL SURGERY......................... 1.8 -1
HEMATOLOGY ONCOLOGY..................... 0.6 0
INTERNAL MEDICINE....................... 6.3 0
NEPHROLOGY.............................. 0.9 2
NEUROLOGY............................... 0.8 0
NEUROSURGERY............................ 0.3 -1
OBSTETRICS/GYNECOLOGY................... 0.4 1
OPHTHALMOLOGY........................... 3.5 2
ORTHOPEDIC SURGERY...................... 2.0 0
OTHER PHYSICIAN......................... 1.2 -2
OTOLARYNGOLOGY.......................... 0.6 1
PATHOLOGY............................... 0.5 8
PLASTIC SURGERY......................... 0.2 1
[[Page 59437]]
PSYCHIATRY.............................. 1.1 -1
PULMONARY............................... 1.0 -2
RADIATION ONCOLOGY...................... 0.6 0
RADIOLOGY............................... 2.8 -3
RHEUMATOLOGY............................ 0.3 4
THORACIC SURGERY........................ 0.5 -6
UROLOGY................................. 1.2 1
VASCULAR SURGERY........................ 0.3 -1
OTHERS:
CHIROPRACTOR........................ 0.4 1
NONPHYSICIAN PRACTITIONER........... 0.9 0
OPTOMETRIST......................... 0.4 5
PODIATRY............................ 1.0 2
SUPPLIERS........................... 0.4 17
------------------------------------------------------------------------
Comment: A few commenters indicated that HCFA has not fulfilled its
statutory obligation to provide impacts on the practice expense RVUs in
different geographical areas or compare Medicare payments under the new
practice expense RVUS with actual practice costs for physicians in each
specialty.
Response: Section 4505(d)(3) of the BBA required the Secretary to
provide the impacts suggested by this commenter as part of a notice of
proposed rule making in the Spring of 1998. We provided impacts of the
newly adopted resource-based practice expense by specialty and
geographic area in the proposed rule published June 5, 1998 (63 FR
58895). Unlike adoption of the physician fee schedule published on
January 1, 1992, the adoption of the practice expense methodology has a
negligible impact on payments by geographical area. For this reason we
are not continuing to display those impacts. With respect to comparing
the new practice expense RVUs to actual practice expenses for
physicians in each specialty, we do not believe that the data are
available to make reliable comparisons. Although we do have aggregate,
specialty level data on practice expense from the SMS, these data are
used to establish relative payment amounts for the more than 7,000
physician services paid for by Medicare and are intended to represent
the relative resources used by physicians in providing services to
Medicare patients. The SMS data do not allow us to directly compare
these practice expense relative values to ``actual'' practice expenses.
Table 7 shows the combined impact of the changes in the malpractice
RVUs and the fully implemented practice expense RVUs. The impact of the
changes on the total revenue (Medicare and non-Medicare) for a given
specialty is less than the impact displayed in these tables since
physicians furnish services to both Medicare and non-Medicare patients.
The magnitude of the impact that Medicare payment has on a specialty
depends generally on the mix of services a physician in the specialty
provides and the sites in which the services are performed.
C. Adjustment to the Practice Expense Relative Value Units for a
Physician's Interpretation of Abnormal Papanicolaou Smears
Currently, there are several codes for a physician's interpretation
of an abnormal pap smear (three HCPCS codes and one CPT code). We
evaluated the practice expense RVUs for each of these codes in a
slightly different manner, and the practice expense RVUs assigned to
HCPCS code G0141 were much lower than those for the other codes. We
believe it is more appropriate to have the RVUs for all of these codes
identical to those for CPT code 88141. The impact of this provision has
been incorporated into the physician fee schedule budget-neutrality
calculation.
D. Physician Pathology Services and Independent Laboratories
Independent laboratories usually bill for a combined service that
is the sum of the PC and TC services. These services can be furnished
to both hospital and nonhospital patients.
The claims processing instructions require the independent
laboratory to use the hospital as the place of service (POS) for TC
billing of hospital patients. However, our analysis of national claims
data indicates that independent laboratories are likely to use the
independent laboratory as the POS. Thus, we cannot directly calculate
the independent laboratory's billings for the combined service to
hospital inpatients.
Based on our knowledge of laboratory practice arrangements, we have
assumed that 20 percent of the allowed charges for independent
laboratories represent billings for hospital inpatients. We adjusted
this amount to remove PC billings because they are billable
notwithstanding the provisions of this final rule. We estimated the PC
amount by multiplying the total allowed charges for each code by the
ratio of the PC RVUs to total RVUs for that code. The remaining amount
represents the total allowed charges for TC services for hospital
inpatients.
We estimated that payment under the physician fee schedule for TC
billings by independent laboratories will decrease by $6 million.
However, we are delaying implementation for 1 year so hospitals can
make the necessary arrangements
The hospital is paid under the prospective payment system for the
TC of a physician pathology service to hospital inpatients. If the
independent laboratory furnishes the TC, it must enter into an
arrangement with a hospital to be paid appropriately for this service.
E. Discontinuous Anesthesia Time
This final rule clarifies that if an anesthesia practitioner has
not been billing for a block of time before an interruption in
services, he or she would be able to bill for that block of time and
receive payment. It is our understanding that, in most instances, a
block of time before an interruption is generally about 15 minutes, or
one time
[[Page 59438]]
unit. However, some anesthesia practitioners may have interpreted our
regulations as allowing them to bill for the block of time before an
interruption. If an anesthesia practitioner has billed in this manner,
then our revision to the regulations will not have any economic effect.
We estimate that overall there are no costs or savings to the Medicare
program.
F. Optometrist Services
The provisions of the OBRA 1986 expanded coverage of optometrist
services. While this statutory provision had been implemented through
manual provisions, we had not revised the regulations to reflect this
change. We proposed to revise the regulations at Sec. 410.23 to specify
that Medicare Part B pays for the services of a doctor of optometry,
acting within the scope of his or her license, if the services are
those described in section 1861(s) of the Act and 42 CFR 410.10.
We received comments from the American Optometric Association
supporting the proposed revision to the regulations. We are revising
the regulations at Sec. 410.23 to specify that Medicare Part B pays for
services of a doctor of optometry, acting within the scope of his or
her license, if the services are those described in section 1861(s) of
the Act and 42 CFR 410.10.
G. Assisted Suicide
This final rule conforms the regulations to a provision in the
Assisted Suicide Funding Act of 1997. This statute prohibits the use of
Federal funds to furnish or pay for any health care service or health
benefit coverage for the purpose of causing, or assisting to cause, the
death of any individual. We believe that this change will have no
program costs or savings given the exclusion from Medicare payment of
expenses for these services under section 1862(a)(1)(A) of the Act.
This section states that no payment may be made under Part A or Part B
for any expenses incurred for items or services that are not reasonable
or necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member.
H. CPT Modifier -25
For selected procedures for which current global surgery rules do
not apply (for example, those for which the global indicator is ``XXX''
in the database), this rule provides that a practitioner may bill for
an E/M service only if it is a significant separately identifiable
service. This situation will be reported by appending modifier -25 to
the E/M service code. This policy will assist carriers in claims
adjudication and eliminate unnecessary denials when practitioners
append modifier -25 to the E/M service to signify that the E/M service
reported is appropriate because it was a significant and separately
identifiable service from the procedure performed. We expect the
savings to be minimal because the specific procedures to which this
policy is to be applied have still to be identified and edits for these
procedures will not begin to be implemented until October 2000 at the
earliest.
I. Nurse Practitioner Qualifications
The NP qualifications stated in this final rule provide a mechanism
that permits those individuals who have a Medicare NP billing number
before January 1, 2001, to continue to bill as NPs. Therefore, an
individual who may not have been nationally certified as an NP, or who
does not have a master's degree in nursing, is permitted to continue to
bill under the Medicare program. However, after January 1, 2003, to
obtain a Medicare NP billing number, a new applicant is required to
possess a master's degree in nursing, State authorization to practice
as an NP, and national certification as an NP. By this time, nursing
professionals will have had ample notification and time to acquire
these credentials. There are no Medicare program costs or savings
associated with this provision. Furthermore, these requirements are
consistent with our understanding of certification and training
requirements being implemented by NP professional groups.
J. Relative Value Units for Pediatric Services
This final rule corrects our use of the wrong data in establishing
the work RVUs for certain pediatric surgical services. Since pediatric
services are a small portion of services under Medicare, this change
has a negligible cost or saving impact on the Medicare program
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
We have established payment for a new HCPCS code that more
accurately describes the activities regarding percutaneous thrombectomy
of a dialysis graft or fistula. Since this is basically a coding change
we do not anticipate any costs or savings to the Medicare program.
L. Pulse Oximetry, Temperature Gradient Studies, and Venous Pressure
Determinations
We discontinued separate payment for CPT codes 94760 (noninvasive
ear or pulse oximetry for oxygen saturation; single determination);
94761 (non-invasive ear or pulse oximetry for oxygen saturation;
multiple determinations); 93740 (temperature gradient studies); and
93770 (determination of venous pressure). Payment for these codes is
bundled into payment for other services. Any savings from this
provision are incorporated into the physician fee schedule budget-
neutrality calculation.
M. Removal of Requirement for X-ray Before Chiropractic Manipulation
This final rule conforms the regulations to section 4513(a) of the
BBA. We expect that removal of the requirement will encourage increased
billing for chiropractic manipulation. The impact of this BBA provision
is shown in the table below.
Estimated Costs
[$ millions]
------------------------------------------------------------------------
------------------------------------------------------------------------
FY 2000.......................................................... 20
FY 2001.......................................................... 40
FY 2002.......................................................... 50
FY 2003.......................................................... 70
FY 2004.......................................................... 80
------
Total.......................................................... 260
------------------------------------------------------------------------
N. Coverage of Prostate Cancer Screening Tests
Section 4103 of the BBA authorizes coverage of certain prostate
cancer screening tests, effective January 1, 2000, subject to certain
frequency and payment limitations. The new tests include: (1) screening
DREs and (2) screening prostate-specific antigen tests. Based on the
projected utilization of these screening services and related medically
necessary follow-up tests and treatment that may be required for the
beneficiaries screened, we estimate that this BBA provision will result
in an increase in Medicare payments as described in the table below for
FYs 2000 through 2002. These payments will be made to many urologists,
primary care physicians, and other practitioners (involved in screening
DREs), and to clinical laboratories (involved in screening prostate-
specific antigen tests) nationally.
[[Page 59439]]
Estimated Medicare Costs
[$ million]
------------------------------------------------------------------------
Part A Part B Total
------------------------------------------------------------------------
FY 2000...................................... 170 590 760
FY 2001...................................... 300 1,100 1,400
FY 2002...................................... 400 1,270 1,670
FY 2003...................................... 500 1,470 1,970
FY 2004...................................... 620 1,710 2,330
--------------------------
Total...................................... 1,990 6,140 8,130
------------------------------------------------------------------------
We believe that the effect of the rule will be positive. Prostate
cancer is the most commonly diagnosed cancer in men and the second
leading cause of cancer death for American men. The American Cancer
Society estimates that in 1999 about 179,000 new cases of prostate
cancer will be diagnosed in the United States, and about 37,000 people
will die directly from the disease. According to the American
Urological Association, the use of a screening prostate-specific
antigen blood test, in combination with a screening DRE, is the best
method for detecting prostate cancer when the disease is localized and
potentially curable. Although coverage of prostate cancer screening
should improve access to this service for Medicare beneficiaries, the
benefits of such screening, based on the available medical literature,
are not entirely clear. The literature on the benefits of cancer
detection, especially among men over 70, indicates that screening for
prostate cancer does not necessarily lead to the prolongation of life
or improvement in the quality of life. However, when prostate cancer is
found early, there is evidence that it can often be treated
successfully. Through early detection of prostate cancer made possible
under the new benefit and the use of appropriate treatment measures,
our expectation is that the harmful effects of this serious disease
among the Medicare population will be reduced in the future.
O. Diagnostic Tests
1. Supervision of Diagnostic Test
The requirements of the physician supervision policy in
Sec. 410.32(b) conform to the BBA provisions relating to PAs, NPs, and
CNSs. We clarified that the level of physician supervision for
diagnostic tests performed by PAs, when they are authorized by the
State to perform these tests, is general. This means that we will not
require that the supervising physician for the diagnostic test be on
the premises when the test is performed. No level of physician
supervision is required for diagnostic tests performed by NPs and CNSs
when they are authorized by the State to perform these tests. The scope
of services for which PAs, NPs, or CNSs can bill will not be affected;
therefore, we do not expect any significant costs or savings.
2. Independent Diagnostic Testing Facilities (IDTF)
The IDTF provision at Sec. 410.33 states that NPs and CNSs are
included among the entities that may bill carriers directly for
diagnostic tests. This final rule is a technical one and will not have
a significant effect on costs or savings.
P. Budget-Neutrality
Each year since the fee schedule has been implemented, our
actuaries have determined any adjustments needed to meet the budget-
neutrality requirement of the statute. A component of the actuarial
determination of budget-neutrality involves estimating the impact of
changes in the volume-and-intensity of physicians' services provided to
Medicare beneficiaries as a result of the proposed changes. Consistent
with the provision in the November 2, 1998 final rule, the actuaries
used a model that assumes a 30 percent volume-and-intensity response to
price reductions.
Q. Impact on Beneficiaries
Although changes in payments to physicians when the physician fee
schedule was implemented in 1992 were large, we detected no problems
with beneficiary access to care. Furthermore, because there is a 4-year
transition to the resource-based practice expense system, we expect
minimal impact on beneficiary access to care.
We are currently conducting substantial research to evaluate
beneficiary access to physicians. This research includes, but is not
limited to, augmenting the beneficiary survey questionnaire to further
clarify access problems, conducting a survey of Medicare physicians to
identify physician specialties and procedures by geographic areas, and
tracking claims data in ``vulnerable populations.''
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
Federalism
We have examined this rule in accordance with Executive Order 13132
and have determined that this final rule will not have any negative
impact on the rights, roles, or responsibilities of State, local, or
Tribal governments.
List of Subjects
42 CFR Part 410
Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Rural areas, X-rays.
42 CFR Part 411
Kidney diseases, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 414
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
42 CFR Part 415
Health facilities, Health professions, Medicare and Reporting and
recordkeeping requirements.
42 CFR Part 485
Grant programs--health, Health facilities, Medicaid, Medicare,
Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, 42 CFR chapter IV is
amended as follows:
PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
A. Part 410 is amended as set forth below:
1. The authority citation for part 410 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 410.22, paragraph (b)(1) is revised to read as follows:
Sec. 410.22. Limitations on services of a chiropractor.
* * * * *
(b) Limitations on services. (1) Medicare Part B pays only for a
chiropractor's manual manipulation of the spine to correct a
subluxation if the subluxation has resulted in a neuromusculoskeletal
condition for which manual manipulation is appropriate treatment.
* * * * *
3. Section 410.23 is revised to read as follows:
Sec. 410.23 Limitations on services of an optometrist.
Medicare Part B pays for the services of a doctor of optometry,
which he or she is legally authorized to perform in the State in which
he or she performs them, if the services are among those described in
section 1861(s) of the Act and Sec. 410.10 of this part.
[[Page 59440]]
4. In Sec. 410.32, the introductory text to paragraph (b)(2) is
republished for the convenience of the reader, paragraph (b)(2) is
amended by adding new paragraphs (b)(2)(v) and (b)(2)(vi), and the
introductory text to paragraph (b)(3) is revised to read as follows:
Sec. 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and
other diagnostic tests: Conditions.
* * * * *
(b) Diagnostic x-ray and other diagnostic tests. * * *
(2) Exceptions. The following diagnostic tests payable under the
physician fee schedule are excluded from the basic rule set forth in
paragraph (b)(1) of this section:
* * * * *
(v) Diagnostic tests performed by a nurse practitioner or clinical
nurse specialist authorized to perform the tests under applicable State
laws.
(vi) Pathology and laboratory procedures listed in the 80000 series
of the Current Procedural Terminology published by the American Medical
Association.
(3) Levels of supervision. Except where otherwise indicated, all
diagnostic x-ray and other diagnostic tests subject to this provision
and payable under the physician fee schedule must be furnished under at
least a general level of physician supervision as defined in paragraph
(b)(3)(i) of this section. In addition, some of these tests also
require either direct or personal supervision as defined in paragraphs
(b)(3)(ii) or (b)(3)(iii) of this section, respectively. (However,
diagnostic tests performed by a physician assistant (PA) that the PA is
legally authorized to perform under State law require only a general
level of physician supervision.) When direct or personal supervision is
required, physician supervision at the specified level is required
throughout the performance of the test.
* * * * *
5. In Sec. 410.33, paragraph (a)(1) is revised to read as follows:
Sec. 410.33 Independent diagnostic testing facility.
(a) General rule. (1) Effective for diagnostic procedures performed
on or after March 15, 1999, carriers will pay for diagnostic procedures
under the physician fee schedule only when performed by a physician, a
group practice of physicians, an approved supplier of portable x-ray
services, a nurse practitioner, or a clinical nurse specialist when he
or she performs a test he or she is authorized by the State to perform,
or an independent diagnostic testing facility (IDTF). An IDTF may be a
fixed location, a mobile entity, or an individual nonphysician
practitioner. It is independent of a physician's office or hospital;
however, these rules apply when an IDTF furnishes diagnostic procedures
in a physician's office.
* * * * *
6. A new section 410.39 is added to read as follows:
Sec. 410.39 Prostate cancer screening tests: Conditions for and
limitations on coverage.
(a) Definitions. As used in this section, the following definitions
apply:
(1) Prostate cancer screening tests means any of the following
procedures furnished to an individual for the purpose of early
detection of prostate cancer:
(i) A screening digital rectal examination.
(ii) A screening prostate-specific antigen blood test.
(iii) For years beginning after 2002, other procedures HCFA finds
appropriate for the purpose of early detection of prostate cancer,
taking into account changes in technology and standards of medical
practice, availability, effectiveness, costs, and other factors HCFA
considers appropriate.
(2) A screening digital rectal examination means a clinical
examination of an individual's prostate for nodules or other
abnormalities of the prostate.
(3) A screening prostate-specific antigen blood test means a test
that measures the level of prostate-specific antigen in an individual's
blood.
(b) Condition for coverage of screening digital rectal
examinations. Medicare Part B pays for a screening digital rectal
examination if it is performed by the beneficiary's physician, or by
the beneficiary's physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife who is authorized to
perform this service under State law.
(c) Limitation on coverage of screening digital rectal
examinations. (1) Payment may not be made for a screening digital
rectal examination performed for a man age 50 or younger.
(2) For an individual over 50 years of age, payment may be made for
a screening digital rectal examination only if the man has not had such
an examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening
digital rectal examination was performed.
(d) Condition for coverage of screening prostate-specific antigen
blood tests. Medicare Part B pays for a screening prostate-specific
antigen blood test if it is ordered by the beneficiary's physician, or
by the beneficiary's physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife who is authorized to order
this test under State law.
(e) Limitation on coverage of screening prostate-specific antigen
blood test. (1) Payment may not be made for a screening prostate-
specific antigen blood test performed for a man age 50 or younger.
(2) For an individual over 50 years of age, payment may be made for
a screening prostate-specific antigen blood test only if the man has
not had such an examination paid for by Medicare during the preceding
11 months following the month in which his last Medicare-covered
screening prostate-specific antigen blood test was performed.
7. In Sec. 410.75, paragraph (b) is revised to read as follows:
Sec. 410.75 Nurse practitioner's services.
* * * * *
(b) Qualifications. For Medicare Part B coverage of his or her
services, a nurse practitioner must--(1)(i) Be a registered
professional nurse who is authorized by the State in which the services
are furnished to practice as a nurse practitioner in accordance with
State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(2) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000;
or
(3) Be a nurse practitioner who on or after January 1, 2001,
applies for a Medicare billing number for the first time and meets the
standards for nurse practitioners in paragraphs (b)(1)(i) and
(b)(1)(ii) of this section; or
(4) Be a nurse practitioner who on or after January 1, 2003,
applies for a Medicare billing number for the first time and possesses
a master's degree in nursing and meets the standards for nurse
practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this section.
* * * * *
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE
PAYMENT
B. Part 411 is amended as set forth below:
[[Page 59441]]
1. The authority citation for Part 411 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 411.15, the introductory text in the section is revised,
the introductory text to paragraph (a) is republished, paragraph (a)(1)
is revised, the introductory text to paragraph (k) is republished, and
new paragraphs (k)(9) and (q) are added to read as follows:
Sec. 411.15 Particular services excluded from coverage.
The following services are excluded from coverage:
(a) Routine physical checkups such as:
(1) Examinations performed for a purpose other than treatment or
diagnosis of a specific illness, symptoms, complaint, or injury, except
for screening mammography, colorectal cancer screening tests, screening
pelvic examinations, or prostate cancer screening tests that meet the
criteria specified in paragraphs (k)(6) through (k)(9) of this section.
* * * * *
(k) Any services that are not reasonable and necessary for one of
the following purposes:
* * * * *
(9) In the case of prostate cancer screening tests, for the purpose
of early detection of prostate cancer, subject to the conditions and
limitations specified in Sec. 410.39 of this chapter.
* * * * *
(q) Assisted suicide. Any health care service used for the purpose
of causing, or assisting to cause, the death of any individual. This
does not pertain to the withholding or withdrawing of medical treatment
or care, nutrition or hydration or to the provision of a service for
the purpose of alleviating pain or discomfort, even if the use may
increase the risk of death, so long as the service is not furnished for
the specific purpose of causing death.
PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
C. Part 414 is amended as set forth below:
1. The authority citation for part 414 continues to read as
follows:
Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social
Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)).
2. In Sec. 414.22, the introductory text is republished, paragraph
(b)(5)(i) is revised, and a new paragraph (c)(3) is added to read as
follows:
Sec. 414.22 Relative value units (RVUs).
HCFA establishes RVUs for physicians' work, practice expense, and
malpractice insurance.
* * * * *
(b) Practice expense RVUs. * * *
(5) * * *
(i) Usually one of two levels of practice expense RVUs can be
applied to each code. The lower facility practice expense RVUs apply to
services furnished to patients in the hospital, skilled nursing
facility, or ambulatory surgical center when the physician performs
procedures on the ASC approved procedures list. The higher non-facility
practice expense RVUs apply to services performed in a physician's
office or in an ASC if the physician is performing a procedure not on
the ASC approved procedures list, services furnished to patients in a
nursing facility, in a facility or institution other than a hospital,
skilled nursing facility, or in the home. The facility practice expense
RVUs for a particular code may not be greater than the non-facility
RVUs for that code.
* * * * *
(c) Malpractice insurance RVUs. * * *
(3) For services furnished in the year 2000 and subsequent years,
the malpractice RVUs are based on the relative malpractice insurance
resources.
3. In Sec. 414.46, the introductory texts to paragraphs (a) and (b)
are republished, paragraphs (a)(1) and (a)(2) are revised, paragraph
(a)(3) is added, and paragraphs (b)(1) and (b)(2) are revised to read
as follows:
Sec. 414.46 Additional rules for payment of anesthesia services.
(a) Definitions. For purposes of this section, the following
definitions apply:
(1) Base unit means the value for each anesthesia code that
reflects all activities other than anesthesia time. These activities
include usual preoperative and postoperative visits, the administration
of fluids and blood incident to anesthesia care, and monitoring
services.
(2) Anesthesia practitioner, for the purpose of anesthesia time,
means a physician who performs the anesthesia service alone, a CRNA who
is not medically directed who performs the anesthesia service alone, or
a medically directed CRNA.
(3) Anesthesia time means the time during which an anesthesia
practitioner is present with the patient. It starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services and
ends when the anesthesia practitioner is no longer furnishing
anesthesia services to the beneficiary, that is, when the beneficiary
may be placed safely under postoperative care. Anesthesia time is a
continuous time period from the start of anesthesia to the end of an
anesthesia service. In counting anesthesia time, the anesthesia
practitioner can add blocks of anesthesia time around an interruption
in anesthesia time as long as the anesthesia practitioner is furnishing
continuous anesthesia care within the time periods around the
interruption.
(b) Determinations of payment amount--Basic rule. For anesthesia
services performed, medically directed, or medically supervised by a
physician, the carrier pays the lesser of the actual charge or the
anesthesia fee schedule amount.
(1) The carrier bases the fee schedule amount for an anesthesia
service on the product of the sum of allowable base and time units and
an anesthesia-specific CF. The carrier calculates the time units from
the anesthesia time reported by the anesthesia practitioner for the
anesthesia procedure. The physician who fulfills the conditions for
medical direction in Sec. 415.110 (Conditions for payment:
Anesthesiology services) reports the same anesthesia time as the
medically-directed CRNA.
(2) HCFA furnishes the carrier with the base units for each
anesthesia procedure code. The base units are derived from the 1988
American Society of Anesthesiologists' Relative Value Guide except that
the number of base units recognized for anesthesia services furnished
during cataract or iridectomy surgery is four units.
* * * * *
4. In Sec. 414.60, the introductory text of paragraph (a) is
revised to read as follows:
Sec. 414.60 Payment for the services of CRNAs.
(a) Basis for payment. The allowance for the anesthesia service
furnished by a CRNA, medically directed or not medically directed, is
based on allowable base and time units as defined in Sec. 414.46(a).
Beginning with CY 1994--
* * * * *
PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS,
SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN
CERTAIN SETTINGS
D. Part 415 is amended as set forth below:
[[Page 59442]]
1. The authority citation for part 415 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 415.130(c) is revised to read as follows:
Sec. 415.130 Conditions for payment; Physician pathology services.
* * * * *
(c) Physician pathology services furnished by an independent
laboratory. The technical component of physician pathology services
furnished by an independent laboratory to a hospital inpatient before
January 1, 2001, or to an outpatient are paid on a fee schedule basis
under this subpart. On or after January 1, 2001, payment is made only
to the hospital for the technical component of physician pathology
services furnished to a hospital inpatient.
PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
E. Part 485 is amended as set forth below:
1. The authority citation for part 485 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395(hh)
2. In Sec. 485.705, paragraph(c)(8) is revised to read as follows:
Sec. 485.705 Personnel qualifications.
* * * * *
(8) A nurse practitioner is a person who must:
(i) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(iii) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000;
or
(iv) Be a nurse practitioner who on or after January 1, 2001,
applies for a Medicare billing number for the first time and meets the
standards for nurse practitioners in paragraphs (c)(8)(i) and
(c)(8)(ii) of this section; or
(v) Be a nurse practitioner who on or after January 1, 2003,
applies for a Medicare billing number for the first time and possesses
a master's degree in nursing and meets the standards for nurse
practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this section.
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: October 21, 1999.
Michael M. Hash,
Deputy Administrator, Health Care Financing Administration.
Dated: October 22, 1999.
Donna E. Shalala,
Secretary.
Note: These addenda will not appear in the Code of Federal
Regulations.
Addendum A--Explanation and Use of Addendum B
The addenda on the following pages provide various data pertaining
to the Medicare fee schedule for physicians' services furnished in
2000. Addendum B contains the RVUs for work, non-facility practice
expense, facility practice expense, and malpractice expense, and other
information for all services included in the physician fee schedule.
Addendum B--2000 Relative Value Units and Related Information Used
in Determining Medicare Payments for 2000
This addendum contains the following information for each CPT code
and alphanumeric HCPCS code, except for alphanumeric codes beginning
with B (enteral and parenteral therapy), E (durable medical equipment),
K (temporary codes for nonphysicians' services or items), or L
(orthotics), and codes for anesthesiology.
1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number for
the service. Alphanumeric HCPCS codes are included at the end of this
addendum.
2. Modifier. A modifier is shown if there is a technical component
(modifier TC) and a professional component (PC) (modifier -26) for the
service. If there is a PC and a TC for the service, Addendum B contains
three entries for the code: One for the global values (both
professional and technical); one for modifier -26 (PC); and one for
modifier TC. The global service is not designated by a modifier, and
physicians must bill using the code without a modifier if the physician
furnishes both the PC and the TC of the service.
Modifier -53 is shown for a discontinued procedure. There will be
RVUs for the code (CPT code 45378) with this modifier.
3. Status indicator. This indicator shows whether the CPT/HCPCS
code is in the physician fee schedule and whether it is separately
payable if the service is covered.
A = Active code. These codes are separately payable under the fee
schedule if covered. There will be RVUs for codes with this status. The
presence of an ``A'' indicator does not mean that Medicare has made a
national decision regarding the coverage of the service. Carriers
remain responsible for coverage decisions in the absence of a national
Medicare policy.
B = Bundled code. Payment for covered services is always bundled
into payment for other services not specified. If RVUs are shown, they
are not used for Medicare payment. If these services are covered,
payment for them is subsumed by the payment for the services to which
they are incident. (An example is a telephone call from a hospital
nurse regarding care of a patient.)
C = Carrier-priced code. Carriers will establish RVUs and payment
amounts for these services, generally on a case-by-case basis following
review of documentation, such as an operative report.
D = Deleted code. These codes are deleted effective with the
beginning of the calendar year.
E = Excluded from physician fee schedule by regulation. These codes
are for items or services that we chose to exclude from the physician
fee schedule payment by regulation. No RVUs are shown, and no payment
may be made under the physician fee schedule for these codes. Payment
for them, if they are covered, continues under reasonable charge or
other payment procedures.
G = Code not valid for Medicare purposes. Medicare does not
recognize codes assigned this status. Medicare uses another code for
reporting of, and payment for, these services.
N = Noncovered service. These codes are noncovered services.
Medicare payment may not be made for these codes. If RVUs are shown,
they are not used for Medicare payment.
P = Bundled or excluded code. There are no RVUs for these services.
No separate payment should be made for them under the physician fee
schedule.
--If the item or service is covered as incident to a physician's
service and is furnished on the same day as a physician's service,
payment for it is bundled into the payment for the physician's service
to which it is incident (an example is an elastic bandage furnished by
a physician incident to a physician's service).
[[Page 59443]]
--If the item or service is covered as other than incident to a
physician's service, it is excluded from the physician fee schedule
(for example, colostomy supplies) and is paid under the other payment
provisions of the Act.
R = Restricted coverage. Special coverage instructions apply. If
the service is covered and no RVUs are shown, it is carrier-priced.
T = Injections. There are RVUs for these services, but they are
only paid if there are no other services payable under the physician
fee schedule billed on the same date by the same provider. If any other
services payable under the physician fee schedule are billed on the
same date by the same provider, these services are bundled into the
service(s) for which payment is made.
X = Exclusion by law. These codes represent an item or service that
is not within the definition of ``physicians' services'' for physician
fee schedule payment purposes. No RVUs are shown for these codes, and
no payment may be made under the physician fee schedule. (Examples are
ambulance services and clinical diagnostic laboratory services.)
4. Description of code. This is an abbreviated version of the
narrative description of the code.
5. Physician work RVUs. These are the RVUs for the physician work
for this service in 2000. Codes that are not used for Medicare payment
are identified with a ``+.''
6. Fully implemented non-facility practice expense RVUs. These are
the fully implemented resource-based practice expense RVUs for non-
facility settings.
7. Year 2000 Transition non-facility practice expense RVUs. Blended
non-facility practice expense RVUs for use in 2000.
8. Fully implemented facility practice expense RVUs. These are the
fully implemented resource-based practice expense RVUs for facility
settings.
9. Year 2000 transition facility practice expense RVUs. Blended
facility practice expense RVUs for use in 2000.
10. Malpractice expense RVUs. These are the RVUs for the
malpractice expense for the service for 2000.
11. Fully implemented non-facility total. This is the sum of the
work, fully implemented non-facility practice expense, and malpractice
expense RVUs.
12. Year 2000 transition non-facility total. This is the sum of the
work, transition non-facility practice expense, and malpractice expense
RVUs for use in 2000.
13. Fully implemented facility total. This is the sum of the work,
fully implemented facility practice expense, and malpractice expense
RVUs.
14. Year 2000 transition facility total. This is the sum of the
work, transition facility practice expense, and malpractice expense
RVUs for use in 2000.
15. Global period. This indicator shows the number of days in the
global period for the code (0, 10, or 90 days). An explanation of the
alpha codes follows:
MMM = The code describes a service furnished in uncomplicated
maternity cases including antepartum care, delivery, and postpartum
care. The usual global surgical concept does not apply. See the 1999
Physicians' Current Procedural Terminology for specific definitions.
XXX = The global concept does not apply.
YYY = The global period is to be set by the carrier (for example,
unlisted surgery codes).
ZZZ = The code is part of another service and falls within the
global period for the other service.
\4\ PE RVUs = Practice Expense Relative Value
Units.
[[Page 59443]]
Addendum B.--Relative Value Units (RVUs) and Related Information Used in Determining Medicare Payments for 2000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Year Year
Fully 2000 Year Fully 2000 Year
Physician Implemented Transi- Fully 2000 Mal- Implemented Transi- Fully 2000
CPT \1\/ HCPCS MOD Status Description Work RVUs Non- tional Implemented Transi- Practice Non- tional Implemented Transi- Global
\2\ \3\ Facility PE Non- Facility PE tional RVUs Facility Non- Facility tional
RVUs Facility RVUs Facility Total Facility Total Facility
PE RVUs PE RVUs Total Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10040.......... ............. A Acne surgery of skin 1.18 1.57 0.96 0.52 0.35 0.05 2.80 2.19 1.75 1.58 010
abscess.
10060.......... ............. A Drainage of skin 1.17 1.26 0.87 0.62 0.43 0.08 2.51 2.12 1.87 1.68 010
abscess.
10061.......... ............. A Drainage of skin 2.40 1.95 1.32 1.12 0.74 0.15 4.50 3.87 3.67 3.29 010
abscess.
10080.......... ............. A Drainage of pilonidal 1.17 1.95 1.25 0.68 0.48 0.09 3.21 2.51 1.94 1.74 010
cyst.
10081.......... ............. A Drainage of pilonidal 2.45 2.71 1.96 1.57 1.09 0.20 5.36 4.61 4.22 3.74 010
cyst.
10120.......... ............. A Remove foreign body... 1.22 1.72 1.11 0.69 0.47 0.10 3.04 2.43 2.01 1.79 010
10121.......... ............. A Remove foreign body... 2.69 2.64 1.87 1.74 1.15 0.24 5.57 4.80 4.67 4.08 010
10140.......... ............. A Drainage of hematoma/ 1.53 1.32 0.92 0.82 0.54 0.11 2.96 2.56 2.46 2.18 010
fluid.
10160.......... ............. A Puncture drainage of 1.20 1.46 0.94 0.72 0.47 0.09 2.75 2.23 2.01 1.76 010
lesion.
10180.......... ............. A Complex drainage, 2.25 1.33 1.24 1.24 1.19 0.23 3.81 3.72 3.72 3.67 010
wound.
11000.......... ............. A Debride infected skin. 0.60 0.52 0.48 0.23 0.23 0.04 1.16 1.12 0.87 0.87 000
11001.......... ............. A Debride infected skin 0.30 0.29 0.29 0.12 0.13 0.02 0.61 0.61 0.44 0.45 ZZZ
add-on.
11010.......... ............. A Debride skin, fx...... 4.20 2.42 3.36 2.08 3.19 0.36 6.98 7.92 6.64 7.75 010
11011.......... ............. A Debride skin/muscle, 4.95 3.66 4.39 2.58 3.85 0.48 9.09 9.82 8.01 9.28 000
fx.
11012.......... ............. A Debride skin/muscle/ 6.88 4.83 5.98 4.06 5.59 0.71 12.42 13.57 11.65 13.18 000
bone, fx.
11040.......... ............. A Debride skin, partial. 0.50 0.45 0.44 0.19 0.21 0.03 0.98 0.97 0.72 0.74 000
11041.......... ............. A Debride skin, full.... 0.82 0.61 0.61 0.32 0.32 0.06 1.49 1.49 1.20 1.20 000
11042.......... ............. A Debride skin/tissue... 1.12 0.85 0.78 0.44 0.40 0.09 2.06 1.99 1.65 1.61 000
11043.......... ............. A Debride tissue/muscle. 2.38 2.40 2.18 1.37 1.67 0.22 5.00 4.78 3.97 4.27 010
11044.......... ............. A Debride tissue/muscle/ 3.06 3.10 3.08 1.79 2.43 0.30 6.46 6.44 5.15 5.79 010
bone.
11055.......... ............. R Trim skin lesion...... 0.27 0.34 0.31 0.11 0.13 0.02 0.63 0.60 0.40 0.42 000
11056.......... ............. R Trim skin lesions, 2 0.39 0.38 0.38 0.15 0.17 0.03 0.80 0.80 0.57 0.59 000
to 4.
11057.......... ............. R Trim skin lesions, 0.50 0.42 0.36 0.20 0.18 0.03 0.95 0.89 0.73 0.71 000
over 4.
11100.......... ............. A Biopsy of skin lesion. 0.81 1.53 1.04 0.37 0.33 0.04 2.38 1.89 1.22 1.18 000
11101.......... ............. A Biopsy, skin add-on... 0.41 0.68 0.50 0.19 0.18 0.02 1.11 0.93 0.62 0.61 ZZZ
11200.......... ............. A Removal of skin tags.. 0.77 1.05 0.76 0.31 0.28 0.04 1.86 1.57 1.12 1.09 010
11201.......... ............. A Remove skin tags add- 0.29 0.42 0.30 0.12 0.11 0.02 0.73 0.61 0.43 0.42 ZZZ
on.
11300.......... ............. A Shave skin lesion..... 0.51 1.00 0.79 0.22 0.26 0.03 1.54 1.33 0.76 0.80 000
11301.......... ............. A Shave skin lesion..... 0.85 1.10 0.92 0.40 0.39 0.04 1.99 1.81 1.29 1.28 000
11302.......... ............. A Shave skin lesion..... 1.05 1.20 1.09 0.48 0.49 0.05 2.30 2.19 1.58 1.59 000
11303.......... ............. A Shave skin lesion..... 1.24 1.31 1.40 0.56 0.65 0.06 2.61 2.70 1.86 1.95 000
11305.......... ............. A Shave skin lesion..... 0.67 0.79 0.68 0.28 0.28 0.04 1.50 1.39 0.99 0.99 000
11306.......... ............. A Shave skin lesion..... 0.99 1.05 0.91 0.43 0.41 0.05 2.09 1.95 1.47 1.45 000
[[Page 59444]]
11307.......... ............. A Shave skin lesion..... 1.14 1.15 1.09 0.51 0.51 0.05 2.34 2.28 1.70 1.70 000
11308.......... ............. A Shave skin lesion..... 1.41 1.22 1.37 0.61 0.69 0.07 2.70 2.85 2.09 2.17 000
11310.......... ............. A Shave skin lesion..... 0.73 1.10 0.93 0.34 0.36 0.04 1.87 1.70 1.11 1.13 000
11311.......... ............. A Shave skin lesion..... 1.05 1.21 1.07 0.51 0.49 0.05 2.31 2.17 1.61 1.59 000
11312.......... ............. A Shave skin lesion..... 1.20 1.28 1.25 0.58 0.60 0.05 2.53 2.50 1.83 1.85 000
11313.......... ............. A Shave skin lesion..... 1.62 1.52 1.57 0.76 0.79 0.08 3.22 3.27 2.46 2.49 000
11400.......... ............. A Removal of skin lesion 0.91 2.37 1.48 0.71 0.50 0.07 3.35 2.46 1.69 1.48 010
11401.......... ............. A Removal of skin lesion 1.32 2.39 1.56 0.86 0.62 0.10 3.81 2.98 2.28 2.04 010
11402.......... ............. A Removal of skin lesion 1.61 2.48 1.73 0.95 0.72 0.11 4.20 3.45 2.67 2.44 010
11403.......... ............. A Removal of skin lesion 1.92 2.69 1.98 1.08 0.86 0.15 4.76 4.05 3.15 2.93 010
11404.......... ............. A Removal of skin lesion 2.20 2.83 2.17 1.17 0.96 0.18 5.21 4.55 3.55 3.34 010
11406.......... ............. A Removal of skin lesion 2.76 3.13 2.59 1.40 1.72 0.25 6.14 5.60 4.41 4.73 010
11420.......... ............. A Removal of skin lesion 1.06 1.96 1.26 0.75 0.52 0.08 3.10 2.40 1.89 1.66 010
11421.......... ............. A Removal of skin lesion 1.53 2.28 1.53 0.96 0.68 0.11 3.92 3.17 2.60 2.32 010
11422.......... ............. A Removal of skin lesion 1.76 2.46 1.74 1.03 0.77 0.12 4.34 3.62 2.91 2.65 010
11423.......... ............. A Removal of skin lesion 2.17 2.75 2.09 1.22 0.97 0.17 5.09 4.43 3.56 3.31 010
11424.......... ............. A Removal of skin lesion 2.62 2.90 2.21 1.39 1.08 0.20 5.72 5.03 4.21 3.90 010
11426.......... ............. A Removal of skin lesion 3.78 3.56 2.78 1.86 1.93 0.32 7.66 6.88 5.96 6.03 010
11440.......... ............. A Removal of skin lesion 1.15 2.50 1.63 0.91 0.65 0.08 3.73 2.86 2.14 1.88 010
11441.......... ............. A Removal of skin lesion 1.61 2.62 1.77 1.12 0.79 0.11 4.34 3.49 2.84 2.51 010
11442.......... ............. A Removal of skin lesion 1.87 2.68 1.95 1.22 0.92 0.13 4.68 3.95 3.22 2.92 010
11443.......... ............. A Removal of skin lesion 2.49 3.14 2.36 1.53 1.16 0.18 5.81 5.03 4.20 3.83 010
11444.......... ............. A Removal of skin lesion 3.42 3.59 2.60 1.94 1.37 0.25 7.26 6.27 5.61 5.04 010
11446.......... ............. A Removal of skin lesion 4.49 4.07 3.00 2.47 1.72 0.32 8.88 7.81 7.28 6.53 010
11450.......... ............. A Removal, sweat gland 2.73 3.94 3.43 1.08 2.00 0.24 6.91 6.40 4.05 4.97 090
lesion.
11451.......... ............. A Removal, sweat gland 3.95 4.85 4.00 1.56 2.36 0.37 9.17 8.32 5.88 6.68 090
lesion.
11462.......... ............. A Removal, sweat gland 2.51 3.89 3.26 1.01 1.82 0.23 6.63 6.00 3.75 4.56 090
lesion.
11463.......... ............. A Removal, sweat gland 3.95 5.20 3.69 1.63 1.90 0.39 9.54 8.03 5.97 6.24 090
lesion.
11470.......... ............. A Removal, sweat gland 3.25 4.41 3.72 1.30 2.16 0.31 7.97 7.28 4.86 5.72 090
lesion.
11471.......... ............. A Removal, sweat gland 4.41 5.44 4.06 1.81 2.24 0.42 10.27 8.89 6.64 7.07 090
lesion.
11600.......... ............. A Removal of skin lesion 1.41 2.53 1.88 0.96 0.79 0.09 4.03 3.38 2.46 2.29 010
11601.......... ............. A Removal of skin lesion 1.93 2.61 2.06 1.08 0.92 0.11 4.65 4.10 3.12 2.96 010
11602.......... ............. A Removal of skin lesion 2.09 2.66 2.32 1.27 1.13 0.12 4.87 4.53 3.48 3.34 010
11603.......... ............. A Removal of skin lesion 2.35 2.82 2.63 1.35 1.29 0.15 5.32 5.13 3.85 3.79 010
11604.......... ............. A Removal of skin lesion 2.58 2.99 2.90 1.43 1.42 0.18 5.75 5.66 4.19 4.18 010
11606.......... ............. A Removal of skin lesion 3.43 3.51 3.45 1.74 2.56 0.28 7.22 7.16 5.45 6.27 010
11620.......... ............. A Removal of skin lesion 1.34 2.49 1.97 0.98 0.86 0.09 3.92 3.40 2.41 2.29 010
11621.......... ............. A Removal of skin lesion 1.97 2.63 2.27 1.22 1.09 0.11 4.71 4.35 3.30 3.17 010
11622.......... ............. A Removal of skin lesion 2.34 2.79 2.59 1.43 1.32 0.14 5.27 5.07 3.91 3.80 010
11623.......... ............. A Removal of skin lesion 2.93 2.71 2.76 1.67 1.54 0.20 5.84 5.89 4.80 4.67 010
11624.......... ............. A Removal of skin lesion 3.43 3.01 3.25 1.90 1.82 0.25 6.69 6.93 5.58 5.50 010
11626.......... ............. A Removal of skin lesion 4.30 3.96 3.83 2.29 3.00 0.34 8.60 8.47 6.93 7.64 010
11640.......... ............. A Removal of skin lesion 1.53 2.56 2.18 1.13 1.02 0.10 4.19 3.81 2.76 2.65 010
11641.......... ............. A Removal of skin lesion 2.44 2.90 2.59 1.58 1.36 0.14 5.48 5.17 4.16 3.94 010
11642.......... ............. A Removal of skin lesion 2.93 2.80 2.80 1.80 1.60 0.18 5.91 5.91 4.91 4.71 010
11643.......... ............. A Removal of skin lesion 3.50 3.12 3.20 2.09 1.87 0.24 6.86 6.94 5.83 5.61 010
11644.......... ............. A Removal of skin lesion 4.55 3.72 3.77 2.60 2.26 0.32 8.59 8.64 7.47 7.13 010
11646.......... ............. A Removal of skin lesion 5.95 4.92 4.81 3.32 4.01 0.46 11.33 11.22 9.73 10.42 010
11719.......... ............. R Trim nail(s).......... 0.11 0.47 0.37 0.04 0.09 0.01 0.59 0.49 0.16 0.21 000
11720.......... ............. A Debride nail, 1-5..... 0.32 0.40 0.38 0.13 0.16 0.02 0.74 0.72 0.47 0.50 000
11721.......... ............. A Debride nail, 6 or 0.54 0.50 0.55 0.21 0.26 0.04 1.08 1.13 0.79 0.84 000
more.
11730.......... ............. A Removal of nail plate. 1.13 0.71 0.60 0.44 0.35 0.07 1.91 1.80 1.64 1.55 000
11732.......... ............. A Remove nail plate, add- 0.57 0.28 0.28 0.23 0.19 0.04 0.89 0.89 0.84 0.80 ZZZ
on.
11740.......... ............. A Drain blood from under 0.37 0.64 0.53 0.14 0.18 0.03 1.04 0.93 0.54 0.58 000
nail.
11750.......... ............. A Removal of nail bed... 1.86 1.48 1.88 0.77 0.96 0.12 3.46 3.86 2.75 2.94 010
11752.......... ............. A Remove nail bed/finger 2.67 1.82 2.44 1.61 1.57 0.20 4.69 5.31 4.48 4.44 010
tip.
11755.......... ............. A Biopsy, nail unit..... 1.31 0.96 1.02 0.57 0.82 0.08 2.35 2.41 1.96 2.21 000
11760.......... ............. A Repair of nail bed.... 1.58 1.50 1.26 1.10 0.81 0.13 3.21 2.97 2.81 2.52 010
11762.......... ............. A Reconstruction of nail 2.89 1.93 2.36 1.70 1.55 0.20 5.02 5.45 4.79 4.64 010
bed.
11765.......... ............. A Excision of nail fold, 0.69 0.93 0.74 0.42 0.35 0.05 1.67 1.48 1.16 1.09 010
toe.
11770.......... ............. A Removal of pilonidal 2.61 2.89 2.90 1.28 2.09 0.24 5.74 5.75 4.13 4.94 010
lesion.
11771.......... ............. A Removal of pilonidal 5.74 5.06 4.99 4.01 4.46 0.55 11.35 11.28 10.30 10.75 090
lesion.
11772.......... ............. A Removal of pilonidal 6.98 6.01 5.62 4.49 4.86 0.70 13.69 13.30 12.17 12.54 090
lesion.
11900.......... ............. A Injection into skin 0.52 0.70 0.49 0.21 0.18 0.02 1.24 1.03 0.75 0.72 000
lesions.
11901.......... ............. A Added skin lesions 0.80 0.83 0.64 0.36 0.29 0.03 1.66 1.47 1.19 1.12 000
injection.
11920.......... ............. R Correct skin color 1.61 1.82 1.55 0.77 1.03 0.17 3.60 3.33 2.55 2.81 000
defects.
11921.......... ............. R Correct skin color 1.93 2.01 1.77 0.98 1.25 0.20 4.14 3.90 3.11 3.38 000
defects.
11922.......... ............. R Correct skin color 0.49 0.34 0.37 0.26 0.33 0.05 0.88 0.91 0.80 0.87 ZZZ
defects.
11950.......... ............. R Therapy for contour