01-14336. Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule

AGENCY:

Health Care Financing Administration (HCFA), HHS.

ACTION:

Proposed notice.

SUMMARY:

This proposed notice discusses changes to work relative value units (RVUs) affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of the Social Security Act requires that we review RVUs no less often than every 5 years. This is the second review of work RVUs since we implemented the physician fee schedule on January 1, 1992. These work RVUs are proposed to be effective for services furnished beginning January 1, 2002.

DATES:

To be assured of consideration, we must receive comments at the appropriate address, as provided below, no later than 5 p.m. on August 7, 2001.

ADDRESSES:

Mail written comments (1 original and 3 copies) to the following address only: Health Care Financing Administration, Department of Health and Human Services, Attention: HCFA-1170-PN, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be timely received in the event of delivery delays. If you prefer, you may deliver your written comments by courier (1 original and 3 copies) to one of the following addresses:

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201,

  or

Room C5-14-03, 7500 Security Boulevard, Baltimore, MD 21244-8013

Comments mailed to the above addresses may be delayed and received too late to be considered.

Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code HCFA-1170-PN. Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document at the headquarters of the Health Care Financing Administration, 7500 Security Boulevard, Baltimore, Maryland, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. Please call [phone] to make an appointment to view the public comments.

FOR FURTHER INFORMATION CONTACT:

Jim Menas, [phone].

Rick Ensor, [phone].

Diane Milstead, [phone].

Marc Hartstein (Regulatory Impact Analysis), [phone].

Supplementary Information

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This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. The Website address is: http://www.access.gpo.gov/​nara/​index.html.

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

Table of Contents

I. Background

A. Legislative History

B. Published Changes to the Physician Fee Schedule

C. Current Proposed Notice

D. The 5-Year Review Process

II. Discussion of Comments and Decisions

A. Review of Comments

B. Discussion of Comments by Clinical Area

1. Vascular Surgery

2. General Surgery/Colon and Rectal Surgery

3. Thoracic Surgery

4. Orthopedic Surgery

5. Ophthalmology

6. Urology

7. Obstetrics/Gynecology

a. Specialty Comments

b. Other Concerns

8. Gastroenterology

9. Pulmonary Medicine/Critical Care

10. Cardiology

11. Pediatrics

12. Pediatric Surgery

13. Radiology

14. Plastic Surgery

C. Other Comments

1. Anesthesia Services

2. Spine Injection Procedures

3. Biofeedback

4. Surgical Management of Burn Wounds

5. Transplantation

6. Arthroscopy Services

7. Wheelchair Management

8. Psychological Testing

9. Podiatric Services

D. Other Issues

1. Critical Care Services in a Global Period

2. Codes Referred to CPT

3. Budget Neutrality

4. Calculation of Practice Expense and Malpractice Relative Value Units

5. Nature and Format of Comments on Work Relative Value Units

III. Collection of Information Requirements

IV. Response to Comments

V. Regulatory Impact Analysis

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

AANA Arthroscopy Association of North America

AAO American Academy of Opthalmology

AAP American Academy of Pediatrics

ABA American Burn Association

ACG American College of Gastroenterology

ACOG American College of Obstetrics and Gynecology

ACR American College of Radiology

ACS American College of Surgeons

AGA American Gastrointestinal Association

AMA American Medical Association

APMA American Podiatric Medical Association

APSA American Pediatric Surgical Association

APTA American Physical Therapy Association

ASA American Society of Anesthesiologists

ASCRS American Society of Colon and Rectal Surgeons

ASGE American Society for Gastrointestinal Endoscopy

ASPS American Society of Plastic Surgery

ASTS American Society for Transplant Surgeons

AUA American Urological Association

BBA Balanced Budget Act

CPT Current procedural terminology

CY Calendar year

ERCP Endoscopic retrograde cholangio-pancreatography

FDA Food and Drug Administration

FR Federal Register

GAF Geographic adjustment factor

GCPI Geographic practice cost index

GPO Government Printing Office

HCFA Health Care Financing Administration

HCPAC Health Care Professionals Advisory Committee

HCPCS HCFA Common Procedure Coding System

HHS Health and Human Services

IWPUT Intra-service work per unit of time

MEI Medicare economic index

MQSA Mammography Quality Standards Act of 1992

MSA Metropolitan statistical area

PE Practice expense

PEAC Practice Expense Advisory Committee

RFA Regulatory Flexibility Act

RIA Regulatory impact analysis

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

RVU Relative value unit

STS Society of Thoracic Surgeons

SVS Society for Vascular Surgery

I. Background

A. Legislative History

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

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

B. Published Changes to the Physician Fee Schedule

In the July 2000 proposed rule (65 FR 44177), we listed all of the final rules published through November 1999, relating to updates to the RVUs and revisions to the payment policies under the physician fee schedule. In the November 2000 final rule (65 FR 65376), we finalized the calendar year (CY) 2000 interim physician work RVUs and issued new interim work RVUs for new and revised codes for CY 2001. The final rule also discussed the activities underway with respect to the second 5-year refinement of work RVUs.

C. Current Proposed Notice

This proposed notice discusses changes to work RVUs affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than every 5 years. We implemented the physician fee schedule effective for services furnished beginning January 1, 1992: the first 5-year review of work was initiated in December 1994 and was effective for services furnished beginning January 1, 1997. The revisions proposed in this notice are subject to a 60-day public comment period. We will review public comments, make adjustments as appropriate, and include revised values in our physician fee schedule final rule, to be published by November 1, 2001, effective for services furnished beginning January 1, 2002.

D. The 5-Year Review Process

We initiated the second 5-year review by soliciting public comments on potentially misvalued work RVUs for all services in the 2000 physician fee schedule in our November 2, 1999 final rule (64 FR 59427). To allow sufficient time for recommendations, we provided a 120-day comment period. We included a discussion of the activities underway with respect to the second 5-year refinement of work RVUs in the July 17, 2000 proposed rule (65 FR 44201).

We received comments from approximately 30 specialty groups, organizations, and individuals involving over 900 CPT and HCPCS codes. We also received comments on the proposed process for the 5-year review. As we indicated in the November 2, 1999 final rule and in the July 17, 2000 proposed rule, we shared these comments with the AMA Specialty Society Relative Value Update Committee (RUC). The RUC was formed in November 1991 and grew out of a series of discussions between the AMA and major national medical specialty societies. The work of the RUC is supported by the RUC Advisory Committee, which is made up of representatives of 100 specialty societies in the AMA's House of Delegates.

The RUC currently makes recommendations to us on RVUs for new and revised CPT codes (hereafter referred to as codes). This process was used during the first 5-year review, and we believe that it was beneficial. We indicated that we believe the perspective of the RUC is helpful because of its experience in recommending RVUs for the codes that have been added to, or revised by, the CPT panel since we implemented the physician fee schedule in 1992. By virtue of its multispecialty membership and consultation with specialty societies, the RUC involves the medical community in formulating its recommendations. For codes used only by non-physician practitioners, the Health Care Professionals Advisory Committee (HCPAC), a companion to the RUC, has made recommendations to us.

As we stated in the first 5-year review, we retain the responsibility for analyzing the comments and recommendations, developing the proposed rule, evaluating comments on the proposed rule, and deciding whether to revise RVUs.

After we sent the RUC the comments we received on potentially misvalued services, the RUC identified specialty societies interested in making presentations concerning those misvalued services. In making presentations to the RUC, specialty societies compiled data using a standard survey instrument whereby respondents compared the surveyed service with similar “reference” services that have established, agreed upon work values. Respondents were asked to estimate the work for the survey code, the time to perform pre-, intra-, and postservice activities, and the technical skill, risk, and judgement involved with performing the service. Postservice activities were broken down into hospital and office visits and were assigned an appropriate evaluation and management code by the respondent. Each specialty society selected the physician sample that was surveyed. A minimum of 30 responses was required by the RUC for the survey to be considered valid.

For this 5-year review, the RUC permitted a specialty society to use a “minisurvey” for some codes if the number of codes a specialty was reviewing was extremely high. These minisurveys required less information from the respondent but were similar in design.

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

The results of the surveys were reviewed and organized by the specialty society and then presented to the RUC. Based on the survey results and a discussion, the RUC developed a recommendation. The RUC used six workgroups to evaluate the codes. Each workgroup evaluated a series of related codes and submitted its report to the full RUC. The RUC then evaluated those reports and sent recommendations to us. Both the workgroups and the RUC evaluated the relative work (time and intensity) for each service compared to other services on the fee schedule.

We received recommendations on work RVUs from the RUC for all of the codes we forwarded, with the exception of the anesthesia codes and conscious sedation codes.

II. Discussion of Comments and Decisions

A. Review of Comments

During the comment period for our November 2, 1999 final rule, we received approximately 35 public comments on approximately 900 codes. After review by our medical staff, we forwarded all of the comments we received concerning misvalued services to the RUC. The RUC submitted work RVU recommendations for all of the codes we forwarded with the exception of the anesthesia codes and conscious sedation codes. The RUC used six workgroups to evaluate the codes. Each workgroup evaluated a series of related codes and submitted its report to the full RUC. The RUC then evaluated those reports and sent its recommendations to us. Both the workgroups and the RUC evaluated the relative work (time and intensity) for each service compared to other services on the fee schedule.

As discussed below, we further analyzed all of the RUC recommendations; we evaluated both the recommended work RVUs and the rationale for the recommendations. If we had concerns about the application of a particular methodology, we verified that the recommended work RVUs were appropriate by using alternative methodologies.

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

• CPT/HCPCS Code. This is the CPT or alphanumeric HCPCS code for a service.
• Modifier. A modifier-26 is shown if the work RVUs represent the professional component of the service.
• Description. This is an abbreviated version of the narrative description of the code.
• 2000 Work RVUs. The work RVUs that appeared in the November 2, 1999 final rule are shown for each reviewed code.
• Requested Work RVUs. This column identifies the work RVUs requested by the commenting specialty or individual commenter. If we received more than one comment on a code, the code is listed more than once with the recommended RVUs. If the commenters did not recommend specific RVUs, we indicate this by “N/A”. A “WD” (withdrawal) indicates the commenter withdrew the request for review of a code and chose not to pursue review of the code under the 5-year review.
• RUC Recommendation. This column identifies the work RVUs recommended by the RUC. “CPT” indicates that that the RUC referred this code to the AMA CPT Editorial Panel for review and clarification and recommended maintaining the current work RVUs. An “(e)” indicates the commenting specialty withdrew the proposal; therefore, the RUC recommends maintaining the current work RVUs.
• HCPAC Recommendation. This column identifies the work RVUs recommended by the HCPAC. An “(a)” in this column indicates there was no HCPAC recommendation.
• HCFA Decision. This column indicates whether we agreed with the RUC recommendation (“agree”); we are proposing work RVUs higher than the RUC recommendation (“increase”); or we are proposing work RVUs that are less than the RUC recommendation (“decrease”). Codes for which we did not accept the RUC recommendation are discussed in greater detail following Table 1. An “(a)” in this column indicates that in the absence of a RUC recommendation we are proposing to maintain the present work RVUs. A “(b)” in this column indicates that these services were reviewed as part of the July 2000 Multispecialty Refinement Panels for new and/or revised services. (Meetings of Multispecialty Refinement Panels are conducted as needed to allow specialty representatives the opportunity to discuss the comments they submitted on our decisions on new or revised services published in the final rule. The goal of multispecialty refinement panels is to consider the interests of those who commented on the work RVUs against the redistributive effects that would occur in other specialties. Following each discussion of a specific service, panel members were instructed to individually rate the service under discussion. We then used a statistical analysis of these ratings to create final work RVUs for the services under discussion.) A “(d)” indicates there was no HCPAC recommendation. We propose maintaining current work RVUs.
• Proposed work RVUs: This column contains the 2002 proposed work RVUs.

The following is a categorization of our proposals as related to the RUC recommended work RVUs from the 5-year review of work RVUs. The RUC supplied us with recommendations on 857 services. We accepted RUC's recommended work RVUs for 792 of the services reviewed and disagreed with RUC's recommended work RVUs for 65 of the services reviewed. This is an acceptance percentage of 92 percent. Of the 65 services for which we did not accept the RUC's recommended work RVUs we increased the work RVUs for 37 services, decreased the work RVUs for 22 services, and rejected the RUC recommendation of an increase for 6 services that had already been reviewed at the Multispecialty Refinement Panel for CY 2000.

Additionally, the HCPAC reviewed a total of 12 services as part of the 5-year review. For 5 of the services reviewed, the HCPAC did not offer a recommendation. Of the remaining 7 services reviewed by the HCPAC, we have accepted the HCPAC recommendations.

—————————— ¹ All CPT codes and descriptors copyright 2000 American Medical Association

Table 1.—Five-Year Review of Work Relative Value Units

CPT/HCPCS code 1	Mod	Descriptor	2000 work RVU	Requested work RVU	RUC REC	HCPAC REC	HCFA decision	Proposed work RVU
11055		Trim skin lesion	0.27	0.43		(a)	(a)	0.27
11056		Trim skin lesion, 2 to 4	0.39	0.61		(a)	(a)	0.39
11057		Trim skin lesions, over 4	0.50	0.79		(a)	(a)	0.50
11100		Biopsy of skin lesion	0.81	WD	(e)		(a)	0.81
11402		Removal of skin lesion	1.61	2.20	1.61		agree	1.61
11642		Removal of skin lesion	2.93	3.05	2.93		agree	2.93
11642		Removal of skin lesion	2.93	3.87	2.93		agree	2.93
11719		Trim nail(s)	0.11	0.17		(a)	(a)	0.11
11730		Removal of nail plate	1.13	WD	(e)		(a)	1.13
12001		Repair superficial wound(s)	1.70	N/A	CPT		CPT	1.70
12002		Repair superficial wound(s)	1.86	N/A	CPT		CPT	1.86
12011		Repair superficial wound(s)	1.76	2.37	1.76		agree	1.76
13101		Repair of wound or lesion	3.92	5.43	3.92		agree	3.92
13131		Repair of wound or lesion	3.79	4.79	3.79		agree	3.79
13132		Repair of wound or lesion	5.95	6.95	5.95		agree	5.95
15000		Skin graft	4.00	5.95	CPT		CPT	4.00
15001		Skin graft add-on	1.00	2.50	CPT		CPT	1.00
15100		Skin split graft	9.05	9.05	CPT		CPT	9.05
15101		Skin split graft add-on	1.72	1.72	CPT		CPT	1.72
15120		Skin split graft	9.83	9.83	CPT		CPT	9.83
15121		Skin split graft add-on	2.67	2.67	CPT		CPT	2.67
15350		Skin homograft	4.00	4.00	CPT		CPT	4.00
15351		Skin homograft add-on	1.00	1.00	CPT		CPT	1.00
15400		Skin heterograft	4.00	4.00	CPT		CPT	4.00
15401		Skin heterograft add-on	1.00	1.00	CPT		CPT	1.00
17000		Destroy benign/premal lesion	0.60	WD	(e)		(a)	0.60
17003		Destroy lesions, 2-14	0.15	WD	(e)		(a)	0.15
17004		Destroy lesions, 15 or more	2.79	WD	(e)		(a)	2.79
19000		Drainage of breast lesion	0.84	1.27	0.84		agree	0.84
19100		Biopsy of breast	1.27	3.88	1.27		agree	1.27
19125		Excision, breast lesion	6.06	9.00	6.06		agree	6.06
19160		Removal of breast tissue	5.99	8.38	5.99		agree	5.99
19162		Remove breast tissue, nodes	13.53	15.68	13.53		agree	13.53
19240		Removal of breast	16.00	18.87	16.00		agree	16.00
20205		Deep muscle biopsy	2.35	3.42	CPT		CPT	2.35
20245		Bone biopsy, excisional	3.95	7.97	8.50		decrease	7.78
20600		Drain/inject, joint/bursa	0.66	WD	(e)		(a)	0.66
20605		Drain/inject, joint/bursa	0.68	WD	(e)		(a)	0.68
21740		Reconstruction of sternum	16.50	21.00	CPT		CPT	16.50
21800		Treatment of rib fracture	0.96	1.77	0.96		agree	0.96
23076		Removal of shoulder lesion	7.63	13.40	CPT		CPT	7.63
23472		Reconstruct shoulder joint	16.92	21.27	21.10		agree	21.10
23485		Revision of collar bone	13.43	18.73	13.43		agree	13.43
23585		Treat scapula fracture	8.96	11.46	8.96		agree	8.96
23615		Treat humerus fracture	9.35	15.85	9.35		agree	9.35
23630		Treat humerus fracture	7.35	12.45	7.35		agree	7.35
23680		Treat dislocation/fracture	10.06	13.10	10.06		agree	10.06
24076		Remove arm/elbow lesion	6.30	10.20	CPT		CPT	6.30
24435		Repair humerus with graft	13.17	20.36	13.17		agree	13.17
24545		Treat humerus fracture	10.46	12.26	10.46		agree	10.46
25076		Removal of forearm lesion	4.92	12.96	CPT		CPT	4.92
26562		Repair of web finger	9.68	12.56	15.00		agree	15.00
27048		Remove hip/pelvis lesion	6.25	13.01	CPT		CPT	6.25
27075		Extensive hip surgery	17.23	28.52	35.00		agree	35.00
27077		Extensive hip surgery	23.13	30.00	40.00		agree	40.00
27216		Treat pelvic ring fracture	15.19	25.00	15.19		agree	15.19
27217		Treat pelvic ring fracture	14.11	17.11	14.11		agree	14.11
27218		Treat pelvic ring fracture	20.15	22.15	20.15		agree	20.15
27226		Treat hip wall fracture	14.91	19.91	14.91		agree	14.91
27236		Treat thigh fracture	15.60	17.60	15.60		agree	15.60
27280		Fusion of sacroiliac joint	13.39	21.00	13.39		agree	13.39
27282		Fusion of pubic bones	11.34	21.66	11.34		agree	11.34
27284		Fusion of hip joint	16.76	20.12	23.45		agree	23.45
27328		Removal of thigh lesion	5.57	8.70	CPT		CPT	5.57
27472		Repair/graft of thigh	17.72	23.62	17.72		agree	17.72
27513		Treatment of thigh fracture	17.92	20.92	17.92		agree	17.92
27536		Treat knee fracture	15.65	19.00	15.65		agree	15.65
27590		Amputate leg at thigh	12.03	15.52	12.03		agree	12.03
27619		Remove lower leg lesion	8.40	10.02	CPT		CPT	8.40
27724		Repair/graft of tibia	14.99	19.34	18.20		agree	18.20
27822		Treatment of ankle fracture	9.20	10.68	11.00		agree	11.00
27823		Treatment of ankle fracture	11.80	13.27	13.00		agree	13.00
27828		Treat lower leg fracture	16.23	19.00	16.23		agree	16.23
28299		Correction of bunion	8.88	11.90	9.18		agree	9.18
28322		Repair of metatarsals	8.34	13.26	8.34		agree	8.34
28420		Treat/graft heel fracture	16.64	23.52	16.64		agree	16.64
28445		Treat ankle fracture	9.33	15.97	15.62		agree	15.62
28705		Fusion of foot bones	15.21	20.46	18.80		agree	18.80
29450		Application of leg cast	1.02	3.00	2.08		agree	2.08
29450		Application of leg cast	1.02	N/A	2.08		agree	2.08
29881		Knee arthroscopy/surgery	7.76	WD	(e)		(a)	7.76
29883		Knee arthroscopy/surgery	9.46	12.00	11.05		agree	11.05
29889		Knee arthroscopy/surgery	15.13	16.68	16.00		agree	16.00
29889		Knee arthroscopy/surgery	15.13	18.47	16.00		agree	16.00
31600		Incision of windpipe	3.62	6.42	7.18		agree	7.18
31622		Dx bronchoscope/wash	2.78	4.17	2.78		agree	2.78
31622		Dx bronchoscope/wash	2.78	N/A	2.78		agree	2.78
31625		Bronchoscopy with biopsy	3.37	N/A	3.37		agree	3.37
31645		Bronchoscopy, clear airways	3.16	N/A	3.16		agree	3.16
32000		Drainage of chest	1.54	2.88	1.54		agree	1.54
32000		Drainage of chest	1.54	N/A	1.54		agree	1.54
32005		Treat lung lining chemically	2.19	N/A	2.19		agree	2.19
32020		Insertion of chest tube	3.98	N/A	3.98		agree	3.98
32035		Exploration of chest	8.67	N/A	8.67		agree	8.67
32095		Biopsy through chest wall	8.36	N/A	8.36		agree	8.36
32100		Exploration/biopsy of chest	11.84	N/A	15.24		agree	15.24
32110		Explore/repair chest	13.62	N/A	23.00		agree	23.00
32220		Release of lung	19.27	N/A	24.00		agree	24.00
32225		Partial release of lung	13.96	N/A	13.96		agree	13.96
32320		Free/remove chest lining	20.54	N/A	24.00		agree	24.00
32440		Removal of lung	21.02	35.08	25.00		agree	25.00
32440		Removal of lung	21.02	N/A	25.00		agree	25.00
32480		Partial removal of lung	18.32	27.17	23.75		agree	23.75
32480		Partial removal of lung	18.32	N/A	23.75		agree	23.75
32482		Bilobectomy	19.71	N/A	25.00		agree	25.00
32491		Lung volume reduction	21.25	N/A	21.25		agree	21.25
32500		Partial removal of lung	14.30	N/A	22.00		agree	22.00
32520		Remove lung & revise chest	21.68	N/A	21.68		agree	21.68
32602		Thoracoscopy, diagnostic	5.96	N/A	5.96		agree	5.96
32651		Thoracoscopy, surgical	12.91	N/A	12.91		agree	12.91
32652		Thoracoscopy, surgical	18.66	N/A	18.66		agree	18.66
32655		Thoracoscopy, surgical	13.10	N/A	13.10		agree	13.10
32657		Thoracoscopy, surgical	13.65	N/A	13.65		agree	13.65
33207		Insertion of heart pacemaker	8.04	WD	(e)		(a)	8.04
33234		Removal of pacemaker system	7.82	N/A	7.82		agree	7.82
33235		Removal of pacemaker electrode	9.40	N/A	9.40		agree	9.40
33400		Repair of aortic valve	25.34	N/A	28.50		agree	28.50
33405		Replacement of aortic valve	30.61	N/A	35.00		agree	35.00
33406		Replacement of aortic valve	32.30	N/A	37.50		agree	37.50
33410		Replacement of aortic valve	32.46	N/A	32.46		agree	32.46
33411		Replacement of aortic valve	32.47	N/A	36.25		agree	36.25
33412		Replacement of aortic valve	34.79	N/A	42.00		agree	42.00
33413		Replacement of aortic valve	35.24	N/A	43.50		agree	43.50
33415		Revision, subvalvular tissue	27.15	N/A	27.15		agree	27.15
33425		Repair of mitral valve	27.00	N/A	27.00		agree	27.00
33426		Repair of mitral valve	31.03	N/A	33.00		agree	33.00
33427		Repair of mitral valve	33.72	N/A	40.00		agree	40.00
33430		Replacement of mitral valve	31.43	N/A	33.50		agree	33.50
33468		Revision of tricuspid valve	30.12	N/A	30.12		agree	30.12
33475		Replacement, pulmonary valve	28.41	N/A	33.00		agree	33.00
33506		Repair artery, translocation	26.71	N/A	35.50		agree	35.50
33510		CABG, vein, single	25.12	N/A	29.00		agree	29.00
33511		CABG, vein, two	27.40	N/A	30.00		agree	30.00
33512		CABG, vein, three	29.67	N/A	31.80		agree	31.80
33513		CABG, vein, four	31.95	N/A	32.00		agree	32.00
33514		CABG, vein, five	35.00	N/A	32.75		agree	32.75
33516		Cabg, vein, six or more	37.40	N/A	35.00		agree	35.00
33517		CABG, artery-vein, single	2.57	N/A	2.57		agree	2.57
33518		CABG, artery-vein, two	4.85	N/A	4.85		agree	4.85
33519		CABG, artery-vein, three	7.12	N/A	7.12		agree	7.12
33521		CABG, artery-vein, four	9.40	N/A	9.40		agree	9.40
33522		CABG, artery-vein, five	11.67	N/A	11.67		agree	11.67
33523		Cabg, art-vein, six or more	13.95	N/A	13.95		agree	13.95
33530		Coronary artery, bypass/reop	5.86	N/A	5.86		agree	5.86
33533		CABG, arterial, single	25.83	N/A	30.00		agree	30.00
33534		CABG, arterial, two	28.82	N/A	32.20		agree	32.20
33535		CABG, arterial, three	31.81	N/A	34.50		agree	34.50
33536		Cabg, arterial, four or more	34.79	N/A	37.50		agree	37.50
33611		Repair double ventricle	32.30	N/A	34.00		agree	34.00
33612		Repair double ventricle	33.26	N/A	35.00		agree	35.00
33615		Repair, simple fontan	32.06	N/A	34.00		agree	34.00
33617		Repair, modified fontan	34.03	N/A	37.00		agree	37.00
33619		Repair single ventricle	37.57	N/A	45.00		agree	45.00
33641		Repair heart septum defect	21.39	N/A	21.39		agree	21.39
33660		Repair of heart defects	25.54	N/A	30.00		agree	30.00
33670		Repair of heart chambers	32.73	N/A	35.00		agree	35.00
33681		Repair heart septum defect	27.67	N/A	30.61		agree	30.61
33694		Repair of heart defects	31.73	N/A	34.00		agree	34.00
33697		Repair of heart defects	33.71	N/A	36.00		agree	36.00
33730		Repair heart-vein defect(s)	31.67	N/A	34.25		agree	34.25
33750		Major vessel shunt	21.41	N/A	21.41		agree	21.41
33767		Major vessel shunt	24.50	N/A	24.50		agree	24.50
33770		Repair great vessels defect	33.29	N/A	37.00		agree	37.00
33778		Repair great vessels defect	35.82	N/A	40.00		agree	40.00
33780		Repair great vessels defect	36.94	N/A	41.75		agree	41.75
33786		Repair arterial trunk	34.84	N/A	39.00		agree	39.00
33820		Revise major vessel	16.29	N/A	16.29		agree	16.29
33840		Remove aorta constriction	20.63	N/A	20.63		agree	20.63
33860		Ascending aortic graft	33.96	N/A	38.00		agree	38.00
33861		Ascending aortic graft	34.52	N/A	42.00		agree	42.00
33863		Ascending aortic graft	36.47	N/A	45.00		agree	45.00
33870		Transverse aortic arch graft	40.31	N/A	44.00		agree	44.00
33875		Thoracic aortic graft	33.06	N/A	CPT		CPT	33.06
33877		Thoracoabdominal graft	42.60	N/A	CPT		CPT	42.60
33917		Repair pulmonary artery	24.50	N/A	24.50		agree	24.50
33919		Repair pulmonary atresia	32.67	N/A	40.00		agree	40.00
33945		Transplantation of heart	42.10	N/A	42.10		agree	42.10
34001		Removal of artery clot	12.91	WD	(e)		(a)	12.91
34101		Removal of artery clot	9.97	N/A	10.00		agree	10.00
34111		Removal of arm artery clot	8.07	N/A	10.00		agree	10.00
34151		Removal of artery clot	16.86	27.51	25.00		agree	25.00
34151		Removal of artery clot	16.86	28.00	25.00		agree	25.00
34201		Removal of artery clot	9.13	10.40	10.03		agree	10.03
34201		Removal of artery clot	9.13	10.58	10.03		agree	10.03
34203		Removal of leg artery clot	12.21	14.99	16.50		agree	16.50
34203		Removal of leg artery clot	12.21	16.50	16.50		agree	16.50
34401		Removal of vein clot	12.86	26.63	25.00		agree	25.00
34401		Removal of vein clot	12.86	28.00	25.00		agree	25.00
34421		Removal of vein clot	9.93	15.75	12.00		agree	12.00
34421		Removal of vein clot	9.93	15.94	12.00		agree	12.00
34451		Removal of vein clot	14.44	29.05	27.00		agree	27.00
34451		Removal of vein clot	14.44	30.00	27.00		agree	27.00
34490		Removal of vein clot	7.60	N/A	9.86		agree	9.86
34501		Repair valve, femoral vein	10.93	N/A	16.00		agree	16.00
34510		Transposition of vein valve	13.25	N/A	18.95		agree	18.95
34520		Cross-over vein graft	13.74	N/A	17.95		agree	17.95
34530		Leg vein fusion	17.61	N/A	16.64		agree	16.64
35011		Repair defect of artery	11.65	14.10	18.00		agree	18.00
35011		Repair defect of artery	11.65	18.00	18.00		agree	18.00
35013		Repair artery rupture, arm	17.40	15.38	22.00		agree	22.00
35013		Repair artery rupture, arm	17.40	20.00	22.00		agree	22.00
35045		Repair defect of arm artery	11.26	11.05	17.57		agree	17.57
35045		Repair defect of arm artery	11.26	16.50	17.57		agree	17.57
35081		Repair defect of artery	28.01	33.13	28.01		agree	28.01
35082		Repair artery rupture, aorta	36.35	37.00	38.50		agree	38.50
35082		Repair artery rupture, aorta	36.35	41.80	38.50		agree	38.50
35092		Repair artery rupture, aorta	38.39	50.00	45.00		agree	45.00
35092		Repair artery rupture, aorta	38.39	58.61	45.00		agree	45.00
35103		Repair artery rupture, groin	33.57	41.00	40.50		agree	40.50
35103		Repair artery rupture, groin	33.57	44.12	40.50		agree	40.50
35111		Repair defect of artery	16.43	23.24	25.00		agree	25.00
35111		Repair defect of artery	16.43	28.00	25.00		agree	25.00
35112		Repair artery rupture,spleen	18.69	29.20	30.00		agree	30.00
35112		Repair artery rupture,spleen	18.69	30.00	30.00		agree	30.00
35121		Repair defect of artery	25.99	30.29	30.00		agree	30.00
35121		Repair defect of artery	25.99	32.00	30.00		agree	30.00
35122		Repair artery rupture, belly	33.45	36.83	35.00		agree	35.00
35122		Repair artery rupture, belly	33.45	37.00	35.00		agree	35.00
35131		Repair defect of artery	18.55	23.15	25.00		agree	25.00
35131		Repair defect of artery	18.55	28.00	25.00		agree	25.00
35132		Repair artery rupture, groin	21.95	30.00	30.00		agree	30.00
35132		Repair artery rupture, groin	21.95	30.54	30.00		agree	30.00
35141		Repair defect of artery	14.46	19.38	20.00		agree	20.00
35141		Repair defect of artery	14.46	20.00	20.00		agree	20.00
35142		Repair artery rupture, thigh	15.86	23.36	23.30		agree	23.30
35142		Repair artery rupture, thigh	15.86	25.00	23.30		agree	23.30
35151		Repair defect of artery	17.00	20.26	22.64		agree	22.64
35151		Repair defect of artery	17.00	22.00	22.64		agree	22.64
35152		Repair artery rupture, knee	16.70	24.98	25.62		agree	25.62
35152		Repair artery rupture, knee	16.70	27.50	25.62		agree	25.62
35182		Repair blood vessel lesion	17.74	N/A	30.00		agree	30.00
35184		Repair blood vessel lesion	12.25	N/A	18.00		agree	18.00
35189		Repair blood vessel lesion	18.43	N/A	28.00		agree	28.00
35190		Repair blood vessel lesion	12.75	N/A	12.75		agree	12.75
35201		Repair blood vessel lesion	9.99	12.74	16.14		agree	16.14
35201		Repair blood vessel lesion	9.99	18.35	16.14		agree	16.14
35206		Repair blood vessel lesion	9.25	N/A	13.25		agree	13.25
35221		Repair blood vessel lesion	16.42	26.00	24.39		agree	24.39
35221		Repair blood vessel lesion	16.42	28.95	24.39		agree	24.39
35226		Repair blood vessel lesion	9.06	14.00	14.50		agree	14.50
35226		Repair blood vessel lesion	9.06	15.82	14.50		agree	14.50
35231		Repair blood vessel lesion	12.00	15.64	20.00		agree	20.00
35231		Repair blood vessel lesion	12.00	18.90	20.00		agree	20.00
35236		Repair blood vessel lesion	10.54	12.85	17.11		agree	17.11
35236		Repair blood vessel lesion	10.54	18.00	17.11		agree	17.11
35246		Repair blood vessel lesion	19.84	26.00	26.45		agree	26.45
35246		Repair blood vessel lesion	19.84	N/A	26.45		agree	26.45
35251		Repair blood vessel lesion	17.49	31.00	30.20		agree	30.20
35251		Repair blood vessel lesion	17.49	34.04	30.20		agree	30.20
35256		Repair blood vessel lesion	11.38	N/A	18.36		agree	18.36
35261		Repair blood vessel lesion	11.63	15.51	17.80		agree	17.80
35261		Repair blood vessel lesion	11.63	18.90	17.80		agree	17.80
35266		Repair blood vessel lesion	10.30	15.79	14.91		agree	14.91
35266		Repair blood vessel lesion	10.30	17.00	14.91		agree	14.91
35276		Repair blood vessel lesion	18.75	22.00	24.25		agree	24.25
35276		Repair blood vessel lesion	18.75	N/A	24.25		agree	24.25
35281		Repair blood vessel lesion	16.48	29.00	28.00		agree	28.00
35281		Repair blood vessel lesion	16.48	32.01	28.00		agree	28.00
35286		Repair blood vessel lesion	11.87	N/A	16.16		agree	16.16
35311		Rechanneling of artery	23.85	30.00	27.00		agree	27.00
35311		Rechanneling of artery	23.85	N/A	27.00		agree	27.00
35321		Rechanneling of artery	11.97	16.47	16.00		agree	16.00
35321		Rechanneling of artery	11.97	18.35	16.00		agree	16.00
35331		Rechanneling of artery	23.52	24.81	26.20		agree	26.20
35331		Rechanneling of artery	23.52	28.01	26.20		agree	26.20
35351		Rechanneling of artery	20.11	24.09	23.00		agree	23.00
35351		Rechanneling of artery	20.11	25.50	23.00		agree	23.00
35355		Rechanneling of artery	16.09	20.01	18.50		agree	18.50
35355		Rechanneling of artery	16.09	20.75	18.50		agree	18.50
35361		Rechanneling of artery	23.59	29.08	28.20		agree	28.20
35361		Rechanneling of artery	23.59	30.00	28.20		agree	28.20
35363		Rechanneling of artery	24.66	32.00	30.20		agree	30.20
35363		Rechanneling of artery	24.66	35.67	30.20		agree	30.20
35371		Rechanneling of artery	11.64	12.97	14.72		agree	14.72
35371		Rechanneling of artery	11.64	17.75	14.72		agree	14.72
35372		Rechanneling of artery	13.56	18.04	18.00		agree	18.00
35372		Rechanneling of artery	13.56	19.53	18.00		agree	18.00
35381		Rechanneling of artery	15.81	N/A	CPT		CPT	15.81
35511		Artery bypass graft	16.83	19.75	21.20		agree	21.20
35511		Artery bypass graft	16.83	21.50	21.20		agree	21.20
35518		Artery bypass graft	15.42	18.59	21.20		agree	21.20
35518		Artery bypass graft	15.42	23.00	21.20		agree	21.20
35521		Artery bypass graft	16.17	20.46	22.20		agree	22.20
35521		Artery bypass graft	16.17	25.25	22.20		agree	22.20
35526		Artery bypass graft	20.00	30.00	29.95		agree	29.95
35526		Artery bypass graft	20.00	N/A	29.95		agree	29.95
35531		Artery bypass graft	25.61	33.62	36.20		agree	36.20
35531		Artery bypass graft	25.61	38.00	36.20		agree	36.20
35533		Artery bypass graft	20.52	28.00	28.00		agree	28.00
35533		Artery bypass graft	20.52	29.99	28.00		agree	28.00
35536		Artery bypass graft	23.11	25.33	31.70		agree	31.70
35536		Artery bypass graft	23.11	33.00	31.70		agree	31.70
35541		Artery bypass graft	25.80	N/A	CPT		CPT	25.80
35546		Artery bypass graft	25.54	N/A	CPT		CPT	25.54
35551		Artery bypass graft	26.67	N/A	CPT		CPT	26.67
35556		Artery bypass graft	21.76	24.50	21.76		agree	21.76
35556		Artery bypass graft	21.76	24.50	21.76		agree	21.76
35558		Artery bypass graft	14.04	22.00	21.20		agree	21.20
35558		Artery bypass graft	14.04	22.08	21.20		agree	21.20
35560		Artery bypass graft	23.56	28.19	32.00		agree	32.00
35560		Artery bypass graft	23.56	35.50	32.00		agree	32.00
35563		Artery bypass graft	15.14	24.00	24.20		agree	24.20
35563		Artery bypass graft	15.14	25.00	24.20		agree	24.20
35565		Artery bypass graft	15.14	23.65	23.20		agree	23.20
35565		Artery bypass graft	15.14	24.00	23.20		agree	23.20
35571		Artery bypass graft	18.58	23.65	24.06		agree	24.06
35571		Artery bypass graft	18.58	26.92	24.06		agree	24.06
35582		Vein bypass graft	27.13	N/A	CPT		CPT	27.13
35587		Vein bypass graft	19.05	24.47	24.75		agree	24.75
35587		Vein bypass graft	19.05	27.00	24.75		agree	24.75
35621		Artery bypass graft	14.54	16.53	20.00		agree	20.00
35621		Artery bypass graft	14.54	21.50	20.00		agree	20.00
35623		Bypass graft, not vein	16.62	17.62	24.00		agree	24.00
35623		Bypass graft, not vein	16.62	25.75	24.00		agree	24.00
35626		Artery bypass graft	23.63	27.58	27.75		agree	27.75
35626		Artery bypass graft	23.63	30.00	27.75		agree	27.75
35631		Artery bypass graft	24.60	32.51	34.00		agree	34.00
35631		Artery bypass graft	24.60	36.00	34.00		agree	34.00
35636		Artery bypass graft	22.46	27.32	29.50		agree	29.50
35636		Artery bypass graft	22.46	36.00	29.50		agree	29.50
35641		Artery bypass graft	24.57	N/A	CPT		CPT	24.57
35646		Artery bypass graft	25.81	N/A	CPT		CPT	25.81
35650		Artery bypass graft	14.36	15.74	19.00		agree	19.00
35650		Artery bypass graft	14.36	19.80	19.00		agree	19.00
35654		Artery bypass graft	18.61	23.54	25.00		agree	25.00
35654		Artery bypass graft	18.61	26.00	25.00		agree	25.00
35661		Artery bypass graft	13.18	17.89	19.00		agree	19.00
35661		Artery bypass graft	13.18	19.53	19.00		agree	19.00
35663		Artery bypass graft	14.17	20.90	22.00		agree	22.00
35663		Artery bypass graft	14.17	23.00	22.00		agree	22.00
35665		Artery bypass graft	15.40	19.84	21.00		agree	21.00
35665		Artery bypass graft	15.40	22.00	21.00		agree	21.00
35666		Artery bypass graft	19.19	20.00	22.19		agree	22.19
35666		Artery bypass graft	19.19	22.00	22.19		agree	22.19
35671		Artery bypass graft	14.80	17.80	19.33		agree	19.33
35671		Artery bypass graft	14.80	24.00	19.33		agree	19.33
35701		Exploration, carotid artery	5.55	9.38	8.50		agree	8.50
35701		Exploration, carotid artery	5.55	15.00	8.50		agree	8.50
35721		Exploration, femoral artery	5.28	N/A	7.18		agree	7.18
35741		Exploration popliteal artery	5.37	N/A	8.00		agree	8.00
35840		Explore abdominal vessels	9.77	N/A	CPT		CPT	9.77
35860		Explore limb vessels	5.55	N/A	CPT		CPT	5.55
35905		Excision, graft, thorax	18.19	32.00	31.25		agree	31.25
35905		Excision, graft, thorax	18.19	N/A	31.25		agree	31.25
35907		Excision, graft, abdomen	19.24	37.33	35.00		agree	35.00
35907		Excision, graft, abdomen	19.24	40.00	35.00		agree	35.00
36400		Drawing blood	0.18	N/A	0.38		decrease	0.18
36405		Drawing blood	0.18	N/A	0.32		decrease	0.18
36406		Drawing blood	0.18	N/A	CPT		CPT	0.18
36489		Insertion of catheter, vein	1.22	2.75	2.50		agree	2.50
36489		Insertion of catheter, vein	1.22	3.41	2.50		agree	2.50
36520		Plasma and/or cell exchange	1.74	N/A	CPT		CPT	1.74
36533		Insertion of access device	5.32	5.28	CPT		CPT	5.32
36534		Revision of access device	2.80	5.15	CPT		CPT	2.80
36535		Removal of access device	2.27	3.89	CPT		CPT	2.27
36600		Withdrawal of arterial blood	0.32	WD	(e)		(a)	0.32
36620		Insertion catheter, artery	1.15	2.25	CPT		CPT	1.15
36625		Insertion catheter, artery	2.11	2.65	2.11		agree	2.11
36822		Insertion of cannula(s)	5.42	19.00	5.42		agree	5.42
37565		Ligation of neck vein	4.44	9.01	10.88		agree	10.88
37565		Ligation of neck vein	4.44	14.50	10.88		agree	10.88
37600		Ligation of neck artery	4.57	9.19	11.25		agree	11.25
37600		Ligation of neck artery	4.57	14.00	11.25		agree	11.25
37605		Ligation of neck artery	6.19	11.85	13.11		agree	13.11
37605		Ligation of neck artery	6.19	17.50	13.11		agree	13.11
37609		Temporal artery procedure	2.30	3.38	3.00		agree	3.00
37609		Temporal artery procedure	2.30	N/A	3.00		agree	3.00
37615		Ligation of neck artery	5.73	12.31	CPT		CPT	5.73
37615		Ligation of neck artery	5.73	18.00	CPT		CPT	5.73
37617		Ligation of abdomen artery	15.95	N/A	22.06		agree	22.06
37618		Ligation of extremity artery	4.84	N/A	CPT		CPT	4.84
37650		Revision of major vein	5.13	N/A	7.80		agree	7.80
37660		Revision of major vein	10.61	N/A	21.00		agree	21.00
37700		Revise leg vein	3.73	N/A	CPT		CPT	3.73
37720		Removal of leg vein	5.66	10.71	CPT		CPT	5.66
37730		Removal of leg veins	7.33	N/A	CPT		CPT	7.33
37735		Removal of leg veins/lesion	10.53	N/A	CPT		CPT	10.53
37760		Revision of leg veins	10.47	N/A	CPT		CPT	10.47
37785		Revision secondary varicosity	3.84	N/A	CPT		CPT	3.84
38100		Removal of spleen, total	13.01	14.70	14.50		agree	14.50
38100		Removal of spleen, total	13.01	16.21	14.50		agree	14.50
38101		Removal of spleen, partial	13.74	14.79	15.31		agree	15.31
38115		Repair of ruptured spleen	14.19	15.55	15.82		agree	15.82
38300		Drainage, lymph node lesion	1.53	1.01	1.99		agree	1.99
38305		Drainage, lymph node lesion	4.61	6.59	6.00		agree	6.00
38308		Incision of lymph channels	4.95	7.35	6.45		agree	6.45
38500		Biopsy/removal, lymph nodes	2.88	3.29	3.75		agree	3.75
38500		Biopsy/removal, lymph nodes	2.88	4.58	3.75		agree	3.75
38510		Biopsy/removal, lymph nodes	4.14	6.28	6.43		agree	6.43
38520		Biopsy/removal, lymph nodes	5.12	6.93	6.67		agree	6.67
38525		Biopsy/removal, lymph nodes	4.66	5.30	6.07		agree	6.07
38530		Biopsy/removal, lymph nodes	6.13	9.58	7.98		agree	7.98
38571		Laparoscopy, lymphadenectomy	12.38	19.84	12.38		agree	12.38
38572		Laparoscopy, lymphadenectomy	14.32	23.17	16.59		agree	16.59
38740		Remove armpit lymph nodes	6.77	10.68	8.42		increase	10.02
38745		Remove armpit lymph nodes	8.84	12.78	11.00		increase	13.00
38746		Remove thoracic lymph nodes	4.39	N/A	4.89		agree	4.89
38760		Remove groin lymph nodes	8.74	11.35	10.88		increase	12.94
38765		Remove groin lymph nodes	16.06	18.77	19.98		agree	19.98
38780		Remove abdomen lymph nodes	16.59	N/A	16.59		agree	16.59
39010		Exploration of chest	11.79	N/A	11.79		agree	11.79
39220		Removal chest lesion	17.42	N/A	17.42		agree	17.42
39400		Visualization of chest	5.61	N/A	5.61		agree	5.61
39503		Repair of diaphragm hernia	34.85	122.75	95.00		decrease	34.85
42205		Reconstruct cleft palate	9.59	12.00	13.29		agree	13.29
43107		Removal of esophagus	28.79	N/A	40.00		agree	40.00
43112		Removal of esophagus	31.22	N/A	43.50		agree	43.50
43117		Partial removal of esophagus	30.02	N/A	40.00		agree	40.00
43122		Parital removal of esophagus	29.11	N/A	40.00		agree	40.00
43215		Esophagus endoscopy	2.60	4.91	CPT		CPT	2.60
43217		Esophagus endoscopy	2.90	3.63	2.90		agree	2.90
43219		Esophagus endoscopy	2.80	3.50	3.18		decrease	2.80
43228		Esoph endoscopy, ablation	3.77	4.72	3.77		agree	3.77
43239		Upper GI endoscopy, biopsy	2.69	2.96	2.87		decrease	2.69
43239		Upper GI endoscopy, biopsy	2.69	3.79	2.87		decrease	2.69
43244		Upper GI endoscopy/ligation	4.59	5.05	5.05		decrease	4.59
43246		Place gastrostomy tube	4.33	4.76	4.33		agree	4.33
43246		Place gastrostomy tube	4.33	5.04	4.33		agree	4.33
43247		Operative upper GI endoscopy	3.39	4.51	3.59		decrease	3.39
43249		Esoph endoscopy, dilation	2.90	5.01	3.35		decrease	2.90
43251		Operative upper GI endoscopy	3.70	4.44	3.70		agree	3.70
43255		Operative upper GI endoscopy	4.40	5.40	4.82		decrease	4.40
43258		Operative upper GI endoscopy	4.55	5.01	4.55		agree	4.55
43259		Endoscopic ultrasound exam	4.89	N/A	8.59		decrease	4.89
43263		Endo cholangiopancreatograph	6.19	7.12	7.29		decrease	6.19
43265		Endo cholangiopancreatograph	8.90	N/A	10.02		decrease	8.90
43269		Endo cholangiopancreatograph	6.04	7.50	8.21		decrease	6.04
43305		Repair esophagus and fistula	17.15	WD	(e)		(a)	17.15
43310		Repair of esophagus	25.39	50.50	CPT		CPT	25.39
43312		Repair esophagus and fistula	28.42	56.75	CPT		CPT	28.42
43320		Fuse esophagus & stomach	16.07	26.45	19.93		agree	19.93
43324		Revise esophagus & stomach	16.58	17.75	20.57		agree	20.57
43325		Revise esophagus & stomach	16.17	21.65	20.06		agree	20.06
43326		Revise esophagus & stomach	15.91	20.53	19.74		agree	19.74
43330		Repair of esophagus	15.94	15.44	19.77		agree	19.77
43331		Repair of esophagus	16.23	17.60	20.13		agree	20.13
43340		Fuse esophagus & intestine	15.81	26.72	19.61		agree	19.61
43341		Fuse esophagus & intestine	16.81	29.07	20.85		agree	20.85
43350		Surgical opening, esophagus	12.72	32.97	15.78		agree	15.78
43351		Surgical opening, esophagus	14.79	31.92	18.35		agree	18.35
43352		Surgical opening, esophagus	12.30	25.47	15.26		agree	15.26
43360		Gastrointestinal repair	28.78	61.17	35.70		agree	35.70
43361		Gastrointestinal repair	32.65	65.83	40.50		agree	40.50
43400		Ligate esophagus veins	17.09	29.96	21.20		agree	21.20
43401		Esophagus surgery for veins	17.81	34.94	22.09		agree	22.09
43405		Ligate/staple esophagus	16.13	36.67	20.01		agree	20.01
43410		Repair esophagus wound	10.86	13.65	13.47		agree	13.47
43415		Repair esophagus wound	17.06	30.45	25.00		agree	25.00
43420		Repair esophagus opening	11.57	14.10	14.35		agree	14.35
43425		Repair esophagus opening	16.95	26.93	21.03		agree	21.03
43500		Surgical opening of stomach	8.44	11.81	11.05		agree	11.05
43501		Surgical repair of stomach	15.31	20.44	20.04		agree	20.04
43502		Surgical repair of stomach	17.67	21.20	23.13		agree	23.13
43510		Surgical opening of stomach	9.99	18.81	13.08		agree	13.08
43520		Incision of pyloric muscle	7.63	8.88	9.99		agree	9.99
43605		Biopsy of stomach	9.15	10.41	11.98		agree	11.98
43610		Excision of stomach lesion	11.15	17.37	14.60		agree	14.60
43611		Excision of stomach lesion	13.63	23.82	17.84		agree	17.84
43620		Removal of stomach	22.54	33.61	30.04		agree	30.04
43621		Removal of stomach	23.06	35.55	30.73		agree	30.73
43622		Removal of stomach	24.41	35.56	32.53		agree	32.53
43631		Removal of stomach, partial	19.66	23.28	22.59		agree	22.59
43632		Removal of stomach, partial	19.66	25.92	22.59		agree	22.59
43633		Removal of stomach, partial	20.10	27.68	23.10		agree	23.10
43634		Removal of stomach, partial	21.86	34.19	25.12		agree	25.12
43638		Removal of stomach, partial	21.76	29.96	29.00		agree	29.00
43638		Removal of stomach, partial	21.76	39.80	29.00		agree	29.00
43639		Removal of stomach, partial	22.25	39.80	29.65		agree	29.65
43640		Vagotomy & pylorus repair	14.81	17.32	17.02		agree	17.02
43641		Vagotomy & pylorus repair	15.03	21.34	17.27		agree	17.27
43651		Laparoscopy, vagus nerve	10.15	15.17	10.15		agree	10.15
43652		Laparoscopy, vagus nerve	12.15	19.21	12.15		agree	12.15
43800		Reconstruction of pylorus	10.46	11.86	13.69		agree	13.69
43810		Fusion of stomach and bowel	11.19	13.81	14.65		agree	14.65
43820		Fusion of stomach and bowel	11.74	15.78	15.37		agree	15.37
43825		Fusion of stomach and bowel	14.68	18.16	19.22		agree	19.22
43830		Place gastrostomy tube	7.28	7.28	9.53		agree	9.53
43832		Place gastrostomy tube	11.92	11.92	15.60		agree	15.60
43840		Repair of stomach lesion	11.89	11.89	15.56		agree	15.56
43842		Gastroplasty for obesity	14.71	17.14	18.47		agree	18.47
43843		Gastroplasty for obesity	14.85	20.62	18.65		agree	18.65
43846		Gastric bypass for obesity	19.15	23.43	24.05		agree	24.05
43847		Gastric bypass for obesity	21.44	29.95	26.92		agree	26.92
43848		Revision gastroplasty	23.41	27.07	29.39		agree	29.39
43850		Revise stomach-bowel fusion	19.69	23.27	24.72		agree	24.72
43855		Revise stomach-bowel fusion	20.83	24.15	26.16		agree	26.16
43860		Revise stomach-bowel fusion	19.91	26.08	25.00		agree	25.00
43865		Revise stomach-bowel fusion	21.12	27.30	26.52		agree	26.52
43870		Repair stomach opening	7.40	9.65	9.69		agree	9.69
43880		Repair stomach-bowel fistula	19.63	23.60	24.65		agree	24.65
44005		Freeing of bowel adhesion	13.84	15.43	16.23		agree	16.23
44010		Incision of small bowel	10.68	15.90	12.52		agree	12.52
44020		Exploration of small bowel	11.93	15.04	13.99		agree	13.99
44021		Decompress small bowel	12.01	15.18	14.08		agree	14.08
44025		Incision of large bowel	12.18	14.08	14.28		agree	14.28
44050		Reduce bowel obstruction	11.40	13.75	14.03		agree	14.03
44050		Reduce bowel obstruction	11.40	14.58	14.03		agree	14.03
44055		Correct malrotation of bowel	13.14	22.00	22.00		agree	22.00
44110		Excision of bowel lesion(s)	10.07	14.39	11.81		agree	11.81
44111		Excision of bowel lesion(s)	12.19	16.32	14.29		agree	14.29
44120		Removal of small intestine	14.50	15.82	17.00		agree	17.00
44125		Removal of small intestine	14.96	17.54	17.54		agree	17.54
44130		Bowel to bowel fusion	12.36	17.87	14.49		agree	14.49
44130		Bowel to bowel fusion	12.36	N/A	14.49		agree	14.49
44140		Partial removal of colon	18.35	20.94	18.35		increase	21.00
44140		Partial removal of colon	18.35	24.58	18.35		increase	21.00
44143		Partial removal of colon	20.17	30.36	20.17		increase	22.99
44144		Partial removal of colon	18.89	29.46	18.89		increase	21.53
44144		Partial removal of colon	18.89	N/A	18.89		increase	21.53
44145		Partial removal of colon	23.18	27.91	23.18		increase	26.42
44146		Partial removal of colon	24.16	30.97	24.16		increase	27.54
44147		Partial removal of colon	18.17	N/A	18.17		increase	20.71
44150		Removal of colon	21.01	27.41	21.01		increase	23.95
44151		Removal of colon/ileostomy	20.04	32.89	20.04		increase	26.88
44151		Removal of colon/ileostomy	20.04	N/A	20.04		increase	26.88
44152		Removal of colon/ileostomy	24.41	33.61	24.41		increase	27.83
44153		Removal of colon/ileostomy	26.83	33.11	26.83		increase	30.59
44155		Removal of colon/ileostomy	24.44	33.61	24.44		increase	27.86
44156		Removal of colon/ileostomy	23.01	36.27	23.01		increase	30.79
44156		Removal of colon/ileostomy	23.01	N/A	23.01		increase	30.79
44160		Removal of colon	15.88	17.45	18.62		agree	18.62
44200		Laparoscopy, enterolysis	14.44	16.11	14.44		agree	14.44
44300		Open bowel to skin	8.88	13.09	12.11		agree	12.11
44310		Ileostomy/jejunostomy	11.70	18.14	15.95		agree	15.95
44312		Revision of ileostomy	5.88	6.79	8.02		agree	8.02
44314		Revision of ileostomy	11.04	14.45	15.05		agree	15.05
44316		Devise bowel pouch	15.47	26.57	21.09		agree	21.09
44320		Colostomy	12.94	18.84	17.64		agree	17.64
44340		Revision of colostomy	5.66	6.79	7.72		agree	7.72
44345		Revision of colostomy	11.32	14.45	15.43		agree	15.43
44346		Revision of colostomy	12.46	17.19	16.99		agree	16.99
44388		Colon endoscopy	2.82	3.10	3.70		decrease	2.82
44389		Colonoscopy with biopsy	3.13	3.44	4.26		decrease	3.13
44390		Colonoscopy for foreign body	3.83	4.21	4.81		decrease	3.83
44391		Colonoscopy for bleeding	4.32	4.75	5.18		decrease	4.32
44392		Colonoscopy and polypectomy	3.82	4.20	4.81		decrease	3.82
44393		Colonoscopy, lesion removal	4.84	5.32	5.00		decrease	4.84
44394		Colonoscopy w/snare	4.43	4.87	4.43		agree	4.43
44394		Colonoscopy w/snare	4.43	N/A	4.43		agree	4.43
44602		Suture, small intestine	10.61	15.26	11.91		increase	16.03
44603		Suture, small intestine	14.00	19.50	15.72		increase	18.66
44604		Suture, large intestine	14.28	16.59	16.03		agree	16.03
44605		Repair of bowel lesion	15.37	25.03	17.25		increase	19.53
44615		Intestinal stricturoplasty	14.19	18.97	15.93		agree	15.93
44620		Repair bowel opening	10.87	14.99	12.20		agree	12.20
44625		Repair bowel opening	13.41	16.79	15.05		agree	15.05
44626		Repair bowel opening	22.59	24.43	25.36		agree	25.36
44640		Repair bowel-skin fistula	14.83	22.29	16.65		increase	21.65
44650		Repair bowel fistula	15.25	22.29	17.12		increase	22.27
44660		Repair bowel-bladder fistula	14.63	24.70	16.42		increase	21.36
44661		Repair bowel-bladder fistula	16.99	25.63	19.07		increase	24.81
44680		Surgical revision, intestine	13.72	21.32	15.40		agree	15.40
44700		Suspend bowel w/prosthesis	14.35	19.35	16.11		agree	16.11
44800		Excision of bowel pouch	11.23	10.85	11.23		agree	11.23
44820		Excision of mesentery lesion	10.31	11.23	12.09		agree	12.09
44850		Repair of mesentery	9.57	12.00	10.74		agree	10.74
44900		Drain app abscess, open	8.82	11.79	10.14		agree	10.14
44950		Appendectomy	8.70	8.37	10.00		agree	10.00
44960		Appendectomy	10.74	13.67	12.34		agree	12.34
44970		Laparoscopy, appendectomy	8.70	10.26	8.70		agree	8.70
45000		Drainage of pelvic abscess	4.52	10.29	3.88		increase	4.52
45020		Drainage of rectal abscess	4.72	7.71	4.05		increase	4.72
45100		Biopsy of rectum	3.68	4.34	3.16		increase	3.68
45108		Removal of anorectal lesion	4.76	5.25	4.09		increase	4.76
45110		Removal of rectum	23.80	29.53	28.00		agree	28.00
45111		Partial removal of rectum	16.48	N/A	16.48		agree	16.48
45112		Removal of rectum	25.96	32.46	30.54		agree	30.54
45113		Partial proctectomy	25.99	33.11	30.58		agree	30.58
45114		Partial removal of rectum	23.22	29.46	27.32		agree	27.32
45116		Partial removal of rectum	20.89	21.98	24.58		agree	24.58
45119		Remove rectum w/reservoir	26.21	31.60	30.84		agree	30.84
45120		Removal of rectum	24.60	31.09	24.60		agree	24.60
45121		Removal of rectum and colon	27.04	32.14	27.04		agree	27.04
45123		Partial proctectomy	14.20	22.51	16.71		agree	16.71
45126		Pelvic exenteration	38.39	47.99	45.16		agree	45.16
45130		Excision of rectal prolapse	13.97	14.26	16.44		agree	16.44
45135		Excision of rectal prolapse	16.39	30.14	19.28		agree	19.28
45160		Excision of rectal lesion	13.02	19.86	15.32		agree	15.32
45170		Excision of rectal lesion	9.77	12.81	11.49		agree	11.49
45190		Destruction, rectal tumor	8.28	9.09	9.74		agree	9.74
45305		Proctosigmoidoscopy & biopsy	1.01	1.22	1.01		agree	1.01
45309		Proctosigmoidoscopy	2.01	2.45	2.01		agree	2.01
45330		Diagnostic sigmoidoscopy	0.96	1.39	0.96		agree	0.96
45337		Sigmoidoscopy & decompress	2.36	N/A	2.36		agree	2.36
45339		Sigmoidoscopy	3.14	N/A	3.14		agree	3.14
45378		Diagnostic colonoscopy	3.70	4.66	3.70		agree	3.70
45380		Colonoscopy and biopsy	4.01	5.01	4.44		decrease	4.01
45383		Lesion removal colonoscopy	5.87	7.34	5.87		agree	5.87
45384		Colonoscopy	4.70	5.88	4.70		agree	4.70
45385		Lesion removal colonoscopy	5.31	6.64	5.31		agree	5.31
45505		Repair of rectum	6.02	7.57	7.58		agree	7.58
45540		Correct rectal prolapse	12.92	17.79	16.27		agree	16.27
45541		Correct rectal prolapse	10.64	13.23	13.40		agree	13.40
45550		Repair rectum/remove sigmoid	18.26	27.91	23.00		agree	23.00
45560		Repair of rectocele	8.40	7.70	10.58		agree	10.58
45562		Exploration/repair of rectum	12.21	12.09	15.38		agree	15.38
45563		Exploration/repair of rectum	18.63	21.50	23.47		agree	23.47
45800		Repair rect/bladder fistula	14.11	14.36	17.77		agree	17.77
45805		Repair fistula w/colostomy	16.50	20.94	20.78		agree	20.78
45820		Repair rectourethral fistula	14.67	13.81	18.48		agree	18.48
45825		Repair fistula w/colostomy	16.87	20.38	21.25		agree	21.25
45900		Reduction of rectal prolapse	1.83	3.27	2.61		agree	2.61
45905		Dilation of anal sphincter	1.61	3.15	2.30		agree	2.30
45910		Dilation of rectal narrowing	1.96	3.23	2.80		agree	2.80
45910		Dilation of rectal narrowing	1.96	N/A	2.80		agree	2.80
45915		Remove rectal obstruction	2.20	3.58	3.14		agree	3.14
46040		Incision of rectal abscess	4.96	5.53	4.26		increase	4.96
46045		Incision of rectal abscess	4.32	5.38	3.71		increase	4.32
46060		Incision of rectal abscess	5.69	8.55	4.89		increase	5.69
46083		Incise external hemorrhoid	1.40	1.52	1.40		agree	1.40
46083		Incise external hemorrhoid	1.40	2.34	1.40		agree	1.40
46221		Ligation of hemorrhoid(s)	1.43	1.94	2.04		agree	2.04
46230		Removal of anal tabs	2.57	1.94	2.57		agree	2.57
46250		Hemorrhoidectomy	4.53	4.13	3.89		agree	3.89
46255		Hemorrhoidectomy	5.36	4.98	4.60		agree	4.60
46257		Remove hemorrhoids & fissure	6.28	5.43	5.40		agree	5.40
46258		Remove hemorrhoids & fistula	6.67	5.86	5.73		agree	5.73
46258		Remove hemorrhoids & fistula	6.67	N/A	5.73		agree	5.73
46260		Hemorrhoidectomy	7.42	6.18	6.37		agree	6.37
46261		Remove hemorrhoids & fissure	8.24	7.11	7.08		agree	7.08
46262		Remove hemorrhoids & fistula	8.73	7.11	7.50		agree	7.50
46270		Removal of anal fistula	3.72	4.28	3.20		increase	3.72
46275		Removal of anal fistula	4.56	5.18	3.92		increase	4.56
46280		Removal of anal fistula	5.98	5.95	5.14		increase	5.98
46288		Repair anal fistula	7.13	8.08	6.13		increase	7.13
46320		Removal of hemorrhoid clot	1.61	1.52	1.61		agree	1.61
46320		Removal of hemorrhoid clot	1.61	2.63	1.61		agree	1.61
46700		Repair of anal stricture	7.25	10.22	9.13		agree	9.13
46705		Repair of anal stricture	7.17	6.90	6.90		agree	6.90
46715		Repair of anovaginal fistula	7.46	7.20	7.20		agree	7.20
46716		Repair of anovaginal fistula	12.15	15.15	15.07		agree	15.07
46730		Construction of absent anus	21.57	25.50	26.75		agree	26.75
46735		Construction of absent anus	25.94	36.00	32.17		agree	32.17
46740		Construction of absent anus	23.11	35.00	30.00		agree	30.00
46742		Repair of imperforated anus	29.67	38.00	35.80		agree	35.80
46744		Repair of cloacal anomaly	33.21	52.00	52.63		agree	52.63
46746		Repair of cloacal anomaly	36.74	53.50	58.22		agree	58.22
46748		Repair of cloacal anomaly	40.52	55.00	64.21		agree	64.21
46750		Repair of anal sphincter	8.14	10.99	10.25		agree	10.25
46753		Reconstruction of anus	6.58	5.45	8.29		agree	8.29
46754		Removal of suture from anus	1.54	2.93	2.20		agree	2.20
46760		Repair of anal sphincter	11.46	21.77	14.43		agree	14.43
46761		Repair of anal sphincter	10.99	12.15	13.84		agree	13.84
46762		Implant artificial sphincter	10.09	15.01	12.71		agree	12.71
46900		Destruction, anal lesion(s)	1.91	1.32	1.91		agree	1.91
46910		Destruction, anal lesion(s)	1.86	1.72	1.86		agree	1.86
46916		Cryosurgery, anal lesion(s)	1.86	1.72	1.86		agree	1.86
46917		Laser surgery, anal lesions	1.86	3.32	1.86		agree	1.86
46922		Excision of anal lesion(s)	1.86	3.12	1.86		agree	1.86
46924		Destruction, anal lesion(s)	2.76	3.93	2.76		agree	2.76
46924		Destruction, anal lesion(s)	2.76	4.24	2.76		agree	2.76
46934		Destruction of hemorrhoids	4.08	4.63	3.51		agree	3.51
46935		Destruction of hemorrhoids	2.43	4.17	2.43		agree	2.43
46936		Destruction of hemorrhoids	4.30	5.12	3.69		agree	3.69
46940		Treatment of anal fissure	2.32	1.71	2.32		agree	2.32
46942		Treatment of anal fissure	2.04	1.71	2.04		agree	2.04
46945		Ligation of hemorrhoids	2.14	2.37	1.84		agree	1.84
46946		Ligation of hemorrhoids	3.00	2.57	2.58		agree	2.58
47010		Open drainage, liver lesion	10.28	16.25	16.01		agree	16.01
47015		Inject/aspirate liver cyst	9.70	19.15	15.11		agree	15.11
47100		Wedge biopsy of liver	7.49	9.24	11.67		agree	11.67
47120		Partial removal of liver	22.79	39.57	35.50		agree	35.50
47122		Extensive removal of liver	35.39	53.02	55.13		agree	55.13
47125		Partial removal of liver	31.58	44.50	49.19		agree	49.19
47130		Partial removal of liver	34.25	46.45	53.35		agree	53.35
47134		Partial removal, donor liver	39.15	49.00	CPT		CPT	39.15
47300		Surgery for liver lesion	9.68	12.45	15.08		agree	15.08
47350		Repair liver wound	12.56	19.16	19.56		agree	19.56
47360		Repair liver wound	17.28	28.64	26.92		agree	26.92
47361		Repair liver wound	30.25	40.14	47.12		agree	47.12
47362		Repair liver wound	11.88	24.94	18.51		agree	18.51
47400		Incision of liver duct	20.86	35.12	32.49		agree	32.49
47420		Incision of bile duct	16.72	27.63	19.88		agree	19.88
47425		Incision of bile duct	16.68	32.49	19.83		agree	19.83
47460		Incise bile duct sphincter	15.17	25.74	18.04		agree	18.04
47480		Incision of gallbladder	9.10	15.26	10.82		agree	10.82
47562		Laparoscopic cholecystectomy	11.09	9.59	11.09		agree	11.09
47563		Laparoscopic cholecystectomy	11.94	12.40	11.94		agree	11.94
47564		Laparo cholecystectomy/explr	14.23	17.67	14.23		agree	14.23
47570		Laparo cholecystoenterostomy	12.58	18.62	12.58		agree	12.58
47600		Removal of gallbladder	11.42	11.67	13.58		agree	13.58
47605		Removal of gallbladder	12.36	13.26	14.69		agree	14.69
47610		Removal of gallbladder	15.83	17.97	18.82		agree	18.82
47612		Removal of gallbladder	15.80	22.68	18.78		agree	18.78
47620		Removal of gallbladder	17.36	24.70	20.64		agree	20.64
47701		Bile duct revision	27.81	36.50	27.81		agree	27.81
47711		Excision of bile duct tumor	19.37	31.38	23.03		agree	23.03
47712		Excision of bile duct tumor	25.44	38.58	30.24		agree	30.24
47715		Excision of bile duct cyst	15.81	32.81	18.80		agree	18.80
47716		Fusion of bile duct cyst	13.83	19.34	16.44		agree	16.44
47720		Fuse gallbladder & bowel	13.38	18.16	15.91		agree	15.91
47721		Fuse upper gi structures	16.08	21.91	19.12		agree	19.12
47740		Fuse gallbladder & bowel	15.54	20.63	18.48		agree	18.48
47741		Fuse gallbladder & bowel	17.95	24.39	21.34		agree	21.34
47760		Fuse bile ducts and bowel	21.74	21.91	25.85		agree	25.85
47765		Fuse liver ducts & bowel	20.93	30.62	24.88		agree	24.88
47780		Fuse bile ducts and bowel	22.29	26.86	26.50		agree	26.50
47785		Fuse bile ducts and bowel	26.23	36.32	31.18		agree	31.18
47800		Reconstruction of bile ducts	19.60	26.89	23.30		agree	23.30
47801		Placement, bile duct support	12.76	23.47	15.17		agree	15.17
47802		Fuse liver duct & intestine	18.13	34.11	21.55		agree	21.55
47900		Suture bile duct injury	16.74	20.50	19.90		agree	19.90
48000		Drainage of abdomen	14.91	40.79	28.07		agree	28.07
48001		Placement of drain, pancreas	18.83	55.20	35.45		agree	35.45
48005		Resect/debride pancreas	22.40	57.70	42.17		agree	42.17
48020		Removal of pancreatic stone	14.22	23.50	15.70		agree	15.70
48100		Biopsy of pancreas	11.08	14.57	12.23		agree	12.23
48120		Removal of pancreas lesion	14.36	26.05	15.85		agree	15.85
48140		Partial removal of pancreas	20.78	28.60	22.94		agree	22.94
48145		Partial removal of pancreas	21.76	34.32	24.02		agree	24.02
48146		Pancreatectomy	23.91	45.57	26.40		agree	26.40
48148		Removal of pancreatic duct	15.71	25.00	17.34		agree	17.34
48150		Partial removal of pancreas	43.48	54.73	48.00		agree	48.00
48150		Partial removal of pancreas	43.48	54.75	48.00		agree	48.00
48152		Pancreatectomy	39.63	39.63	43.75		agree	43.75
48153		Pancreatectomy	43.38	54.73	47.89		agree	47.89
48154		Pancreatectomy	39.95	51.80	44.10		agree	44.10
48155		Removal of pancreas	22.32	44.70	24.64		agree	24.64
48180		Fuse pancreas and bowel	22.39	32.52	24.72		agree	24.72
48500		Surgery of pancreas cyst	13.84	18.99	15.28		agree	15.28
48510		Drain pancreatic pseudocyst	12.96	16.08	14.31		agree	14.31
48520		Fuse pancreas cyst and bowel	14.12	19.68	15.59		agree	15.59
48540		Fuse pancreas cyst and bowel	17.86	21.28	19.72		agree	19.72
48545		Pancreatorrhaphy	16.47	33.39	18.18		agree	18.18
48547		Duodenal exclusion	23.40	41.76	25.83		agree	25.83
49000		Exploration of abdomen	11.68	13.42	11.68		agree	11.68
49002		Reopening of abdomen	10.49	12.67	10.49		agree	10.49
49010		Exploration behind abdomen	12.28	15.06	12.28		agree	12.28
49020		Drain abdominal abscess	16.79	28.33	20.73		increase	22.84
49040		Drain, open, abdom abscess	9.94	23.60	12.27		increase	13.52
49060		Drain, open, retrop abscess	11.66	19.52	14.40		increase	15.86
49085		Remove abdomen foreign body	8.93	14.23	11.03		increase	12.14
49200		Removal of abdominal lesion	10.25	12.19	10.25		agree	10.25
49201		Removal of abdominal lesion	14.84	16.27	14.84		agree	14.84
49215		Excise sacral spine tumor	22.36	24.96	33.50		agree	33.50
49215		Excise sacral spine tumor	22.36	30.00	33.50		agree	33.50
49220		Multiple surgery, abdomen	14.88	17.39	14.88		agree	14.88
49255		Removal of omentum	11.14	13.42	11.14		agree	11.14
49320		Diag laparo separate proc	5.10	5.95	5.10		agree	5.10
49321		Laparoscopy; biopsy	5.40	N/A	5.40		agree	5.40
49322		Laparoscopy; aspiration	5.70	N/A	5.70		agree	5.70
49421		Insert abdominal drain	5.54	6.99	5.54		agree	5.54
49422		Remove perm cannula/catheter	6.25	6.35	6.25		agree	6.25
49425		Insert abdomen-venous drain	11.37	13.82	11.37		agree	11.37
49426		Revise abdomen-venous shunt	9.63	11.10	9.63		agree	9.63
49428		Ligation of shunt	2.38	5.38	6.06		agree	6.06
49429		Removal of shunt	7.40	9.57	7.40		agree	7.40
49495		Repair inguinal hernia, init	5.89	6.96	CPT		CPT	5.89
49495		Repair inguinal hernia, init	5.89	12.50	CPT		CPT	5.89
49496		Repair inguinal hernia, init	8.79	10.56	CPT		CPT	8.79
49496		Repair inguinal hernia, init	8.79	14.00	CPT		CPT	8.79
49500		Repair inguinal hernia	4.68	7.61	5.48		agree	5.48
49501		Repair inguinal hernia, init	7.58	9.26	8.88		agree	8.88
49505		Repair inguinal hernia	6.49	8.31	7.60		agree	7.60
49505		Repair inguinal hernia	6.49	11.50	7.60		agree	7.60
49507		Repair inguinal hernia	8.17	11.38	9.57		agree	9.57
49520		Rerepair inguinal hernia	8.22	11.02	9.63		agree	9.63
49521		Repair inguinal hernia, rec	10.22	13.97	11.97		agree	11.97
49525		Repair inguinal hernia	7.32	8.36	8.57		agree	8.57
49540		Repair lumbar hernia	8.87	8.52	10.39		agree	10.39
49550		Repair femoral hernia	7.37	8.36	8.63		agree	8.63
49553		Repair femoral hernia, init	8.06	10.31	9.44		agree	9.44
49555		Repair femoral hernia	7.71	8.50	9.03		agree	9.03
49557		Repair femoral hernia, recur	9.52	11.82	11.15		agree	11.15
49560		Repair abdominal hernia	9.88	11.69	11.57		agree	11.57
49561		Repair incisional hernia	12.17	15.67	14.25		agree	14.25
49565		Rerepair abdominal hernia	9.88	14.03	11.57		agree	11.57
49566		Repair incisional hernia	12.30	16.43	14.40		agree	14.40
49570		Repair epigastric hernia	4.86	7.00	5.69		agree	5.69
49572		Repair epigastric hernia	5.75	9.77	6.73		agree	6.73
49580		Repair umbilical hernia	3.51	5.71	4.11		agree	4.11
49582		Repair umbilical hernia	5.68	9.99	6.65		agree	6.65
49585		Repair umbilical hernia	5.32	5.71	6.23		agree	6.23
49587		Repair umbilical hernia	6.46	9.34	7.56		agree	7.56
49590		Repair abdominal hernia	7.29	9.54	8.54		agree	8.54
49605		Repair umbilical lesion	22.66	97.62	76.00		decrease	22.66
49606		Repair umbilical lesion	18.60	21.31	18.60		agree	18.60
49650		Laparo hernia repair initial	6.27	7.66	6.27		agree	6.27
49651		Laparo hernia repair recur	8.24	7.88	8.24		agree	8.24
49900		Repair of abdominal wall	12.28	16.92	12.28		agree	12.28
49905		Omental flap	6.55	17.79	CPT		CPT	6.55
50200		Biopsy of kidney	2.63	N/A	CPT		CPT	2.63
50230		Removal of kidney	22.07	N/A	CPT		CPT	22.07
51595		Remove bladder/revise tract	37.14	N/A	37.14		agree	37.14
51596		Remove bladder/create pouch	39.52	N/A	39.52		agree	39.52
52300		Cystoscopy and treatment	5.31	WD	(e)		(a)	5.31
52327		Cystoscopy, inject material	5.19	WD	(e)		(a)	5.19
52340		Cystoscopy and treatment	9.68	WD	(e)		(a)	9.68
56515		Destruction, vulva lesion(s)	1.88	3.09	2.76		agree	2.76
56740		Remove vagina gland lesion	3.76	5.74	4.57		agree	4.57
57100		Biopsy of vagina	0.97	1.90	1.20		agree	1.20
57130		Remove vagina lesion	2.43	5.67	2.43		agree	2.43
57292		Construct vagina with graft	13.09	N/A	13.09		agree	13.09
57307		Fistula repair & colostomy	15.93	20.24	15.93		agree	15.93
57410		Pelvic examination	1.75	4.08	1.75		agree	1.75
57505		Endocervical curettage	1.14	0.97	1.14		agree	1.14
57555		Remove cervix/repair vagina	8.95	WD	(e)		(a)	8.95
58150		Total hysterectomy	15.24	17.75	15.24		agree	15.24
58152		Total hysterectomy	15.09	20.60	20.60		agree	20.60
58260		Vaginal hysterectomy	12.20	12.98	12.98		agree	12.98
58262		Vaginal hysterectomy	13.99	17.88	14.77		agree	14.77
58263		Vaginal hysterectomy	15.28	21.26	16.06		agree	16.06
58267		Hysterectomy & vagina repair	15.00	17.55	17.04		agree	17.04
58270		Hysterectomy & vagina repair	13.48	15.58	14.26		agree	14.26
58275		Hysterectomy/revise vagina	14.98	N/A	15.76		agree	15.76
58280		Hysterectomy/revise vagina	15.41	N/A	17.01		agree	17.01
58285		Extensive hysterectomy	18.57	N/A	22.26		agree	22.26
58323		Sperm washing	0.23	0.55	0.23		agree	0.23
58400		Suspension of uterus	6.36	11.68	6.36		agree	6.36
58600		Division of fallopian tube	3.84	4.60	5.60		agree	5.60
58605		Division of fallopian tube	3.34	4.60	5.00		agree	5.00
58611		Ligate oviduct(s) add-on	0.63	N/A	1.45		agree	1.45
58700		Removal of fallopian tube	6.49	11.68	12.05		agree	12.05
58740		Revise fallopian tube(s)	5.83	11.29	14.00		agree	14.00
58805		Drainage of ovarian cyst(s)	5.88	11.68	5.88		agree	5.88
58820		Drain ovary abscess, open	4.22	6.03	4.22		agree	4.22
58825		Transposition, ovary(s)	6.13	11.68	10.98		agree	10.98
58920		Partial removal of ovary(s)	6.78	11.68	11.36		agree	11.36
58950		Resect ovarian malignancy	15.27	16.93	16.93		agree	16.93
58951		Resect ovarian malignancy	21.81	28.99	22.38		agree	22.38
59150		Treat ectopic pregnancy	6.89	11.67	11.67		agree	11.67
59151		Treat ectopic pregnancy	7.86	11.49	11.49		agree	11.49
59812		Treatment of miscarriage	3.25	4.01	4.01		agree	4.01
59870		Evacuate mole of uterus	4.28	5.00	6.01		agree	6.01
60100		Biopsy of thyroid	0.97	1.88	1.56		agree	1.56
60220		Partial removal of thyroid	10.53	11.82	11.90		agree	11.90
60220		Partial removal of thyroid	10.53	14.24	11.90		agree	11.90
60252		Removal of thyroid	18.20	22.32	20.57		agree	20.57
60254		Extensive thyroid surgery	23.88	27.43	26.99		agree	26.99
60260		Repeat thyroid surgery	15.46	18.83	17.47		agree	17.47
60270		Removal of thyroid	17.94	23.05	20.27		agree	20.27
60271		Removal of thyroid	14.89	18.68	16.83		agree	16.83
60280		Remove thyroid duct lesion	6.08	WD	(e)		(a)	6.08
60540		Explore adrenal gland	17.03	20.53	17.03		agree	17.03
60545		Explore adrenal gland	19.88	25.66	19.88		agree	19.88
62263		Lysis epidural adhesions	6.14	7.20	7.20		(b)	6.14
62310		Inject spine c/t	1.91	1.95	2.20		(b)	1.91
62311		Inject spine l/s (cd)	1.54	1.57	1.78		(b)	1.54
62318		Inject spine w/cath, c/t	2.04	2.26	2.35		(b)	2.04
62319		Inject spine w/cath l/s (cd)	1.87	1.88	2.15		(b)	1.87
65855		Laser surgery of eye	4.30	N/A	3.85		agree	3.85
66170		Glaucoma surgery	12.16	WD	(e)		(a)	12.16
66172		Incision of eye	15.04	WD	(e)		(a)	15.04
66180		Implant eye shunt	14.55	N/A	14.55		agree	14.55
66986		Exchange lens prosthesis	12.28	N/A	12.28		agree	12.28
67028		Injection eye drug	2.52	N/A	2.52		agree	2.52
67108		Repair detached retina	20.82	WD	(e)		(a)	20.82
67218		Treatment of retinal lesion	13.52	N/A	18.53		agree	18.53
67904		Repair eyelid defect	6.26	N/A	6.26		agree	6.26
69000		Drain external ear lesion	1.45	WD	(e)		(a)	1.45
69005		Drain external ear lesion	2.11	WD	(e)		(a)	2.11
69020		Drain outer ear canal lesion	1.48	WD	(e)		(a)	1.48
69100		Biopsy of external ear	0.81	WD	(e)		(a)	0.81
69105		Biopsy of external ear canal	0.85	WD	(e)		(a)	0.85
69110		Remove external ear, partial	3.44	WD	(e)		(a)	3.44
69120		Removal of external ear	4.05	WD	(e)		(a)	4.05
69140		Remove ear canal lesion(s)	7.97	WD	(e)		(a)	7.97
69145		Remove ear canal lesion(s)	2.62	WD	(e)		(a)	2.62
69150		Extensive ear canal surgery	13.43	WD	(e)		(a)	13.43
69155		Extensive ear/neck surgery	20.80	WD	(e)		(a)	20.80
69200		Clear outer ear canal	0.77	WD	(e)		(a)	0.77
69205		Clear outer ear canal	1.20	WD	(e)		(a)	1.20
69210		Remove impacted ear wax	0.61	WD	(e)		(a)	0.61
69220		Clean out mastoid cavity	0.83	WD	(e)		(a)	0.83
69222		Clean out mastoid cavity	1.40	WD	(e)		(a)	1.40
69300		Revise external ear	6.36	WD	(e)		(a)	6.36
69310		Rebuild outer ear canal	10.79	WD	(e)		(a)	10.79
69320		Rebuild outer ear canal	16.96	WD	(e)		(a)	16.96
69400		Inflate middle ear canal	0.83	WD	(e)		(a)	0.83
69401		Inflate middle ear canal	0.63	WD	(e)		(a)	0.63
69405		Catheterize middle ear canal	2.63	WD	(e)		(a)	2.63
69410		Inset middle ear (baffle)	0.33	WD	(e)		(a)	0.33
69420		Incision of eardrum	1.33	WD	(e)		(a)	1.33
69421		Incision of eardrum	1.73	WD	(e)		(a)	1.73
69424		Remove ventilating tube	0.85	WD	(e)		(a)	0.85
69433		Create eardrum opening	1.52	WD	(e)		(a)	1.52
69436		Create eardrum opening	1.96	WD	(e)		(a)	1.96
69440		Exploration of middle ear	7.57	WD	(e)		(a)	7.57
69450		Eardrum revision	5.57	WD	(e)		(a)	5.57
69501		Mastoidectomy	9.07	WD	(e)		(a)	9.07
69502		Mastoidectomy	12.38	WD	(e)		(a)	12.38
69505		Remove mastoid structures	12.99	WD	(e)		(a)	12.99
69511		Extensive mastoid surgery	13.52	WD	(e)		(a)	13.52
69530		Extensive mastoid surgery	19.19	WD	(e)		(a)	19.19
69535		Remove part of temporal bone	36.14	WD	(e)		(a)	36.14
69540		Remove ear lesion	1.20	WD	(e)		(a)	1.20
69550		Remove ear lesion	10.99	WD	(e)		(a)	10.99
69552		Remove ear lesion	19.46	WD	(e)		(a)	19.46
69554		Remove ear lesion	33.16	WD	(e)		(a)	33.16
69601		Mastoid surgery revision	13.24	WD	(e)		(a)	13.24
69602		Mastoid surgery revision	13.58	WD	(e)		(a)	13.58
69603		Mastoid surgery revision	14.02	WD	(e)		(a)	14.02
69604		Mastoid surgery revision	14.02	WD	(e)		(a)	14.02
69605		Remove mastoid structures	18.49	WD	(e)		(a)	18.49
69610		Repair of eardrum	4.43	WD	(e)		(a)	4.43
69620		Repair of eardrum	5.89	WD	(e)		(a)	5.89
69631		Rebuild eardrum structures	9.86	WD	(e)		(a)	9.86
69632		Rebuild eardrum structures	12.75	WD	(e)		(a)	12.75
69633		Rebuild eardrum structures	12.10	WD	(e)		(a)	12.10
69635		Repair eardrum structures	13.33	WD	(e)		(a)	13.33
69636		Rebuild eardrum structures	15.22	WD	(e)		(a)	15.22
69637		Rebuild eardrum structures	15.11	WD	(e)		(a)	15.11
69641		Revise middle ear & mastoid	12.71	WD	(e)		(a)	12.71
69642		Revise middle ear & mastoid	16.84	WD	(e)		(a)	16.84
69643		Revise middle ear & mastoid	15.32	WD	(e)		(a)	15.32
69644		Revise middle ear & mastoid	16.97	WD	(e)		(a)	16.97
69645		Revise middle ear & mastoid	16.38	WD	(e)		(a)	16.38
69646		Revise middle ear & mastoid	17.99	WD	(e)		(a)	17.99
69650		Release middle ear bone	9.66	WD	(e)		(a)	9.66
69660		Revise middle ear bone	11.90	WD	(e)		(a)	11.90
69661		Revise middle ear bone	15.74	WD	(e)		(a)	15.74
69662		Revise middle ear bone	15.44	WD	(e)		(a)	15.44
69666		Repair middle ear structures	9.75	WD	(e)		(a)	9.75
69667		Repair middle ear structures	9.76	WD	(e)		(a)	9.76
69670		Remove mastoid air cells	11.51	WD	(e)		(a)	11.51
69676		Remove middle ear nerve	9.52	WD	(e)		(a)	9.52
69700		Close mastoid fistula	8.23	WD	(e)		(a)	8.23
69711		Remove/repair hearing aid	10.44	WD	(e)		(a)	10.44
69720		Release facial nerve	14.38	WD	(e)		(a)	14.38
69725		Release facial nerve	25.38	WD	(e)		(a)	25.38
69740		Repair facial nerve	15.96	WD	(e)		(a)	15.96
69745		Repair facial nerve	16.69	WD	(e)		(a)	16.69
69801		Incise inner ear	8.56	WD	(e)		(a)	8.56
69802		Incise inner ear	13.10	WD	(e)		(a)	13.10
69805		Explore inner ear	13.82	WD	(e)		(a)	13.82
69806		Explore inner ear	12.35	WD	(e)		(a)	12.35
69820		Establish inner ear window	10.34	WD	(e)		(a)	10.34
69840		Revise inner ear window	10.26	WD	(e)		(a)	10.26
69905		Remove inner ear	11.10	WD	(e)		(a)	11.10
69910		Remove inner ear & mastoid	13.63	WD	(e)		(a)	13.63
69915		Incise inner ear nerve	21.23	WD	(e)		(a)	21.23
69930		Implant cochlear device	16.81	WD	(e)		(a)	16.81
69950		Incise inner ear nerve	25.64	WD	(e)		(a)	25.64
69955		Release facial nerve	27.04	WD	(e)		(a)	27.04
69960		Release inner ear canal	27.04	WD	(e)		(a)	27.04
69970		Remove inner ear lesion	30.04	WD	(e)		(a)	30.04
69990		Microsurgery add-on	3.47	N/A	3.47		agree	3.47
72275		Epidurography	0.76	0.83	0.83		(b)	0.76
76005		Fluoroguide for spine inject	0.60	0.60	10.60		agree	0.60
76065		X-rays, bone evaluation	0.28	0.60	0.70		agree	0.70
76090		Mammogram, one breast	0.58	0.64	0.70		agree	0.70
76091		Mammogram, both breasts	0.69	0.76	0.87		agree	0.87
76095		Stereotactic breast biopsy	1.59	3.58	1.59		agree	1.59
88170		Fine needle aspiration	1.27	3.28	1.27		agree	1.27
88171		Fine needle aspiration	1.27	2.63	1.27		agree	1.27
90901		Biofeedback train, any meth	0.41	N/A		0.41	agree	0.41
90911		Biofeedback peri/uro/rectal	0.89	N/A	0.89		agree	0.89
90935		Hemodialysis, one evaluation	1.22	N/A	CPT		CPT	1.22
90937		Hemodialysis, repeated eval	2.11	N/A	CPT		CPT	2.11
90945		Dialysis, one evaluation	1.28	N/A	CPT		CPT	1.28
90947		Dialysis, repeated eval	2.16	N/A	CPT		CPT	2.16
90989		Dialysis training, complete	0.00	N/A	CPT		CPT	0.00
90993		Dialysis training, incompl	0.00	N/A	CPT		CPT	0.00
90997		Hemoperfusion	1.84	N/A	CPT		CPT	1.84
92018		New eye exam & treatment	1.51	N/A	2.50		agree	2.50
93350		Echo transthoracic	0.78	N/A	1.48		agree	1.48
94640		Airway inhalation treatment	0.00	N/A	0.00		agree	0.00
94664		Aerosol or vapor inhalations	0.00	N/A	CPT		CPT	0.00
94665		Aerosol or vapor inhalations	0.00	N/A	CPT		CPT	0.00
96100		Psychological testing	0.00	2.00		(a)	agree	0.00
96105		Assessment of aphasia	0.00	2.00		(a)	agree	0.00
96110		Developmental test, lim	0.00	2.00		(a)	agree	0.00
96115		Neurobehavior status exam	0.00	2.20		(a)	agree	0.00
96117		Neuropsych test battery	0.00	2.20		(a)	agree	0.00
97542		Wheelchair mngmnt training	0.25	0.45		0.45	agree	0.45
99233		Subsequent hospital care	1.51	N/A	1.51		agree	1.51
99273		Confirmatory consultation	1.19	N/A	1.19		agree	1.19
99274		Confirmatory consultation	1.73	N/A	1.73		agree	1.73
99291		Critical care, first hour	3.60	4.00	4.00		agree	4.00
99291		Critical care, first hour	3.60	5.50	4.00		agree	4.00
99291		Critical care, first hour	3.60	N/A	4.00		agree	4.00
99292		Critical care, addl 30 min	1.80	2.00	2.00		agree	2.00
99292		Critical care, addl 30 min	1.80	2.77	2.00		agree	2.00
99292		Critical care, addl 30 min	1.80	N/A	2.00		agree	2.00
99295		Neonatal critical care	16.00	N/A	16.00		agree	16.00
99296		Neonatal critical care	8.00	N/A	8.00		agree	8.00
99297		Neonatal critical care	4.00	N/A	4.00		agree	4.00
99298		Neonatal critical care	2.75	N/A	2.75		agree	2.75
99436		Attendance, birth	1.50	N/A	1.50		agree	1.50
99440		Newborn resuscitation	2.93	N/A	2.93		agree	2.93
G0127		Trim nail(s)	0.11	N/A		(a)	(a)	0.11

   

 

 

 

B. Discussion of Comments by Clinical Area

1. Vascular Surgery

Comment: The Society for Vascular Surgery (SVS) and the North American Chapter of the International Society for Cardiovascular Surgery requested increases in work RVUs for 95 codes. Both groups commented that vascular surgery procedures were undervalued in the original Harvard Study and that only a small number of these RVUs have been adjusted since that time.

The SVS's recommendations were based on surveys, a full RUC survey of 39 higher volume codes and minisurveys for 56 less frequently performed codes. (The full and minisurveys included estimates for each code of pre-, intra-, and postservice times and visits as well as estimates of physician work. The effect of these recommendations would be to correct current rank-order anomalies, while avoiding creation of new rank-order anomalies.) The SVS used a building-block approach to validate the survey results for each of their codes.

RUC Recommendation

Of the 95 codes, the RUC recommended increases for 91 codes, a decrease for 1 code and no changes for 3 codes. In 60 percent of cases, the RUC recommendations to increase the work RVUs were based on physician surveys. The recommendations were based on either the 25th percentile or the median of survey responses. In almost all other cases, the RUC recommendation for a specific code work RVU was based on the work value of another comparable code. The building-block approach was used only to corroborate findings from the surveys or validate a comparison to another procedure. The following are the RUC recommendations for the codes submitted. (Please note that throughout this document the value in parentheses represents the RUC-recommended work RVUs unless they are shown in columns.)

CPT codes	Work RVUs
Family 1 Aneurysm Repairs in Abdomen
35111	25.00
35131	25.00
35112	30.00
35132	30.00
35121	30.00
35122	35.00
35082	38.50
35103	40.50
35092	45.00
Family 2 Bypass Grafts in the Abdomen
35665	21.00
35663	22.00
35565	23.20
35563	24.20
35636	29.50
35536	31.70
35560	32.00
35631	34.00
35531	36.20
Family 3 Embolectomy/Thrombectomy in the Abdomen
34401	25.00
34151	25.00
34451	27.00
Family 4 Endarterectomy in the Abdomen
35351	23.00
35331	26.20
35361	28.20
35363	30.20
Family 5 Repair Blood Vessels in the Abdomen
37660	21.00
37617	22.06
35221	24.39
35281	28.00
35251	30.20
Family 6 Explorations, Revisions, Other in Chest & Abdomen
35189	28.00
35182	30.00
35905	31.25
35907	35.00
Family 7 Extra-anatomic Bypass Grafts
35661	19.00
35650	19.00
35621	20.00
35558	21.20
35511	21.20
35518	21.20
35623	24.00
35521	22.20
35654	25.00
35533	28.00
Family 8 Arterial Bypass Grafts in Extremities
35666	22.19
35671	19.23
35571	24.06
35587	24.75
Family 9 Embolectomy/Thrombectomy by Extremity Incision
34490	9.86
34111	10.00
34201	10.03
34101	10.00
34421	12.00
34203	16.50
Family 10 Aneurysm Repairs in the Extremity
35045	17.57
35011	18.00
35141	20.00
35013	22.00
35151	22.64
35142	23.30
35152	25.62
Family 11 Endarterectomy of Extremity Arteries
35371	14.72
35321	16.00
35372	18.00
35355	18.50
Family 12 Arteriovenous Fistula Repairs in the Extremities
35190	No change in work RVUs
35184	18.00
Family 13 Peripheral Artery and Vein Ligations
35721	7.18
37650	7.80
35741	8.00
37618	No change in work RVUs
37565	10.88
37600	11.25
35701	8.50
37605	13.11
37615	No change in work RVUs
Family 14 Vessel/Repairs in Extremities and Neck
35201	16.14
35206	13.25
35226	14.50
35266	14.91
35261	17.80
35286	16.16
35236	17.11
35231	20.00
35256	18.36
Family 15 Reconstruction for Chronic Venous Disease
34501	16.00
34520	17.95
34510	18.95
34530	16.64 (decrease)
Family 16 Repairs, Bypass Grafts, Endarterectomies in the Chest
35276	24.25
35246	26.45
35626	27.75
35526	29.95
35311	27.00
Family 17 Ligation or Biopsy of Temporal Artery
37609	3.00
Family 18 Untitled
35081	28.01
35556	21.76

The RUC recommended the following codes be submitted to the CPT Editorial Panel for further consideration: 35381, 35541, 35546, 35551, 35582, 35641, 35646, 35840, 35860, 37615, 37618, 37700, 37730, 37735, 37760, 37785.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the vascular surgery codes. We believe that relativity is maintained, and the RVUs more appropriately reflect the work involved.

2. General Surgery/Colon and Rectal Surgery

Comment: The American Society of General Surgeons (ASGS) submitted 55 codes it believed to be undervalued. The ASGS recommended work RVUs for each service. After submitting the codes, the specialty society ultimately chose not to pursue review of RVUs for the following codes under the 5-year review: 20605, 34001, and 29881.

The following codes 49505, 32440, 46320, 46924, 31622, 44140 (no change), 38500, 32480, 37609, 43239, 43638, 60220, 44050, 48150, and 38100 were also submitted for review by other specialty groups and are discussed in other sections. (Note that codes 56305, 56341, 56300, 56340, and 56306 are laparoscopic surgery codes also submitted for review by the specialty group; however, these services were deleted or renumbered by CPT for 2000.)

RUC Recommendation:

The RUC recommended that the work RVUs for the following codes be increased (the RUC-recommended work RVUs are in parentheses):

Code 36489, Placement of central venous catheter (subclavian, jugular, or other vein (eg, for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy)); percutaneous, age 2 years or under (2.50) to correct a rank-order anomaly; 60100, Biopsy thyroid, percutaneous core needle (1.56), to appropriately reflect the work involved and fit in the range of biopsy codes; and 31600, Tracheostomy, planned (separate procedure) (7.18), based on the building-block approach and the comparison to similar procedures.

For the following codes, the RUC stated that there was no compelling evidence provided to support increasing the work RVUs. Therefore, it recommended maintaining the current work RVUs for the following codes: 19100, 88170, 57410, 76095, 88171, 32000, 21800, 46083, 19000, 19125, 45330, 19160, 13101, 11402, 12011, 11642, 27590, 45378, 36625, 45309, 45305, 35081, 19240, 58150, 43246, 19162, and 35556. The RUC also recommended maintaining the current work RVUs for codes 49321 and 49322 because these services had recently been reviewed by the RUC.

The RUC recommended that the following codes be referred to the CPT Editorial Panel for review or clarification: 37720 and 43215.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for these surgery codes.

Comment:

The American College of Surgeons (ACS) submitted general surgery codes for review that account for approximately 50 percent of general surgery's Medicare-allowed charges for services categorized as surgery under our “type of service” classification. The procedures are predominantly performed by general surgeons, and they involve the gastrointestinal tract, abdominal organs, thyroid, lymph system, and endocrine system. Requests for review of some of these codes were also submitted by other specialty groups.

In its comments, the ACS emphasized that its analysis determined that the work of codes in general surgery has been systematically undervalued.

The ACS used a building-block approach with panel-assigned intraoperative work intensities for procedures. Preoperative work RVUs were determined based on an assigned intensity multiplied by the number of preservice minutes. The assigned preservice work intensity was below that of an evaluation and management service. A panel of ASC members assigned intraservice work intensity to each code using a scale. The intensity of an evaluation and management service was the low end of the scale, and liver resection services were on the high end of the scale. The ends of the scale were chosen to represent “average” work intensity throughout a procedure. The ACS maintains that the work intensity of any surgical procedure is greater than the work intensity of an evaluation and management service. Postservice work RVUs were calculated using current work RVUs for hospital visits and discounted work RVUs for office visits. Pre, intra-, and postwork RVUs were summed to equal the new work RVUs that the ACS developed for each code.

The ACS assigned over 300 codes to 31 families of similar services (for example, all codes related to hernia repair were in one family). It conducted a traditional RUC survey for 32 codes (either high volume services or the service most representative of the family of codes). A minisurvey, which did not include a respondent-recommended work value, was conducted for the remaining codes, with participation from other specialty groups. The ACS indicated that the survey respondents tended to overvalue codes at the low end of the scale and undervalue codes at the high end of the scale. As a result, ACS recommended using the 25th percentile of survey results at the low end and the 75th percentile for work RVUs at the high end of the scale for fully-surveyed codes. However, they stated that acceptance of these survey results without adjustments to other codes in the family that were not fully surveyed would distort the relativity within and across families. They recommended a regression methodology to extrapolate the fully-surveyed code results to the other codes.

RUC Recommendation:

The RUC workgroup reviewed the data collected for the 32 fully-surveyed ACS codes. It also reviewed the families of services proposed by ACS and modified the families that were too dissimilar to permit appropriate comparison within the family. After the anchor code was reviewed, each family was reviewed to determine whether the change to the anchor code should be applied to the entire family of codes. In some instances the RUC agreed that the recommended change in the anchor code should be extrapolated to the entire family to ensure that rank-order and relativity distortions were not created by a change to the anchor code. In other instances the RUC determined that the recommendation for the anchor code did not apply to the family of codes. In these instances, either new RVUs were recommended or the present work RVUs were maintained. The following are the code-specific RUC recommendations:

CPT codes	Work RVUs
Family 1A & B Thyroid/Endocrine
60220	11.90
60252	20.57
60254	26.99
60260	17.47
60270	20.27
60271	16.83
60540	No change
60545	No change
Family 2 Lymphadenectomy
38740	8.42
38745	11.00
38760	10.88
38765	19.98
Family 3 Lymph Nodes and Lymphatic Channels—Incision/Excision
38300	1.99
38305	6.00
38308	6.45
38500	3.75
38510	6.43
38520	6.67
38525	6.07
38530	7.98
Family 4 Intestines—Excision/Incision
44005	16.23
44010	12.52
44020	13.99
44021	14.08
44025	14.28
44050	14.03
44110	11.81
44111	14.29
44120	17.00
44125	17.54
44130	14.49
44160	18.62
44800	11.23
44820	12.09
Family 5 Intestines—External Fistulization
44300	12.11
44310	15.95
44312	8.02
44314	15.05
44316	21.09
44320	17.64
44340	17.72
44345	15.43
44346	16.99
Family 6 Intestines—Colectomy
Codes 44140, 44143, 44144, 44145, 44146, 44150, 44151, 44152, 44153, 44155, and 44156. The RUC made no changes to any of these codes based on the lack of compelling evidence.
Family 7 intestines—Repair
44602	11.91
44603	15.72
44604	16.03
44605	17.25
44615	15.93
44620	12.20
44625	15.05
44626	25.36
44640	16.65
44650	17.12
44660	16.42
44661	19.07
44680	15.40
44700	16.11
44850	10.74
Family 8 Anus/Rectum—Hemorrhoids/Fistula
45000	3.88
45020	4.05
45100	3.16
45108	4.09
46040	4.26
46045	3.71
46060	4.89
46250	3.89
46255	4.60
46257	5.40
46258	5.73
46260	6.37
46261	7.08
46262	7.50
46270	3.20
46275	3.92
46280	5.14
46288	6.13
46934	3.51
46936	3.69
46945	1.84
46946	2.58
Note: All of the work RVUs for Family 8 reflect a recommended decrease from the CY 2000 work RVUs.
Family 9 A B &C Anus/Rectum, Anus (destruction)—10-day global
45900	2.61
45905	2.30
45910	2.80
45915	3.14
46221	2.04
46754	2.20
Note: Based on the lack of compelling evidence, the RUC recommended that no changes be made to the following Family 9 codes: 46083, 46230, 46320, 46935, 46940, 46942, 46900, 46910, 46916, 46917, 46922, and 46924.
Family 10 Anus/Rectum Repair
45505	7.58
45540	16.27
45541	13.40
45550	23.00
45560	10.58
45562	15.38
45563	23.47
45800	17.77
45805	20.78
45820	18.48
45825	21.25
46700	9.13
46750	10.25
46753	8.29
46760	14.43
46761	13.84
46762	12.71
Family 11 Hernia
49500	5.48
49501	8.88
49505	7.60
49507	9.57
49520	9.63
49521	11.97
49525	8.57
49540	10.39
49550	8.63
49553	9.44
49555	9.03
49557	11.15
49560	11.57
49561	14.25
49565	11.57
49566	14.40
49570	5.69
49572	6.73
49580	4.11
49582	6.65
49585	6.23
49587	7.56
49590	8.54
Family 12 A & B Stomach—Gastrectomy and Gastrectomy/Vagotomy
43620	30.04
43621	30.73
43622	32.53
43638	29.00
43639	29.65
43631	22.59
43632	22.59
43633	23.10
43634	25.12
43640	17.02
43641	17.27
Family 13 A & B Stomach—Incision/Excision/Repair
43500	11.05
43501	20.04
43502	23.13
43510	13.08
43520	9.99
43605	11.98
43610	14.60
43611	17.84
43800	13.69
43810	14.65
43820	15.37
43825	19.22
43830	9.53
43832	15.60
43840	15.56
43870	9.69
43842	18.47
43843	18.65
43846	24.05
43847	26.92
43848	29.39
43850	24.72
43855	26.16
43860	25.00
43865	26.52
43880	24.65
Family 14 A Abdomen, Peritoneum, Omentum
The RUC recommended no changes for codes 49000, 49002, 49010, 49200, 49201, 49220, 49255, 49900, 49421, 49422, 49425, 49426, and 49429.
Family 14 B Abdomen, Peritoneum, Omentum
49020	20.73
49040	12.27
49060	14.40
49085	11.03
Family 14 C Abdomen, Peritoneum, Omentum
49428	6.06
Family 15 Appendix
44900	10.14
44950	10.00
44960	12.34
Family 16 Rectum—Proctectomy/Excision
45110	28.00
45112	30.54
45113	30.58
45114	27.32
45116	24.58
45119	30.84
45123	16.71
45126	45.16
45130	16.44
45135	19.28
45160	15.32
45170	11.49
45190	9.74
Family 17 Biliary Tract
47420	19.88
47425	19.83
47460	18.04
47480	10.82
47600	13.58
47605	14.69
47610	18.82
47612	18.78
47620	20.64
47711	23.03
47712	30.24
47715	18.80
47716	16.44
47720	15.91
47721	19.12
47740	18.48
47741	21.34
47760	25.85
47765	24.88
47780	26.50
47785	31.18
47800	23.30
47801	15.17
47802	21.55
47900	19.90
Family 18 Esophagus—Repair/Reconstruction
43320	19.93
43324	20.57
43325	20.06
43326	19.74
43330	19.77
43331	20.13
43340	19.61
43341	20.85
43350	15.78
43351	18.35
43352	15.26
43360	35.70
43361	40.50
43400	21.20
43401	22.09
43405	20.01
43410	13.47
43415	25.00
43420	14.35
43425	21.03
Family 19 Liver
47010	16.01
47015	15.11
47100	11.67
47120	35.50
47122	55.13
47125	49.19
47130	53.35
47300	15.08
47350	19.56
47360	26.92
47361	47.12
47362	18.51
47400	32.49
Family 20 A & B Spleen—Incision/Excision/Repair and Pancreatitis Management
38100	14.50
38101	15.31
38115	15.82
48000	28.07
48001	35.45
48005	42.17
Family 21 Pancreatectomy
48020	15.70
48100	12.23
48120	15.85
48140	22.94
48145	24.02
48146	26.40
48148	17.34
48150	48.00
48152	43.75
48153	47.89
48154	44.10
48155	24.64
48180	24.72
48500	15.28
48510	14.31
48520	15.59
48540	19.72
48545	18.18
48547	25.83
Family 22 Laparoscopy
The RUC recommended no changes to the following codes based on lack of compelling evidence: 43651, 43652, 44200, 44970, 47562, 47563, 47564, 47570, 49320, 49650, and 49651.

The RUC also recommended that the following codes be referred to the CPT Editorial Panel for review and clarification: 36533, 36534, 36535, 49495, and 49496.

HCFA Proposal:

The ACS conducted full surveys of 32 codes, and we agreed with the RUC analysis for most of the 32 codes. For the other codes the ACS did minisurveys that included pre-, intra-, and postservice times as well as the number and type of postservice visits. These minisurveys did not include an estimate of the relative work for the procedure. For this reason, the RUC used an extrapolation methodology to arrive at its work RVU recommendations for all codes that did not have a full RUC survey. To make appropriate extrapolations, the RUC divided all of the general surgery codes into families of related procedures. At least one code in each family was fully surveyed. After the RUC recommended work RVUs for each surveyed code, it applied the percent change for that code to all of the other codes in the family. When more than one code was fully surveyed within a family of services, the RUC extrapolated the percentage from the fully surveyed code that would produce the least increase in work RVUs.

The validity of this extrapolation methodology relies on at least two things—first, that the relative work values of all codes in the family were correct before the extrapolation (or else the extrapolation perpetuates and magnifies any pre-existing anomalies), and second, that the relative misvaluation of each code in a family is similar.

We did an analysis of all the families of codes in the general surgery group to determine whether the relative valuations in the 2001 physician fee schedule contained any anomalies. If any anomalies existed, we reviewed the RUC recommendations to determine whether the anomalies were addressed by the RUC recommendations. If the anomalies were not corrected, we took steps to correct them.

We also analyzed all of the recommended values for general surgery to ensure that the percentage changes for each family were appropriate. To determine if the extrapolation for each family was correct, we compared each extrapolated code to codes in other families, and to codes in other specialties. We compared extrapolated codes to codes whose current or RUC recommended work RVUs (from the 5-year-review) were similar to the extrapolated code. We then compared the preservice, intraservice, and postservice physician times as well as the number of postoperative visits. In addition, we generally determined whether the survey vignette was typical for the procedure. The following is an example of our review of the general surgery codes. Code 35132 (Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, iliac artery (common, internal, external) (30.00 work RVUs) with a preservice time of 67 minutes, intraservice time of 180 minutes, seven hospital visits, and three office visits is similar to codes 47712 (Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic) (30.24 work RVUs) with a preservice time of 75 minutes, intraservice time of 210 minutes, one intensive care unit visit, nine hospital visits, and three office visits and 43638 (Gastrectomy, partial, proximal, thoracic or abdominal approach and esophagogastrostomy with vagotomy) (29.00 work RVUs ) with a preservice time of 75 minutes, intraservice time of 210 minutes, 10 hospital visits, and 4 office visits. A review of these codes demonstrates the similarity in preservice and intraservice time and the proposed RVUs maintain relativity across surgical specialties.

Upon completion of this analysis, we propose to accept the RUC recommendations for the following families of services:

Family 1A and 1B Thyroid and Endocrine.

Family 3 Lymph Nodes and Lymphatic Channels—Incision/Excision.

Family 4 Intestines—Excision/Incision.

Family 5 Intestines—External Fistulization.

Family 9 Anus/Rectum—10-day global period.

Family 10 Anus/Rectum—Repair.

Family 11 Hernia.

Family 12 Stomach—Gastrectomy/Vagotomy.

Family 13 Stomach—Incision/Excision/Repair.

Family 14A and C Abdomen, Peritoneum, Omentum.

Family 15 Appendectomy.

Family 16 Rectum-Proctectomy/Excision.

Family 17 Biliary Tract.

Family 18 Esophagus—Repair/Reconstruction.

Family 19 Liver.

Family 20 Pancreas/Spleen—Incision/Excision/Repair.

Family 21 Pancreatectomy.

Family 22 Laparoscopy.

For the above families, adopting the RUC-recommended RVUs maintains relativity of the codes based upon a comparison of the codes to procedures in other families and within the family.

For other families of services, the extrapolation methodology inappropriately values codes or does not address current rank-order anomalies. Application of the percentage increases derived from the RUC's extrapolation methodology would only exacerbate any current rank-order anomalies within families. Below, we have outlined, for each family of services, our proposed work RVUs to rectify these problems.

Family 2 Lymphadenectomy

The RUC recommended an increase in work RVUs for the fully surveyed code 38745 (Axillary lymphadenectomy; complete) from 8.84 to 11.0 RVUs based on comparisons with codes 60210 (Partial thyroid lobectomy, unilateral, with or without isthmusectomy), and 32100 (Thoracotomy, major with exploration and biopsy). We disagree. Although codes 38745 and 60210 are performed in the outpatient setting and 32100 is not, code 38745 requires more postoperative wound care. Additionally, the RUC compared 38745 to the pre-5-year review value of 32100. Subsequently the RUC reviewed code 32100 for the 5-year review and is recommending an RVU increase to 15.24 RVUs. Because the intraservice times for codes 38745 and 32100 are identical and 38745 requires more postoperative wound care, a clear rank order anomaly would exist if 38745 was valued at 11.00 work RVUs and 32100 was valued at 15.24 work RVUs. Therefore, we are assigning the median survey RVUs of 13.00 to code 38745. We would also note that the survey RVU spread from the 25th percentile to the 75th percentile ranged from 12.15 to 14.29 RVUs, which is relatively small. An RVU of 13.00 places code 38745 in the correct rank order to the comparison codes. To maintain relativity within this family, we are extrapolating the 47 percent increase in work RVUs of code 38745 to codes 38740 (Axillary lymphadenectomy; superficial) and 38760 (Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure)) for proposed work RVUs of 10.02 and 12.94, respectively. However, code 38765 (Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)) represents a rank-order anomaly as it is currently valued too high relative to the other codes in the family. Therefore, we are accepting the RUC recommendation for code 38765 of 19.98 work RVUs.

Family 6 Colectomy

The RUC recommended no change in the work RVUs for this family of codes based on lack of compelling evidence for changing the RVUs of the fully surveyed code 44140 (Partial colectomy). Moreover, the intraservice time for code 44140 had not changed since the last 5-year review. Additionally, the RUC compared code 44140 to code 32480 (Removal of lung, other than total pneumonectomy; single lobe (lobectomy)) and code 50230 (Nephrectomy, including partial ureterectomy, any approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) that have similar work RVUs to 44140 and were believed to be longer, more intense procedures with more postoperative care. We disagree with this recommendation. If the RVUs for procedures in this family are not changed, the procedures will be significantly undervalued compared to other general surgery codes (Family 5 and Family 7) and vascular surgery codes. As an example, we note that the RUC-recommended work RVU for code 44153 Colectomy, total, abdominal, without proctectomy; with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop, will significantly undervalue this code compared to code 45113, Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with our without loop ileostomy, thus creating a rank-order anomaly.

We compared code 44140 to code 32480 for which the RUC is recommending a work RVU increase to 23.75. These procedures have similar intraservice times, and the postoperative visits show that although the initial care required for code 32480 is more intense, the length of stay for code 44140 is frequently longer. We also compared code 44140 to codes 37617, Ligation, major artery (eg post-traumatic, rupture); abdomen, and 35221, Repair blood vessel, direct; intra-abdominal. Code 37617, for which the RUC recommended work RVUs of 22.06, is an emergency operation with a slightly shorter intraservice time and shorter hospital stay. Code 35221, which has RUC-recommended work RVUs of 24.39, is also an emergency operation with an intraservice time and length of stay identical to code 44140. Based on these comparisons, we believe that the survey's 25th percentile work RVUs of 21.00 are appropriate and correctly rank code 44140 to the comparison procedures. This increase is 14 percent greater than the current work RVUs and, with the exception of the two codes discussed below, applying this 14 percent increase to the other codes in this family will place them in proper relationship to other comparable procedures.

Family 6 contains two current rank-order anomalies: code 44151, Colectomy, total, abdominal, without proctectomy; with continent ileostomy, has lower work RVUs than code 44150, Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy, and 44156, Colectomy, total, abdominal, with proctectomy; with continent ileostomy, has lower work RVUs than code 44155, Colectomy, total, abdominal, with proctectomy; with ileostomy. Code 44151 is identical to code 44150, and code 44156 is identical to code 44155, except that codes 44151 and 44156 involve the creation of a “continent ileostomy” instead of an “ileostomy or ileoproctostomy.” The work of creating a “continent ileostomy” is greater than the work of creating an “ileostomy or ileoproctostomy.” To correct this rank-order anomaly, we applied the 14 percent increase discussed above to codes 44150 and 44155. Next, we determined the proper incremental increase in work for creation of a “continent ileostomy” by looking to codes 44310, Ileostomy or jejunostomy, non-tube (separate procedure), and 44316, Continent Ileostomy (Kock procedure) (separate procedure), because the work RVUs of 44316 are the same as the work RVUs of 44310 with the addition of creating a continent ileostomy. We subtracted the RUC-recommended work RVUs of 15.95 for code 44310 from the RUC-recommended work RVUs of 21.09 for code 44316 and divided by 50 percent (50 percent approximates the intraservice portion of the extra work). This resulted in work RVUs of 2.57 that we increased by 14 percent to yield work RVUs of 2.93. We then added 2.93 work RVUs to the RVUs for codes 44150 and 44155 to yield proposed work RVUs of 26.88 for code 44151 and 30.79 for code 44156.

In summary, we propose the following work RVUs for the codes in this family:

Code	Work RVUs
44140	21.00
44143	22.99
44144	21.53
44145	26.42
44146	27.54
44150	23.95
44151	26.88
44152	27.83
44153	30.59
44155	27.86
44156	30.79

With these assigned work RVUs, we believe that Family 6 is ranked appropriately in relation to other general and vascular surgery codes.

Family 7 Intestines—Repair

The RUC recommended an increase of 14 percent for all work RVUs in this family based on a recommended increase in a fully surveyed code 44604 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy) from 14.28 work RVUs to 16.03 work RVUs.

We agree with the increase in work RVUs for code 44604 but note that there are several rank-order anomalies currently in this family of codes that would be exacerbated by an across-the-board increase in work RVUs. Therefore, we propose to correct the rank-order anomalies as follows:

We propose 16.03 work RVUs for 44602 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation). The work RVUs for code 44602 are identical to the work RVUs for code 44604 because they describe the same procedure except code 44604 is for the large intestine.

We propose work RVUs of 19.53 for code 44605 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy). The work RVUs for code 44605 are identical to the work RVUs for code 44604 except that code 44605 includes creating a colostomy with the attendant increase in postoperative wound care. The intraservice work of creating a colostomy is captured by subtracting the work RVUs for code 44140 from code 44143, which leaves 1.99 RVUs. In addition, there is one extra postoperative visit required for code 44605 that we believe is equivalent to code 99233 that has 1.51. work RVUs. Therefore, we added 1.99 and 1.51 work RVUs to the work RVUs for code 44604 to arrive at 19.53 work RVUs for code 44605.

We propose 18.66 work RVUs for code 44603 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations). The additional work required for code 44603 as compared to code 44602 is similar to the additional work required for code 44605 as compared to code 44604 except, since there is no actual colostomy, the additional postoperative visit is comparable to code 99231 with 0.64 work RVUs. Therefore, we added work RVUs of 1.99 and 0.64 to the work RVUs of code 44602 to arrive at 18.66 work RVUs for code 44603.

The current work RVUs for codes 44640 (Closure of intestinal cutaneous fistula); 44650 (Closure of enteroenteric or enterocolic fistula); 44660 (Closure of enterovesical fistula; without intestinal or bladder resection); and 44661 (Closure of enterovesical fistula; with bowel and/or bladder resection) are rank-order anomalies as they are undervalued compared to code 44604. However, relativity among codes 44640, 44650, 44660, and 44661 is appropriate. To correct the anomalies, we compared codes 44650 to 50525 (Closure of nephrovisceral fistula (eg renocolic) including visceral repair; abdominal approach), which involves similar intraoperative and postoperative work. The intraoperative work for code 50525 is greater than that of code 44650 because code 50525 involves visceral repair but the postoperative work for code 44650 is greater than the postoperative work for code 50525 because the fistula is enteroenteric or enterocolic as opposed to renovisceral (that is, renocolic). Therefore, we propose to assign 22.27 work RVUs to code 44650 and, to keep the current relativity with the other codes, we propose 21.65 work RVUs for code 44640, 21.36 work RVUs for code 44660, and 24.81 work RVUs for code 44661. We propose to accept the RUC recommendations for the remaining codes (44615, 44620, 44625, 44626, 44680, 44700, and 44850).

Family 8 Anus/Rectum—Hemorrhoids/Fistula

The RUC extrapolated a 14 percent decrease in work RVUs to all codes in this family based upon a decrease in work RVUs for the fully surveyed code 46262, Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy. We agree with the RUC recommendation for the surveyed code, but disagree with the extrapolation to the anal fistula repair codes and the anal abscess treatment codes. The surveyed intraoperative time for code 46262 is not consistent with the surveyed intraoperative times for many of the other codes in the family. Moreover, the work RVUs for many of the codes subject to the minisurveys are significantly less than for code 46262 and are not comparable. Therefore, we propose to maintain the current RVUs for codes 46270, 46275, 46280, 46288, 45000, 45020, 45100, 45108, 46040, 46045, and 46060. We agree with the RUC recommendations and propose to decrease the work RVUs for other codes in this family of codes (46250, 46255, 46257, 46258, 46260, 46261, 46262, 46934, 46936, 46945, and 46946).

Family 14B Abdomen, Peritoneum, Omentum

The RUC recommended an increase for the fully-surveyed code 49020, (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open,) from 16.79 work RVUs to 20.73 work RVUs, the 25th percentile of surveyed work RVUs, based on a comparison to code 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural). We disagree and propose the surveyed median work RVUs of 22.84. We compared code 49020 to code 35151 (Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, false aneurysm and associated occlusive disease, popliteal artery), 48000 (Placement of drains, peripancreatic, for acute pancreatitis), and code 48140 (Pancreatectomy, distal subtotal, with our without splenectomy; without pancreaticojejunostomy). Code 48000 involves sicker patients but the intraoperative time (120 minutes) and postoperative visits (10-day length of stay for code 48000 with two critical care visits versus an 11-day length of stay for code 49020 with one critical care visit) are similar, and code 48000 has RUC-recommended work RVUs of 28.07. Code 48140, with RUC-recommended work RVUs of 22.94, has a longer intraoperative time (150 minutes) with a shorter length of stay (9 days with one critical care visit) and involves less sick patients. Code 35151, with RUC-recommended work RVUs of 22.64, involves patients not nearly as ill as patients for whom code 49020 is reported, has a surveyed intraoperative time of 150 minutes, and a 5-day length of stay with no critical care visits. Therefore, we propose the median surveyed work RVUs of 22.84 for code 49020. Since the current relativity within this family is correct, we propose to extrapolate this increase of 36 percent to the other codes in this family and value the work as follows: 49040 (13.52), 49060 (15.86), and 49085 (12.14).

Comment: The American Society of Colon and Rectal Surgeons collaborated with the ACS and submitted 12 codes for review that they believe to be undervalued. They also expressed support for the methodology proposed by ACS to value services. The specific codes referenced were: 44130, 44144, 44147, 44151, 44156, 44394, 45111, 45113, 45337, 45339, 45910, and 46258.

RUC Recommendation:

The RUC recommended increasing the work RVUs for the following codes: 44130 (14.49), 45113 (30.58), and 45910 (2.80) to retain current rank-order and relativity within the grouping of services. However, for code 46258, the RUC recommended decreasing the work RVUs to 5.73 to retain the current rank-order and relativity within these services.

For codes 44147, 44394, 45111, 45337, 45339, 44144, 44151, and 44156, the RUC did not receive compelling evidence to suggest an increase was needed in the work RVUs; therefore, the RUC recommended that the current work RVUs for these codes be maintained.

HCFA Proposal: We propose to accept all but one of the RUC recommendations for the surgical codes submitted by the American Society of Colon and Rectal Surgeons. For code 44147, Colectomy, partial; abdominal and transanal approach, we are proposing to increase the work RVUs by 14 percent to 20.71. This is similar to the increase applied to ACS family 6 and will prevent a rank-order anomaly.

Comment: The American Academy of Otolaryngology-Head and Neck Surgery submitted codes, on behalf of the American Otological Society and the American Academy of Facial Plastic and Reconstructive Surgery, that they believe to be undervalued, along with suggested new work RVUs for each service. However, subsequent to the submission of their comments, the specialty society chose not to pursue revaluing of the following codes: (69450, 69436, 69440, 69631, 69205, 69801, 69633, 69501, 69632, 69905, 69666, 69650, 69806, 69667, 69720, 69641, 69550, 69636, 69637, 69643, 69140, 69505, 69635, 69502, 69645, 69511, 69601, 69602, 69642, 69603, 69644, 69910, 69660, 69604, 69646, 69662, 69661, 69930, 69145, 69676, 69310, 69620, 69805, 69670, 69700, 69802, 69320, 69530, 69820, 68711, 69840, 69540, 69421, 69552, 69150, 69915, 69605, 69300, 69000, 69005, 69020, 69711, 69100, 69105, 69110, 69120, 69140, 69145, 691500, 69155, 69200, 69205, 69210, 69220, 69222, 69300, 69310, 69320, 69400, 69401, 69405, 69410, 69420, 69421, 69424, 69433, 69436, 69535, 69554, 69610, 69725, 69740, 69745, 69950, 69955, 69960, 69970).

RUC Recommendation: For codes 69990, 11642, 13131, and 13132, the RUC recommends no change to the current RVUs for these services, as compelling evidence was not provided to demonstrate the need for an increase.

HCFA Proposal: We have reviewed and propose to accept all of the RUC recommendations for the surgical codes submitted by the American Academy of Otolaryngology-Head and Neck Surgery.

3. Thoracic Surgery

Comment: In their comments, the Society of Thoracic Surgeons (STS) indicated that there have been major changes in the practice of thoracic surgery since the initial development of the physician fee schedule. These major changes in surgical techniques, along with changes in the typical patient, have had an impact on physician work. Time and intensity of a number of procedures, including the reference procedures used by STS, have been affected.

The STS grouped codes into three categories: general thoracic surgery, adult cardiac surgery, and congenital thoracic surgery. These three categories were grouped into 23 families of codes. Each family had an anchor code that received a full RUC survey. Each of the remaining codes in a family received a minisurvey. The minisurvey collected information on time and the number of postoperative visits. The minisurvey also asked respondents to estimate work RVUs for the procedure based on the reference service for the family of codes.

The RUC had a number of concerns with the STS approach. They are as follows: (1) The RUC concluded that STS inappropriately had the same survey respondents review and estimate both misvalued services and reference services. (2) In many instances, the respondents valued the code under review relative to their perception of what the reference code value should be, not the current value of the reference code. (3) The STS also used too many minisurveys and too few full surveys. (4) Within a family of codes, the STS inappropriately mixed codes with different global periods.

To overcome these methodological problems, the RUC first reviewed the reference service that was used for each family, and the resulting value was compared to the codes in each family. For the adult cardiac surgery codes, the RUC developed a building-block methodology to validate the survey results. For the congenital thoracic codes, previous RUC reviews of the codes were used to determine how the work has changed since the last 5-year review. In addition, for the pediatric thoracic codes, the specialty's society's presenter offered additional information demonstrating that the patient population has changed, (for example, more neonates) leading to a higher intensity of work.

Additionally, The STS subsequently chose not to pursue review of code 33207 under the 5-year review.

RUC Recommendations: The RUC reviewed 89 thoracic surgery codes. Of this total, the RUC recommended increases for 44 codes, no changes for 43 codes, and decreases for 2 codes. The recommendations by family are as follows:

Family 1: The RUC generally found that the STS had not furnished compelling evidence or that the STS inappropriately compared codes with a zero global period to codes with a 90-day global period. The RUC recommended no increase in work RVUs for codes 32000, 32005, 32020, 32035, 32225, 32602, 32651, and 32652. The RUC recommended increases in work RVUs for code 32220 (24.00) and code 32320 (24.00), based on the median surveyed work RVUs which would place these codes in proper rank order.

Family 2: The RUC recommended increases for code 32440 (25.00) based on the median survey value, and code 32480 (23.75) based on the value of 43415. The RUC also recommended increases in work RVUs for codes 32100 (15.24) and 32110 (23.00) based on a comparison to code 58150. These values place all these codes in proper rank order.

Family 3: The RUC recommended increases in codes 32482 (25.00) and 32500 (22.00), based on the STS surveyed median work RVUs for each code, which would create the proper rank order within the family of codes.

Family 4: The RUC recommended no increase for code 32655 because the STS had not furnished compelling evidence for an increase in work. The RUC recommended increases for codes 31600 (7.18) and 32500 (22.00) based on survey data, a sicker patient population, and, in the case of 31600, comparison to 35474.

Family 5: The RUC recommended increases for codes 38746 (4.89) based on the work RVU for 38747, but recommended no increases for codes 39010, 39220 or 39400 due to lack of compelling evidence or inappropriate comparisons to codes with 90-day global periods.

Family 6: The RUC agreed with the STS analysis of work for codes 43107 (40.00) and 43112 (43.50) and stated that using the survey median for each code correctly rank ordered these codes in the family of esophagectomy codes.

Family 7: The RUC recommended an increase for code 43117 (40.00) after comparing it to the reference service code 43361 which had similar data. The RUC also recommended an increase for code 43122 (40.00) based on the survey median of 40.00 work RVUs which correctly rank ordered this code in the family of esophagectomy codes.

Family 8: The RUC recommended no increase for codes 31625 or 31645 because the STS did not furnish compelling evidence for an increase in work.

Family 9: The RUC recommended increases for the following codes: 33400 (28.50), 33405 (35.00), 33406 (37.50), 33411 (36.25), 33412 (42.00), and 33413 (43.50), based on a building-block approach that used code 33405 as the anchor code for this family.

Family 10: The RUC recommended increases for the following codes: 33426 (33.00), 33427 (40.00), 33430 (33.50), and 33475 (33.00), based on a building-block approach that used code 33427 as the anchor code for this family. The RUC recommended no increases for codes 33425 or 33468 because the building-block approach did not support the STS's requested increase.

Family 11: The RUC recommended increases for the following codes: 33510 (29.00), 33511 (30.00), 33512 (31.80), and 33513 (32.00), based on a building-block approach that used code 33512 as the anchor code for the family. The RUC recommended decreases for codes 33514 (32.75) and 33516 (35.00). These were the values recommended by the STS and validated through the building-block approach.

Family 12: The RUC recommended no increases for the following add-on codes: 33517, 33518, 33519, 33521, 33522, 33523, and 33530, because it believes that they were inappropriately surveyed as 90-day global procedure codes and the results were not reliable.

Family 13: The RUC recommended increases in work RVUs for the following codes: 33533 (30.00), 33534 (32.20), 33535 (34.50), and 33536 (37.50), based on a building-block approach that used code 33533 as the anchor code for the family of codes. The RUC recommended no increase for code 33530 because it is an add-on code and was inappropriately surveyed as a 90-day global surgical procedure.

Family 14: The RUC recommended increases in work RVUs in the following codes: 33860 (38.00), 33861 (42.00), 33863 (45.00), and 33870 (44.00) based on a building-block approach that used code 33860 as the anchor code for the family. The RUC recommended no increase for code 33945 because the building-block approach did not support the higher value requested by the STS.

Family 15: The RUC recommended no increases in work RVUs for the following codes: 33750, 33820, and 33840, due to lack of compelling evidence to support an increase.

Family 16: The RUC recommended an increase in code 33660 (30.00) based on intraservice work RVUs for 33401 and pre- and postservice work RVUs for 33641. The RUC recommended no increase in code 33641 as it did not find any compelling evidence to warrant a change in the work RVUs.

Family 17: The RUC recommended no increase in work RVUs for code 33415, because it did not believe that the typical patient for this procedure has changed, and the minisurvey did not provide compelling evidence to justify a change in the work RVUs. However, the RUC recommended an increase in work RVUs in code 33681 (30.61), because the intraservice intensity of 33681 is more complex than it was 5 years ago.

Family 18: The RUC recommended increases in the following codes: 33615 (34.00), 33670 (35.00), and 33730 (34.25) based on a comparison to code 33412.

Family 19: The RUC recommended increases in work RVUs for the following codes: 33611 (34.00), 33612 (35.00), 33694 (34.00) and 33697 (36.00). The RUC compared the intraservice time of code 33611 to the family anchor code of 33694 and recommended 34.00 work RVUs to maintain proper rank order in the family. The RUC compared code 33612 to code 33611 and agreed code 33612 was equivalent to 33611 plus 1 additional work RVU. The RUC compared code 33694 to 33412 and concluded that all measures of physician work were greater for 33694. The RUC compared code 33697 to 33694 and recommended 36.00 work RVUs to maintain rank order. The RUC recommended no increase for 33767 because there was no compelling evidence for a change in the work RVUs.

Family 20: The RUC recommended an increase in code 33617 (37.00), after comparing it to code 33412 and noting that 33617 has greater intraservice time and higher intensity ranking than code 33412.

Family 21: The RUC recommended an increase in code 33619 (45.00) after comparing it to codes 48150 and 62530.

Family 22: The RUC recommended an increase in code 33506 (35.50) to preserve proper rank order within this family. The RUC recommended an increase in code 33770 (37.00) after finding that the work of this code is more than that of the comparison code 33697. The RUC recommended an increase in code 33778 (40.00), after comparing it to 33870, and 33412 which are less intense procedures. The RUC recommended an increase in code 33780 (41.75), based on a comparison to 33778. 33780 involves more work and warrants an additional 1.75 RVUs due to the additional 35 minutes of intraservice time.

Family 23: The RUC recommended an increase in code 33786 (39.00) after comparing it to 33412, which has less time and intensity. Given the limited specialty survey data, the RUC believed that the recommended increase in code 33919 to 40.00 work RVUs was warranted, but that the survey did not support a value higher than the median survey value.

Based on information supplied to the RUC, the RUC did not recommend a change in RVUs for codes 32520, 33917, 31622, and 32657. For codes 32095, 33410 and 32491, the RUC indicated that it had recently reviewed these codes, and thus it recommended no change. The RUC recommended that codes 33875, 33877, 43107, and 43112 be referred to the CPT Editorial Panel.

HCFA Proposal:

We validated the RUC recommendations by comparing the thoracic surgery codes to vascular surgery and general surgery codes and propose to use the RUC-recommended work RVUs for the thoracic codes based on our own analysis. The following is an example of our review of the thoracic surgery codes. We compared code 32440 (Removal of lung, total pneumonectomy) (25.00 work RVUs) with a preservice time of 90 minutes, intraservice time of 160 minutes, one intensive care unit visit, six hospital visits, and three office visits with the following surgical codes in other surgical specialties: code 34151 (Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac artery, by abdominal incision) (25.00 work RVUs) with a preservice time of 75 minutes, intraservice time of 150 minutes, seven hospital visits, and three office visits and code 44150 (Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy) (23.95 work RVUs) with a preservice time of 63 minutes, intraservice time of 200 minutes, eight hospital visits, and three office visits. A review of these codes demonstrates the similarity in preservice time and intraservice time and the proposed RVUs maintains relativity across surgical specialties.

4. Orthopedic Surgery

Comment: The American Academy of Orthopaedic Surgeons forwarded 42 codes for review. It indicated that these codes were undervalued when compared to their respective reference codes.

RUC Recommendation:

The RUC recommended increasing the work RVUs for the following codes: 29883 (11.05) because this service consists of two procedures; 29889 (16.00) based on increase in post and intraservice work; 29450 (2.08) based on the increased intraservice time for manipulating the foot of the patient; code 28299 (9.18) which is of value equal to the reference code, with the understanding that the code be sent to CPT Editorial Panel to better define the code; code 28705 (18.80), which more accurately reflects the work of the two distinct services of this procedure (ankle fusion and triple arthrodesis); code 23472 (21.10) to correct a rank-order anomaly; code 26562 (15.00) to correct a rank-order anomaly; code 20245 (8.50) to correct a rank-order anomaly; code 27075 (35.00) noting that this is a major operation and there is increased intraservice time with respect to the reference code; code 27077 (40.00) noting that this a major operation and there is increased intraservice time with respect to the reference code; 27284 (23.45) because this is the value for code 27227 that has identical pre-, intra-, and postservice times; code 27286 (23.45) to avoid creating a rank-order anomaly due to the recommended work RVUs increase of code 27284; code 27822 (11.00) to correct an existing rank-order anomaly; code 27823 (13.00) to avoid creating a rank-order anomaly caused by increasing code 27822; code 28445 (15.62) to correct a rank-order anomaly and appropriately reflect the work involved; code 27724 (18.20) to reflect the work for obtaining a graft that was not included in the last 5-year review.

The RUC believed that the commenter provided no compelling evidence to revise the work RVUs for codes 27280, 27282, 23585, 23615, 23630, 23680, 24545, 27216, 27217, 27218, 27226, 27236, 27513, 27536, 27828, 23485, 24435, 27472, 28322, and 28420. Therefore, the RUC recommended the current work RVUs be maintained for these codes.

The RUC referred the following codes to the CPT Editorial Panel for clarification: 23076, 24076, 25076, 27048, 27328, 27619, and 20205, because these codes are being reported incorrectly.

HCFA Proposal:

We propose to accept all but one of the of the RUC recommendations for the orthopedic surgery codes. For code 20245, (Biopsy, bone, excisional; deep (eg, humerus, ischium, femur), the RUC recommended an increase from 3.95 work RVUs to 8.5 work RVUs and compared code 20245 to codes 27635 (Excision or curettage of bone cyst or benign tumor, tibia or fibula), and 27607 (Incision (eg, osteomyelitis or bone abscess), leg or ankle) (work RVUs of 7.78 and 7.97, respectively), because it believed the work required for code 20245 was similar to the work required for these codes. The survey for code 20245 compared the code to code 27635. The intraservice times were similar (90 versus 85 minutes) and the amount of postservice was similar (169 versus 163 minutes). However, the survey median work RVUs were 13 and the 25th percentile RVUs were 8.5. The RUC recommended the 25th percentile RVUs because the RVUs were reasonably close to the RVUs for code 27635. We agree that the current work RVUs are a rank-order anomaly with code 20240 (Biopsy, bone, excisional; superficial (eg, ilium, sternum, spinous process, ribs, trochanter or femur)); however, we disagree with the RUC recommendation. The intraservice work of a deep excisional bone biopsy is similar to the work of excising a bone cyst or benign tumor from the tibia and fibula (code 27635). This is reflected in the similarity in their pre-, intra-, and postservice times. Moreover, the vignette used for code 20245 was atypical in that it involved an ischial lesion, whereas the code is also to be reported for lesions of the humerus and femur. Lesions of the humerus and femur require less dissection and would be more comparable to lesions of the tibia and fibula. Moreover, code 27635 requires complete removal of a known lesion, whereas code 20245 is only an excisional biopsy. Additionally, we are concerned about the spread of work RVUs in the work survey (25th percentile was 8.5 RVUs and 50th percentile was 13.0 work RVUs) and lack of consistency with the time data from the survey. We do not believe there is compelling evidence that the work of code 20245 is greater than the work of code 27635 and are therefore proposing to assign 7.78 work RVUs to code 20245, which is identical to work RVUs for the reference service code 27635.

5. Ophthalmology

Comment: The American Academy of Ophthalmology submitted comments requesting nine codes be reviewed, including one code for evaluation of the global period and not the work RVU. The specialty society subsequently chose not to pursue review of codes 66170, 66172, and 67108.

RUC Recommendation:

The RUC agreed with the request from the specialty society to change the global period from 90 days to 10 days for code 65855 (Laser surgery of eye) and also reduced the work RVUs to 3.85 to account for this reduction in the global period. The RUC noted that code 67218 includes two procedures, and the specialty society indicated that this was not reflected in the original valuation. To correct this error, a building-block approach was used to arrive at new RVUs more reflective of the work of both procedures. The RUC recommended work RVUs of 18.53 for this service. For code 92018, the RUC acknowledged that the preservice work of this service was greater than the standard office procedure because of the need for anesthesia. While concerned about the reliability of the data provided, the RUC recommended that the work RVUs be increased to 2.50, as it suggested during the first 5-year review, with the understanding that the code would be sent to the CPT Editorial Panel for clarification.

For codes 66180, 66986, 67028, and 67904, the RUC believed that the commenters provided no compelling evidence to justify an increase in the work RVUs; therefore, the RUC recommended maintaining the current value for this code.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the ophthalmology codes.

6. Urology

Comment: The American Urological Association presented four codes for review: 50230, 51595, 51596, and 38780. They believed that the work RVUs for these codes do not account for all the in-hospital and office-based postoperative care.

RUC Recommendation:

The RUC questioned the arguments for an increase in RVUs, noting that there was no compelling evidence presented for recommending an increase for three of these codes (51595, 51596 and 38780). However, the RUC noted that the code descriptor for code 50230 includes the term “and/or vena caval thrombectomy” which impacts the work RVU. The RUC agreed to refer this code back to the CPT Editorial Panel to separate these two distinct services so each may be reported and valued appropriately.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the urology codes.

7. Obstetrics/Gynecology

a. Specialty Comments

Comment: The American College of Obstetrics and Gynecology (ACOG) referenced 35 codes in their written comments submitted to us. The specialty society chose not to pursue the review of work RVUs for code 57555, as well as the work RVUs for codes 59150 and 59151.

RUC recommendation:

The RUC recommended increases in the RVUs for the following codes: 38572 (16.59) that would align the code relative to the work of other laparoscopic codes; 56515 (2.76), which was not the value requested by the specialty group but was the value assigned to code 46924, which has comparable work and intraservice time; 56740 (4.57) based on a modified building-block approach, which was similar to ACOG's approach; 57100 (1.20) as presented by the specialty society; 58152 (20.60) in recognition that the current work RVUs are less than the RVUs for code 58150 performed alone even though 58152 combines the work of codes 58150 and 58840; 58260 (12.98) to reflect work of additional office visits included in the procedure; 58262 (14.77) to accurately reflect the work of its component procedures; 58263 (16.06), 58275 (15.76), 58270 (14.26) and 58280 (17.01) to maintain relativity within family of hysterectomy codes; 58267 (17.04) because the procedure is currently undervalued since it encompasses three separate components; 58285 (22.26), which was lower than requested by the specialty group, but which the RUC believed was more reflective of the work for the procedure; 58600 (5.60) based on similarity of this procedure to code 58670; 58605 (5.00) to reflect the slightly lower pre-, intra-, and post-times for this code as compared to 58670; 58611 (1.45) to appropriately reflect the increase in preservice work; 58700 (12.05) reflecting the higher technical skill associated with this procedure (removing only fallopian tube versus ovary and fallopian tube); 58740 (14.00) to reflect increase in intra-service time and postoperative work; 58825 (10.98) which aligns the work value with other codes with similar work; 58920 (11.36) to correct a rank-order anomaly; 58950 (16.93) which combines both codes 58720 and 49255 and applies the multiple procedure rule; 58951 (22.38) based on the similarity of work to 58285 which has the same recommended value; 59812 (4.01) based on the similarity of work to code 59820; 59870 (6.01) based on increased physician work and postoperative time.

The RUC indicated that the commenter provided no compelling evidence to support an increase in the work RVUs for codes 38571, 57130, 57292, 57307, 57505, 58323, 58400, and 58805.

For code 58820, the RUC indicated that this service had recently been reviewed by the RUC and, therefore, the current work RVUs should be maintained.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the obstetrics/gynecology codes.

b. Other Concerns

We have been alerted to concerns that certain female-specific procedures may be undervalued. Our staff has reviewed the work RVUs associated with a number of female-specific procedures, including major and minor surgical procedures as well as several laparoscopic procedures and has determined that, for the most part, the RVUs assigned seem reasonable and consistent with the time, intensity, and postoperative care involved with the procedures. However, there were several codes that seemed to be inappropriately valued as compared to other similar procedures. These procedures are: code 56515 (Destruction of vulvar lesions, extensive); code 57100 (Biopsy of vagina); code 56605 (Biopsy of vulva); code 58100 (Biopsy of endometrium); and code 56810 (Perineoplasty).

We forwarded two of these codes (codes 56515 and 57100) to the RUC for review under the 5-year refinement process, and the RUC has recommended an increase in work RVUs for both of these codes.

We have referred the remaining three codes that appear to be misvalued to the RUC for review, and we anticipate receiving a response from the RUC that we can consider in the November 1, 2001 final rule.

8. Gastroenterology

Comment: The American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), and the American Gastrointestinal Association (AGA) provided comments describing gastrointestinal services that they believed to be misvalued. Their comments focused on the identification of specific services whose work RVUs they believe are too low in comparison to other gastroenterology services when comparing time and intensity of the procedures. They also expressed concern that the work RVUs for all gastroenterology procedures involving conscious sedation are substantially undervalued and need to be increased because of the added requirements associated with conscious sedation.

RUC Recommendation:

With regard to conscious sedation, the RUC was concerned about—(1) The need to break out different levels of physician work for conscious sedation, and (2) many gastroenterology codes have been previously valued with conscious sedation included and some codes were not valued with conscious sedation included. Therefore, the RUC agreed to create a joint RUC and CPT workgroup to review and define the issues related to conscious sedation. Based upon information presented by the specialty at the February 2001 RUC meeting, the RUC agreed that elements of conscious sedation have changed over the past 5 years; however, the RUC was not able to quantify the change in physician work. While the RUC did not recommend a specific increase, it did recommend and urge us to allow separate reporting and payment of conscious sedation codes 99141 and 99142 when conscious sedation is not inherently included as a component of the physician work of the procedure.

Based on technological advances, increased complexity in procedure, and changes in patient population the RUC recommended an increase in work RVUs for the following codes: 43219 (3.18); 43239 (2.87); 43244 (5.05); 43247 (3.59): 43249 (3.35); 43255 (4.82); 43259 (8.59); 43263 (7.29); 43265 (10.02); 43269 (8.21); 44388 (3.70); 44389 (4.26); 44390 (4.81); 44391 (5.18); 44392 (4.81); 44393 (5.00); and 45380 (4.44).

Based on the lack of compelling evidence to increase the work RVUs, the RUC recommended that the current work RVUs be maintained for the following codes: 43217, 43228, 43246, 43251, 43258, 44394, 45383, 45384, and 45385.

HCFA Proposal:

The RUC reviewed a selected series of gastrointestinal endoscopy codes for the 5-year review. These codes included endoscopy of the esophagus, stomach, duodenum, small intestine, large intestine, stoma, and biliary tree. The RUC recommended increases in work RVUs for some of the codes and no change in work for other codes. Unfortunately, the RUC could not review all of the endoscopy codes in each family and, therefore, was in the position of having to make recommendations that would likely cause new rank-order anomalies or exacerbate existing rank-order anomalies within and among these families. Furthermore, creation of rank-order anomalies across specialties was also likely. For example, a bronchoscopic biopsy would be valued significantly less than a gastrointestinal endoscopic biopsy if the gastrointestinal endoscopic biopsy was increased in value.

Although we are concerned that some of these endoscopy codes may be misvalued, we are proposing to keep all work RVUs for gastrointestinal endoscopy codes unchanged. However, we believe that a comprehensive review of the work RVUs for all gastrointestinal endoscopy codes is warranted. Therefore, we are asking the RUC to perform a comprehensive review of all gastrointestinal endoscopy codes to ensure that all codes are properly valued, and that no rank-order anomalies within and across specialties are created or exacerbated. We hope to receive recommendations from the RUC for these codes in time for the proposed physician fee schedule regulation in 2002.

Below we discuss our reasons for proposing to reject the recommended work increases for each code. However, we note that many new gastrointestinal endoscopy CPT codes were created for use in 2002 and reviewed by the RUC concurrent with the 5-year review. Recommendations for these new codes were made by comparing them to the current work RVUs of existing gastrointestinal endoscopy codes, some of which were reviewed as part of the 5-year review. Therefore, any increases in work RVUs for codes in the 5-year review will likely invalidate the work RVUs for many of the new codes reviewed by the RUC. Furthermore, proposals have been made for even more gastrointestinal endoscopy CPT codes for CYs 2002 and 2003. We want to ensure that these new codes are properly reviewed and appropriate work RVUs assigned. Until a comprehensive review of all gastrointestinal endoscopy codes is performed we do not believe this is possible.

Code 43219, Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent:

The RUC recommended an increase in work RVUs from 2.8 to 3.18 based upon the increased complexity of the condition of patients receiving these stents. The current work increment between this code and 43200 (1.21 RVUs) has been used extensively by the RUC to make recommendations for other endoscopic stent placement procedures. Therefore, in spite of this recommendation, it appears that the RUC and the specialists who perform this procedure agree that the correct increment for stent placement is 1.21 work RVUs. If the work RVUs for code 43219 were accepted, many other recommendations from the RUC would need to be reevaluated. Furthermore, it is unclear from the vignette used to value this procedure whether or not predilation of the esophagus was included in the work of this code. Currently, code 43226 describes the work of predilation and may be billed in addition to code 43219. The incremental work for placing a tracheal stent with predilation (the difference in work between codes 31622 and 31631) is 1.59 work RVUs. This is significantly less than the current work increment for esophageal stent placement with predilation, 1.96 (1.21 + .75). Additionally, the vignette describes placement of an expandable wire mesh stent but the code is also used for plastic stents, placement of which may require less work. We propose maintaining the current RVU for this code in view of these concerns and the rank-order anomalies that would be created by accepting the RUC recommendation.

Code 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple):

The RUC recommended an increase in work RVUs from 2.69 to 2.87 based on a larger number of biopsies obtained during a procedure. The RUC also stated that technological advances allowing for greater precision and detail in finding abnormalities have increased the need for this service. The RUC also stated that technological advances have allowed for more immediacy of results which increases the post service work in conveying the biopsy information and treatment guidance to the patient. We would note that the current work increments for all endoscopic gastrointestinal biopsy codes (described as the base procedure with “biopsy, single or multiple”) are 0.3 RVUs. Accepting the RUC recommendation would increase this increment to 0.48 work RVUs while keeping all the other biopsy increments at 0.3 work RVUs, creating a clear rank-order anomaly. Furthermore, this code is used for “single” biopsies, and, with the increase in work, these biopsies would be overvalued. We also do not understand how technological advances in locating lesions and getting more immediate results increases the work of the procedure itself. Therefore, we propose maintaining the current work RVU for this procedure.

Code 43244 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with band ligation of esophageal and/or gastric varices) and 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method):

The RUC recommended an increase in work RVUs for code 43255 from 4.4 to 4.82 work RVUs based on new technology, such as lasers, to control bleeding. The RUC also states that this new technology increases the intensity of the procedure. However, the vignette used to survey code 43255 describes use of cautery to control bleeding. The work for this code must be appropriate for all methods of controlling bleeding and the vignette must represent the typical case. The current work increment for “control of bleeding, any method” for gastrointestinal endoscopic procedures is 2.01 work RVUs. Acceptance of the RUC recommendation for code 43255 would make this work increment 2.43 RVUs, for upper gastrointestinal endoscopy only, creating a clear rank-order anomaly.

The RUC recommended an increase in work RVUs for code 43244 from 4.59 to 5.05 RVUs, based on the increased number of bands used to treat esophageal varices. However, the RUC agreed that the work RVUs for code 43244 were similar to the work RVUs for code 43255. Therefore, accepting the RUC recommendation for code 43244 and not code 43255 would create a clear rank-order anomaly. We believe that these two codes should have similar work RVUs. Therefore, we propose to maintain the current work RVUs for these procedures.

Code 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body):

The RUC recommended an increase in work RVUs for this code from 3.39 to 3.59 work RVUs based on increased complexity of the condition of patients undergoing this procedure with a concomitant increase in risk of morbidity. The RUC used a building-block approach to validate its acceptance of the median work RVUs from the survey. We do not fully understand the building-block analysis the RUC used but believe it was invalid. Moreover, the current work increment for “removal of foreign body” for gastrointestinal endoscopy procedures is 1.0 work RVUs. Acceptance of the RUC recommendation would create a clear rank-order anomaly. Therefore, we propose to maintain the current work RVUs for this procedure.

Code 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30mm diameter)):

The RUC recommended an increase from 2.9 to 3.35 work RVUs for this code based on increased complexity of the condition of patients undergoing this procedure. The current work increment for “balloon dilation of esophagus (less than 30 mm diameter)” is 0.51 RVUs for both the esophagus and upper gastrointestinal endoscopy families. Since this is the same procedure in both families, it is unclear why the work should be increased to 0.96 work RVUs for the upper gastrointestinal family only. Accepting the RUC recommendation would create a clear rank-order anomaly. Therefore, we are proposing to maintain the current work RVUs for this code.

Code 43259 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination):

The RUC recommended an increase in work RVUs from 4.59 to 8.59 based on the complexity of the equipment and the skill and judgement required. The RUC also noted that the survey results supported this procedure as more difficult than an endoscopic retrograde cholangio-pancreatography (ERCP). The RUC then used the following building-block methodology: (1) The RUC added 1.5 work RVUs, which was approximately 75 percent of the difference between the RUC recommendation from the last 5-year review (6.11 work RVUs) and the work RVUs that we assigned (4.0 work RVUs). (2) The RUC then added 2.2 work RVUs, which are the work RVUs of code 93312. Not only do we disagree with the RUC methodology for this recommendation, but we also note that the RUC has used the current work RVUs for code 43259 to value not only other gastrointestinal transendoscopic ultrasound procedures but also many transendoscopic ultrasound guided biopsy codes. We would also note that the RUC has recently re-evaluated code 43231, Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination, and will be sending a new recommendation to us regarding the work valuation of this procedure. Accepting the RUC recommendation for this code would be inconsistent with the RUC's reevaluation of code 43231, would invalidate the work valuation of many other gastrointestinal endoscopy codes, and would create numerous rank-order anomalies. Therefore, we propose to maintain this code at its current work RVUs.

Codes 43263 (Endoscopic retrograde cholangio-pancreatography (ERCP); with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct)), 43265 (ERCP; with endoscopic retrograde destruction, lithotripsy of stone(s), any method), and 43269 (ERCP; with endoscopic retrograde removal of foreign body and/or change of tube or stent):

The RUC recommended an increase in work RVUs from 6.19 to 7.29 for code 43263 based on the need to measure pressures in both the biliary and pancreatic sphincters as well as the need for prolonged postoperative monitoring. The RUC arrived at its recommendation by adding 1.1 work RVUs (the value of code 99214) to the current work RVUs. We disagree with valuing a post procedure observation period as equal to an evaluation and management service. Furthermore, increasing the value of this code while not adjusting the values of codes 43262, 43267, and 43268 creates clear rank-order anomalies.

The RUC recommended an increase in work RVUs from 8.9 to 10.02 for code 43265 based on a rank-order anomaly with code 43264. The RUC compared survey times to the Harvard study times for this code and used a building-block method to arrive at its recommendation. We do not fully understand the RUC methodology and disagree with the conclusion. The Harvard study time data show less time for code 43265 than for code 43264, which would indicate that the current valuations of these codes are correct. Moreover, increasing the value of 43265 while not adjusting codes 43264, 43267, and 43268 would create clear rank-order anomalies.

The RUC recommended an increase in work RVUs from 6.04 to 8.21 for code 43269 based on a rank-order anomaly between this code and code 43268. The RUC used a building-block methodology adding 0.82 work RVUs to the work RVUs of code 43268 (7.39) to arrive at its recommendation. We disagree with the RUC methodology of using an evaluation and management service to arrive at its recommendation since this is an invasive procedure. Furthermore, we believe increasing the value of this code creates a rank-order anomaly with codes 43271 and 43272. Therefore, we are proposing maintaining the current work RVUs of all three of these codes.

Codes 44388 (Colonoscopy through stoma; diagnostic with or without collection of specimen(s) by brushing or washing (separate procedure)), 44389 (Colonoscopy through stoma; with biopsy, single or multiple), 44390 (Colonoscopy through stoma; with removal of foreign body), 44391 (Colonoscopy through stoma; with control of bleeding, any method) 44392 (Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery), and 44393 (Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

These codes are in the same family of codes, and the RUC recommended increases in work RVUs for all these codes based on a misvaluation of the base code in this family of codes, code 44388. The RUC valued it similarly to code 45378. We disagree. We think this creates a clear rank-order anomaly between the value of this family and the value of the colonoscopy family of codes beginning with code 45378. Colonoscopy through a stoma is clearly less work than colonoscopy of the complete colon and it has been valued as such since the inception of the physician fee schedule. We question the accuracy of the surveyed intraservice time for this service. Because of our nonacceptance of the increase in work RVUs for the base code in this family, we must also not accept the recommendations for all other increases in work RVUs for other codes in this family. Moreover, the recommendations create increments of work for “biopsy, single or multiple,” “removal of foreign body,” “control of bleeding, any method,” “removal of tumors,” and “ablation of tumors,” which are inconsistent with the same increments for the colonoscopy family of codes beginning with code 45378. Accepting these RUC recommendations would create clear rank-order anomalies that do not currently exist. Therefore, we are proposing to maintain the current work RVUs for these procedures.

Code 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

The RUC recommended an increase in work RVUs from 3.98 to 4.44 for this code based on the increased number of biopsies generally taken during this procedure and the increased difficulty in removing these polyps. The current work increment for “biopsy, single or multiple” for gastrointestinal endoscopic procedures is 0.3 work RVUs. Accepting the RUC recommendation would create a clear rank-order anomaly. Moreover, we note that this code is also used for single biopsies that would become significantly overvalued if we accepted the RUC recommendation. Therefore, we are proposing to maintain the current work RVUs for this code.

In summary, we believe the only way to accurately value gastrointestinal endoscopy procedures is to evaluate the entire series of codes, including all families of codes (esophagus, upper gastrointestinal, ERCP, and colonoscopy etc.) at the same time. Only then can appropriate incremental work RVUs be determined without creating rank-order anomalies. We would also suggest that the RUC consider reorganization of all these codes to facilitate more accurate coding (for example, to determine whether every family of codes needs a code for “removal of foreign body” or whether the base code be revalued to include more procedures than it currently does).

We suggest that while the RUC is reevaluating these codes that it delay making recommendations on any new codes for this series so that conflicting recommendations are not made and the chance of creating rank-order anomalies is minimized.

With respect to the RUC recommendation concerning reporting and payment of conscious sedation codes 90141 and 90142, we will be reviewing data concerning this issue. Any proposals we would have concerning payment and reporting of conscious sedation codes would be the subject of future rulemaking.

9. Pulmonary Medicine/Critical Care

Comment: Several specialty groups, including the societies for pulmonary medicine and critical care, indicated that codes 36620 and 36489 were undervalued. Commenters indicated that the work RVUs for code 36489 should be greater than the work RVUs for the reference service code, 36010, because there is more work involved. Commenters also stated that code 36620 is undervalued as compared to the reference code 36140, because there are more variables affecting the work involved with this procedure.

These specialty groups also requested that codes 99291 and 99292 be evaluated because the groups claimed they were undervalued.

RUC Recommendation:

For code 36489, the RUC noted that there is additional work and postoperative time involved in this procedure as compared to that of the reference service code 36010, and recommended work RVUs of 2.50 which are higher than the reference service code 36010 (2.43), which corrects the rank-order anomaly. With respect to 36620, the RUC compared this procedure to the reference service (code 36140) and agreed that this service appeared to be undervalued. However, the RUC was concerned that anesthesiologists who perform this procedure over 80 percent of the time did not comment or participate in the survey conducted by the specialty groups. The RUC concluded that code 36620 should be referred to the CPT Editorial Panel to clarify the appropriate use of this code.

The RUC recommended maintaining the work RVUs for critical care services (codes 99291 and 99292) due to the lack of compelling evidence to recommend an increase in the work RVUs above the 2001 work RVUs of 4.00 and 2.00, respectively.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the pulmonary medicine and critical care codes.

10. Cardiology

Comment: The American College of Cardiology (ACC) recommended review of three procedure codes under the 5-year refinement. They are code 93350, which was not reviewed during the first 5-year review but which the ACC believes is undervalued; and codes 33234 and 33235, which ACC argues are undervalued because it does not believe the codes reflect the level of difficulty associated with the procedures.

RUC Recommendation:

The RUC supported an increase in the work RVUs for code 93350 to account for the increased work and more complex conditions of the patient population as supported by survey information submitted. The RUC recommendation was to increase the work RVUs to 1.48. For codes 33234 and 33235, they recommended that no change be made in the work RVUs because both procedures had been recently reviewed by the RUC.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the cardiology codes.

11. Pediatrics

Comment: The American Academy of Pediatrics (AAP) submitted approximately 40 codes involving several specialty areas and indicated that they believed these services are undervalued, particularly when they are provided to the pediatric population. A few of these codes were also submitted by other specialty groups and are discussed under those areas (codes 29450, 99291, and 99292). The AAP subsequently indicated to the RUC that they were not interested in pursuing the review of the work RVUs for the following codes for this 5-year review: 11100, 11730, 17000, 17003, 17004, 20600, 36600, 52300, 52327, and 52340.

RUC Recommendation:

For codes 36400 and 36405, the RUC agreed that an increase in the work RVUs appeared to be warranted and recommended work RVUs of 0.38 and 0.32, respectively. However, for codes 94640, 99440, 99233, 99273, and 99274, the RUC indicated that compelling evidence was not provided to suggest a recommendation to increase the work RVUs and thus the current RVUs should be maintained for these services.

The RUC recommended that the following codes be submitted to the CPT Editorial panel for further consideration: 12001, 12002, 36406, 36520, 50200, 90935, 90937, 90945, 90947, 90989, 90993, 90997, 94664, and 94665.

For codes 99295, 99296, 99297, 99298, and 99436, the RUC recommended no change in the work RVUs for these services because these services had recently been reviewed by the RUC.

HCFA Proposal:

We have reviewed and propose to accept all but two of the RUC recommendations for the pediatric codes.

For code 36400 (Venipuncture, under age 3 years; femoral, jugular or sagittal sinus), the RUC recommended an increase in work RVUs from 0.18 to 0.38. The RUC survey compared this code to code 36410 (Drawing blood, child over 3 or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes) (work RVUs of 0.18). The survey times indicated that the pre-, intra-, and postservice times for code 36400 were less than the times for code 36410. The median work RVUs from the survey were 0.71, and the 25th percentile work RVUs were 0.30. The specialty society recommended work RVUs of 0.71, citing the change in population of patients requiring this procedure (being younger and smaller). The RUC also compared code 36400 to code 99212 (Office/outpatient visit, established patient) with work RVUs of 0.45 and believed the work RVUs of code 36400 were comparable to the work RVUs of code 99212). The RUC then recommended work RVUs between the 25th percentile of the survey and the work RVUs of code 99212. We do not believe it is appropriate to compare the work RVUs of a venipuncture to the work of an evaluation and management service. Furthermore, we are concerned about the spread in the survey work RVUs from 0.30 at the 25th percentile to 0.71 at the median. In view of the survey times being less than the reference code (with work RVUs of 0.18), the inconsistency of the survey times with the survey RVUs, and the inappropriate comparison to an evaluation and management service, we are proposing to continue the work RVUs of code 36400 as 0.18 work RVUs.

For code 36405 (Venipuncture, under age 3 years; scalp vein), the RUC recommended an increase in work RVUs from 0.18 to 0.32. The survey compared code 36405 to code 36410. The pre-, intra-, and postservice times for code 36405 were less than the times for the reference code. The survey RVUs were widely spread with the 25th percentile work RVUs being 0.2 and the median work RVUs being 0.4. The RUC also compared code 36405 to code 99212 (0.45) and recommended a value between the survey 25th percentile work RVUs and the work RVUs for code 99212. Our concerns about this recommendation are similar to the concerns about the recommendation for code 36400. In view of the survey times, the wide range of survey work RVUs, and the inappropriate comparison to an evaluation and management service, we are proposing to continue the work RVUs of code 36405 at 0.18.

12. Pediatric Surgery

Comment: The American Pediatric Surgical Association (APSA) stated that the pediatric surgery procedure codes are misvalued and included recommended work RVUs. While they suggested reductions in the work RVUs of codes 46705 and 46715 to retain relativity in the family of services, they believed that the majority of the codes they provide are significantly undervalued. The association justifies the need to increase the work RVUs for these services based on one or more of the following rationales:

• A change in practice and technology.
• A change in the patient population for which the code is most frequently applied.
• An undervaluation of the postservice work in the global period.
• Rank-order anomalies.
• Extended postoperative critical care. It is the provision of very intensive, prolonged services with long episodes of critical care and long hospital stays that account for the very high work RVUs recommended for some procedures. APSA subsequently indicated that they did not want to pursue review of two codes under the 5-year review: 43305 and 60280.

RUC Recommendation:

The RUC recommended that the suggested decreases in the work RVUs for codes 46705 and 46715 be implemented. The recommended work RVUs are 6.90 for code 46705 and 7.20 for code 46715.

Based on the information provided by the specialty society, the RUC recommended increasing work RVUs for the following codes to address the undervalued physician work in the intra- and postservice periods, the extended critical care services, and a change in patient population: 39503 (95.00); 44055 (22.00); 46716 (15.07); 46730 (26.75); 46735 (32.17); 46740 (30.00); 46742 (35.80); 46744 (52.63); 46746 (58.22); 46748 (64.21); 49215 (33.50); and 49605 (76.00).

The RUC did not receive compelling evidence to suggest that an increase is needed in the work RVUs for these codes: 36822, 45120, 45121, 47701, and 49606.

The RUC recommended that the following codes be referred to the CPT Editorial Panel for clarification and review: 21740, 43310, 43312, 49495, and 49496. In some instances, new codes may need to be created to accurately value services performed on the pediatric and adult population.

HCFA Proposal:

We propose to accept all but two of the RUC recommendations for the pediatric surgery codes. The RUC recommended large increases in work RVUs for codes 39503 (Repair, neonatal hernia, with or without chest tube insertion and with or without creation of ventral hernia) and 49605 (Repair of large omphalocele or gastrochsis; with or without prosthesis) for both of these procedures (an increase from 37.54 to 95.0 work RVUs for code 39503 and from 24.94 to 76.0 work RVUs for code 49605). These increases were based entirely on the increase of postoperative work required for these procedures, resulting in an increase of approximately 50 work units for each code. Both procedures are performed on neonates who require prolonged stays in the intensive care unit postoperatively. We understand that the postoperative care may be performed by the surgeon, the intensivist, or both physicians. In situations where the postoperative care is provided by both physicians, we could make duplicate payments for postoperative care if we continue to value these as 90-day global procedures. To permit the physician who is performing the postoperative care to be appropriately paid, but prevent duplicate payment for the same services, we are considering a reduction in the global period (for example, making the global period 10 or 0 days). If we shortened the global period for these services, appropriate work RVUs consistent with this change would need to be developed. If the surgeon provides postoperative care outside of the 10-day global period (that is, 10 days after the date of surgery)or outside of the 0-day global period (that is, the day after surgery) he or she would bill separately for those services. Moreover, if the intensivist provides the postoperative care, then the intensivist would bill for the service, and there would be no duplicate payment to the surgeon.

Based on the above discussion, we are proposing to maintain the current RVUs for these two CPT codes (39503 and 49605) as an interim for 2002 and would ask the RUC to submit work RVU recommendations for these codes valued with reduced global periods (a 0-day or 10-day period). We would consider the RUC recommendations and make a proposal to initiate a change to the global period as well as associated RVUs in next year's proposed rule. We invite comments on the issue of reducing the global period for these services and welcome any alternative suggestions that we could consider that address our concerns of eliminating duplicate payment.

13. Radiology

Comment: The American College of Radiology (ACR) identified three codes that they believe are undervalued. The code 76065, radiologic examination of an infant, is most commonly performed in the situation of alleged child abuse and requires a significant amount of physician work. Additionally, radiologists indicated that the work RVUs for two mammography procedure codes (codes 76090 and 76091) are not reflective of the amount of physician work necessary to perform all the requirements for the government regulated procedures and ACR standards. The level of quality control and quality assurance requirements instituted by the Food and Drug Administration (FDA) and Mammography Quality Standards Act of 1992 (MQSA) have increased the level of physician time outside of the direct patient care time. The current work RVUs assigned to these codes are not adequate to perform this procedure in accordance with Federal regulations or ACR standards. ACR contended the combination of increased mental effort and judgement, psychological stress, time, and intensity mandate that the work RVUs for these codes should be increased.

RUC Recommendation:

The RUC noted that the intensity for code 76065 is higher than the reference service code 76062 and that for intraservice work the physician typically reviews more films. The RUC recommended work RVUs of 0.70 for code 76065. For the mammography procedure codes, the RUC was in agreement that as a result of the revisions of the MQSA requirements, which require the physician to code radiologic results using BIRADs terminology and require that separate reports be sent to the patient and referring physician, the codes result in increased physician time, mental effort, and judgement. In addition, code 76091 is a bilateral mammography requiring two studies to be performed. Based on survey information, the RUC determined the 25th percentile of the survey was the appropriate value and recommended work RVUs of 0.70 for code 76090 and 0.87 for code 76091.

HCFA Proposal:

We have reviewed and propose to accept all of the RUC recommendations for the radiology codes discussed above.

We would also note that section 104 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554) puts screening mammography under the physician fee schedule for services furnished beginning January 1, 2002. We will include our recommendation of the work RVUs for this service for CY 2002 as part of the physician fee schedule proposed rule for CY 2002.

Because this will be a new code in the physician fee schedule, we have asked the RUC to recommend work RVUs for screening mammography.

14. Plastic Surgery

Comment: The American Society of Plastic Surgery (ASPS) requested that codes 42205 and 49905 be reviewed under the 5-year review. ASPS indicated that there currently is a rank-order anomaly for code 42205 that was created when other codes in the family of codes were reviewed and increased during the first 5-year review. They recommended an increase to the work RVUs (9.59 to 12.0) for this code that would reestablish rank-order in the cleft palate family of codes. With respect to code 49905, ASPS stated that this code is currently designated as an add-on code, which was not the intent of the specialty group when they submitted the proposal to the AMA CPT Editorial Panel in 1991 for creation of this code. They also disagree with our assumption that pre- and postoperative work was included in the RUC-recommended work RVUs that we reduced. ASPA recommended that code 49905 be changed from an add-on to a primary procedure code with a 90-day global period and be assigned work RVUs comparable to those of code 15374 (17.79).

RUC Recommendation:

The RUC reviewed code 42205 and recommended an increase in the work RVUs (for work RVUs of 13.29), which will correct the existing rank-order anomaly in this family of codes. The RUC recommended that code 49905 be referred to the CPT Editorial Panel for review.

HCFA Proposal:

We have reviewed and proposed to accept the RUC recommendations for the plastic surgery codes.

C. Other Comments

1. Anesthesia Services

The American Society of Anesthesiologists (ASA) contended that the work of anesthesia services is undervalued by almost 31 percent. (This initial request was subsequently adjusted based on additional discussions with the RUC.)

As required by law, we base Medicare payments for anesthesia services on allowable base and time units. We have developed a uniform relative value guide in which the base unit per anesthesia code is largely based on the American Society of Anesthesiologists' 1988 relative value guide. Anesthesiologists report the actual anesthesia time for each procedure on the claim, and the carrier converts the time to time units. The carriers then multiply the sum of the base units and time units by the anesthesia conversion factor.

We used the results of the original Harvard Study on work to determine the adjustment to the anesthesia CF under the physician fee schedule in 1992. (Anesthesia services do not have work RVUs. Therefore, if work RVUs of other physician services are increased an adjustment has to be made to the anesthesia CF so that the work of anesthesia services remains on the same scale as other physician work.)

In the first 5-year review of work, we accepted the RUC's recommendation that the work of anesthesia services was undervalued by 22.76 percent, which resulted in a 16 percent increase in the anesthesia CF.

The approach to this 5-year review used by the ASA involves a physician survey and a consensus panel review. The survey was sent to 262 members of the ASA in a geographically representative sample. Eighty-five surveys were returned from respondents who were geographically representative of the specialty as a whole. The findings of the survey were presented to an expert consensus panel of 16 practicing anesthesiologists from the ASA's Relative Value System (RVS) Committee. The work of the anesthesia service was uniformly divided into five components. These components are—preoperative evaluation, equipment and supply preparation, induction period, postinduction anesthesia period, and postoperative care and visits. The survey median times were assigned to each of the five components. The consensus panel assigned the work RVUs of an evaluation and management code, usually codes 99202 or 99201, to the preoperative evaluation. The consensus panel developed a code-specific survey time estimate and intensity value for equipment and supply preparation. For postoperative care and visits, the consensus panel assigned work RVUs equivalent to those of an evaluation and management code, usually code 99211 or 99231. The survey median time for the postinduction anesthesia period was divided in quintiles and each quintile was assigned intensity work RVUs ranging from 0.026 to 0.085. The consensus panel identified the typical anesthetic by procedure code and generally used the intensity of code 31500, Intubation, endotracheal, emergency procedure, a similar CPT code, to value the work. This methodology was used for 19 high-volume surgical codes requiring anesthesia and representing a reasonable variety of surgical services.

The following illustrates this approach for anesthesia code 00404 and the underlying surgical code 19240 (Modified radical mastectomy):

	Work RVUs
Preanesthesia Median Time	15 min.
• Preanesthesia reference code 99202	0.88
Equipment and Supply Preparation Median Time	10 min.   0.14
Induction Period Procedure Time	10 min.   0.93
Post Induction Anesthesia Period:
Level 1 Time	87 min.
Level 2 Time	10 min.
Level 3 Time	10 min.
Level 4 Time	0 min.
Level 5 Time	0 min.   3.09
Postanesthesia Time	14 min.
• Postanesthesia Reference Code 99231	0.64
Total Work RVUs	5.68

For each code, the total work RVUs were compared to a Medicare fee schedule imputed work value. The Medicare imputed work value is computed by multiplying the average allowed anesthesia charge per code by the anesthesia work share and dividing by the national CF. The average anesthesia allowed charge is determined by surgical code from HCFA's 5 percent Beneficiary File.

Based on this analysis, the ASA requested a 24 percent increase in anesthesia work.

RUC Recommendation:

The RUC furnished no recommendation on anesthesia services; instead it assigned to a newly created workgroup the responsibility for reviewing anesthesia services in the context of the physician fee schedule. The ASA will be working with this workgroup on clinical issues, such as induction and postinduction intensity RVUs.

HCFA Proposal:

We propose to make no changes to the anesthesia CF at this time to reflect the 5-year review of physician work for anesthesia services. However, we may make changes in response to recommendations the RUC may provide.

2. Spine Injection Procedures

Comment: The American Society of Anesthesiologists submitted a request for re-evaluation of seven spinal injection codes that they, along with several other medical associations, had expressed concern about when the codes were revalued for CY 2000. They continue to believe the work RVUs assigned by the RUC in 1999 and forwarded to HCFA were appropriate.

RUC recommendation:

In 1999, when the RUC forwarded revised work RVUs, we agreed with the relativity of the four injection codes (62310, 62311, 62318, and 62319), but applied a budget-neutrality factor that the specialties believe is inappropriate. In 1999, we also decreased the RUC-recommended work RVUs for codes 72275, 62263, and 76005 based on our belief that the values were too high. The RUC has now reviewed the original surveys and subsequent recommendations and continues to believe that its 1999 recommendations for work RVUs for these codes are appropriate. They recommended the following work RVUs for these services: 62310 (2.20); 62311 (1.78); 62318 (2.35); 62319 (2.15); 62263 (7.20); 72275 (0.83) and 76005 (0.60). (Note: for code 76005, the work RVUs were 0.60 for this service on the CY 2000 fee schedule)

HCFA Proposal:

We propose to reject the RUC recommendations for these codes for the following reasons:

Codes 62310 (Single injection (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic)), 62311 (Single injection (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodoic, opioid, steroid, other solution), epidural or subarachnoid, lumbar, sacral(caudal)), 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast(for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic), and 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodoic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)).

These were new codes for CY 2000. The RUC submitted recommendations for these codes in CY 1999. We accepted the RUC recommendations and made a work-neutrality adjustment because these new codes replaced codes under which these services were billed before 2000. The RUC and several specialty societies disagreed with the data we used in making our work-neutrality adjustment. (Work-neutrality adjustments ensure that the recommendations for work RVUs for new and revised services are adjusted so that the sum of the new or revised work RVUs (weighted by projected frequency of use).) for a family of codes will be the same as the sum of the current work RVUs (weighted by frequency of use). We have reviewed the data used to make our work-neutrality adjustment and have determined that the adjustment made was accurate. The RUC work recommendations for the 5-year review are identical to the recommendations we received and evaluated in CY 1999. In view of this, we are proposing to maintain the current work RVUs for these services.

Code 62263 (Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, spring-wound catheter) including radiologic localization (includes contrast when administered).

This was a new code for CY 2000. We received RUC recommendations in CY 1999 for this code and disagreed with them. The RUC recommendation was 7.20 work RVUs, and we made the interim work RVUs 6.02 for CY 2000. In the summer of 2000, we convened a multispecialty review panel that reviewed this code in detail and recommended work RVUs of 6.14. We finalized the multispecialty review panel recommendation of 6.14 work RVUs for CY 2001. The current RUC recommendation is identical to the RUC recommendation from CY 1999. We find no compelling reason to change the RVUs for this procedure, especially since this procedure was reviewed by a multispecialty panel less than 1 year ago. We propose to continue the current work RVUs for this procedure.

Code 72275 (Epidurography, radiological supervision and interpretation).

This code was new for CY 2000. The RUC submitted a recommendation for 0.83 RVUs. We disagreed with this recommendation and made the interim work RVUs 0.54 for CY 2000. We submitted this code to a multispecialty review panel that recommended an increase to 0.76 work RVUs that we implemented for CY 2001. The RUC now submits a recommendation of 0.83 work RVUs for this procedure, identical to its prior recommendation. In the absence of compelling reasons to change the current work RVUs, and because this code was reviewed by an objective multispecialty panel less than 1 year ago, we are proposing to continue the current work RVUs.

Additionally, codes 62310, 62311, 62318, 62319, 62263, and 72275 were reviewed and finalized in the July 2000 Multispecialty Refinement Panels for new and/or revised services. Since the RUC recommendations have offered no evidence in addition to that which was presented at the July 2000 Multispecialty Refinement Panel Meeting, we propose to retain the existing work RVUs.

3. Biofeedback

Comment: One organization, Medcare, requested review of the work and practice expense RVUs for biofeedback codes 90911 and 90901, as it believes that these codes currently are undervalued.

RUC Recommendation:

The RUC reviewed the original survey data for code 90911 and noted that while we had decreased the original RUC-recommended work RVUs, we received no further information to indicate that our rationale for reducing the work RVUs was inappropriate, and the specialty societies that perform the service did not present new information in response to the decrease. The RUC recommended that the current RVUs be maintained since it received no compelling evidence to recommend an increase in work RVUs.

HCPAC Recommendation:

The HCPAC recommended that the current work RVUs be maintained for code 90901 because we received no additional information from the specialists who perform this service to warrant an increase in work RVUs.

HCFA Proposal:

We reviewed and propose to accept the RUC and HCPAC recommendations for biofeedback services.

4. Surgical Management of Burn Wounds

Comment: The American Burn Association (ABA) submitted codes commonly used for the surgical management of burn wounds (codes 15000 through 15641). The ABA requested assignment of RVUs for these codes that more appropriately reflect the work involved. ABA also requested the creation of more specific codes that would obviate the need for “G” codes. The ABA indicated that these codes should be exempt from CPT payment policies with respect to the 90-day global period, multiple procedures and staged procedures due to the unique clinical case management of burns.

RUC Recommendation:

The RUC recommended that the following codes be reviewed by the CPT Editorial Panel: 15000, 15001, 15100, 15101, 15120, 15121, 15350, 15351, 15400, and 15401.

HCFA Proposal:

We have reviewed and proposed to accept the RUC recommendation for these codes.

5. Transplantation

Comment: The American Society for Transplant Surgeons requested reassessment of the work RVUs for code 47134 because the current work RVUs do not accurately reflect the work involved (it contended that over 50 percent of these procedures involve right lobectomies that are more labor intensive than left lobectomies, on which the current work RVUs are based). As an alternative, the American Society for Transplant Surgeons also suggested referral to the CPT Editorial Panel for consideration of creation of an additional code.

RUC Recommendation:

The RUC recommended that code 47134 be forwarded to the CPT Editorial Panel for further consideration.

HCFA Proposal:

We have reviewed and propose to accept the RUC recommendation for this code.

6. Arthroscopy Services

Comment: The Arthroscopy Association of North America (AANA) requested that work for other arthroscopy services be reconsidered in light of the increase in work RVUs for code 29848 in the last 5-year review. The AANA also requested a specific increase in the work RVUs for code 29889. Subsequently, the specialty society chose not to pursue its request for consideration for code 29881.

RUC Recommendations:

For code 29883, the RUC noted that this service consisted of two procedures, medial and lateral meniscus repair. Because this service encompassed the work involved in code 29882 plus additional work for the lateral meniscus repair, and using the building-block approach, the RUC recommended work RVUs of 11.05 for this service. For code 29889, the RUC indicated that, due to the increase in post-and intraservice time, the work RVUs should be increased to 16.00.

HCFA Proposal:

We have reviewed and propose to accept the RUC recommendation for this code.

7. Wheelchair Management

Comment: The American Physical Therapy Association requested review of code 97542.

HCPAC Proposal: We had revised the recommended work RVUs for this code when it was previously reviewed by the HCPAC in 1995, based on a comparison of code 97542 to code 97032 rather than to code 97110. The HCPAC concluded that our comparison was incorrect because code 97032 is the application of a modality, while code 97542 requires additional skills because the patients requiring this service have cognitive, sensory, and physical disabilities. In addition, HCPAC indicated that we may not have understood that this procedure is reported very infrequently. The HCPAC supports its original recommendation of 0.45 work RVUs for this service.

HCFA Proposal:

We have reviewed and propose to accept the HCPAC recommendation for this code.

8. Psychological Testing

Comment: The American Psychological Association recommended that we review five psychological testing codes (96100, 96105, 96110, 96115, and 96117).

HCPAC Recommendation:

The HCPAC did not have any recommendations for these codes at this time. However, it indicated that the American Psychological Association may request HCPAC to review these services at a future date once additional information is collected.

HCFA Proposal:

We propose to make no changes at this time. We believe more precise definitions of these services may be necessary to value them properly and to ensure proper coding and billing of these services.

9. Podiatric Services

Comment: The American Podiatric Medical Association submitted five codes (trim skin lesions/trim nails) for review (11719, 11055, 11056, 11057, and G0127) indicating that they are undervalued and do not accurately reflect the level of physician work involved.

HCPAC Recommendation:

The HCPAC reviewed these codes and had no information to support an increase in work RVUs. However, the HCPAC requested that we review our current utilization data to ensure that the original utilization assumptions were correct. The HCPAC recommended that the current review of data should be based on actual 1999 utilization data since these codes were not fully implemented until April 1, 1998.

HCFA Proposal:

Taking into account the recommendation of the HCPAC, we propose to review utilization data associated with the aforementioned codes to ensure the original assumptions are still correct. We will publish our final decision in the November 2001 final rule.

D. Other Issues

1. Critical Care Services in a Global Period

Validation of RUC recommendations for the work of many surgical procedures included the use of a “building-block” methodology as previously described. Before this 5-year review, the RUC compared the work of a postoperative intensive care unit visit by the surgeon to a level three subsequent hospital visit (code 99233) which is valued at 1.51 work RVUs. Now, for the first time since the inception of the physician fee schedule, one of the “building blocks” the RUC used to validate postoperative work by the surgeon in the intensive care unit is code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes), which is valued at 4.00 work RVUs. Specifically, the RUC validated the postoperative work of several thoracic, vascular, and general surgical procedures by comparing the surgeon's intensive care unit visits to code 99291.

Current Medicare policy allows separate payment to the surgeon for postoperative critical care services during the surgical global period only when the patient has suffered trauma or burns. If the surgeon provides critical care services during the global period, for reasons unrelated to the surgery, that is separately payable as well.

The RUC recommendations have raised several issues for which we are considering future action. In view of our desire to ensure that Medicare beneficiaries have appropriate access to critical care services, and to ensure that we make appropriate payments to physicians furnishing postoperative critical care services to Medicare beneficiaries, we are soliciting information and comments on the following questions and issues:

1. If critical care (as described in CPT 2001) is provided postoperative, who typically provides this care? The surgeon, an intensivist, other physicians?

2. Do surgeons typically meet the CPT requirements for billing critical care services (as described in CPT 2001) when making intensive care unit visits on their postoperative patients?

3. Are surgeons currently performing more, or less, critical care on their postoperative patients than they were at the time of the last 5-year review?

4. What is, or will be, the effect of “closed” intensive care units (a unit staffed by dedicated intensivists who manage the care for all patients in the intensive care unit) on who performs postoperative critical care services?

5. What is the likelihood of making duplicate payment for critical care services if the surgical global period is valued with the inclusion of critical care in the postoperative work (for example, if we also pay an intensivist for postoperative critical care services)?

6. If valuation of the surgical global period includes postoperative critical care, are there concerns about additional carrier scrutiny being applied to claims from intensivists for postoperative critical care services?

7. Does valuation of the surgical global period with the inclusion of postoperative critical care create an incentive for the surgeon to either (a) not perform postoperative critical care services if there is an intensivist available or (b) to not consult an intensivist if one is available?

Below are some of the options we are considering:

• Removing work RVUs for critical care services from the surgical global period, valuing these services as subsequent hospital visits and allowing surgeons to bill separately for critical care (for an identified subset of surgical procedures where there is a high likelihood that the surgeon is typically providing critical care services).
• Removing the work RVUs for critical care services from the surgical global period, valuing these services as subsequent hospital visits and not allowing surgeons to bill separately for critical care services.
• Leaving the work RVUs for critical care services in the surgical global period, not allowing surgeons to bill separately for critical care services, requiring surgeons to follow documentation rules for critical care services and instructing carriers to make payment for medically necessary critical care services furnished by other physicians. (This option would facilitate tracking of critical care services, permit appropriate medical record review, and provide a basis to re-evaluate the work of the procedure.)

Valuing the surgeon's postoperative intensive care unit visits as critical care services has raised a number of issues. We believe these issues will require a change in payment policy to ensure that postoperative critical care is appropriately paid. Therefore, we are proposing to make the work RVUs for those surgical codes where any postoperative intensive care unit visits were valued as critical care, interim, until we address the issues discussed above.

2. Codes Referred to CPT

As discussed in sections B and C above, there were some codes that commenters had submitted for review that the RUC recommended be referred to the CPT Editorial Panel for clarification or consideration of definitional changes. These codes are listed in Table 2, which follows.

Table 2.—Codes Referred to CPT Editorial Panel From Five-Year Review of Work Relative Value Units

CPT/HCPCS code 1	Mod	Descriptor
12001		Repair superficial wound(s)
12002		Repair superficial wound(s)
15000		Skin graft
15001		Skin graft add-on
15100		Skin split graft
15101		Skin split graft add-on
15120		Skin split graft
15121		Skin split graft add-on
15350		Skin homograft
15351		Skin homograft add-on
15400		Skin heterograft
15401		Skin heterograft add-on
20205		Deep muscle biopsy
21740		Reconstruction of sternum
23076		Removal of shoulder lesion
24076		Remove arm/elbow lesion
25076		Removal of forearm lesion
27048		Remove hip/pelvis lesion
27328		Removal of thigh lesion
27619		Remove lower leg lesion
33875		Thoracic aortic graft
33877		Thoracoabdominal graft
35381		Rechanneling of artery
35541		Artery bypass graft
35546		Artery bypass graft
35551		Artery bypass graft
35582		Vein bypass graft
35641		Artery bypass graft
35646		Artery bypass graft
35840		Explore abdominal vessels
35860		Explore limb vessels
36406		Drawing blood
36520		Plasma and/or cell exchange
36533		Insertion of access device
36534		Revision of access device
36535		Removal of access device
36620		Insertion catheter, artery
37615		Ligation of neck artery
37618		Ligation of extremity artery
37700		Revise leg vein
37720		Removal of leg vein
37730		Removal of leg veins
37735		Removal of leg veins/lesion
37760		Revision of leg veins
37785		Revision secondary varicosity
43215		Esophagus endoscopy
43310		Repair of esophagus
43312		Repair esophagus and fistula
47134		Partial removal, donor liver
49495		Repair inguinal hernia, init
49496		Repair inguinal hernia, init
49905		Omental flap
50200		Biopsy of kidney
50230		Removal of kidney
90935		Hemodialysis, one evaluation
90937		Hemodialysis, repeated eval
90945		Dialysis, one evaluation
90947		Dialysis, repeated eval
90989		Dialysis training, complete
90993		Dialysis training, incompl
90997		Hemoperfusion
94664		Aerosol or vapor inhalations
94665		Aerosol or vapor inhalations

3. Budget Neutrality

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

We considered making the statutorily required budget-neutrality adjustments to account for the 5-year review of physician work by reducing all work RVUs. We estimate that all work RVUs would have to be reduced by 0.7 percent under this option. Alternatively, we considered making an adjustment to the physician fee schedule CF to meet the provisions of section 1848(c)(2)(B). This option would require an estimated 0.3 percent reduction in the conversion factor. For the 5-year review, we are proposing to reduce the conversion factor by 0.3 percent to meet the provisions of section 1848(c)(2)(B).

HCFA Proposal:

We propose to make the budget-neutrality adjustment by reducing the CF.

4. Calculation of Practice Expense and Malpractice Expense RVUs

As we noted in the November 2, 1999 final rule (64 FR 59427), practice expense and malpractice expense RVUs were not subject to comment and will not be recalculated (other than the change to practice expense RVUs that result from changes in work) as part of the 5-year review of work RVUs. Section 4505 of the BBA also provides for the gradual 4-year transition for resource-based practice expenses, with resource-based practice expenses becoming fully effective in CY 2002. We are currently in the process of developing our annual physician fee schedule proposed rule that will continue the 4-year refinement process for resource-based practice expense RVUs.

Section 4505(f) of the Balanced Budget Act of 1997 (BBA) amended section 1848(c)(2)(C) of the Act and requires us to implement resource-based malpractice RVUs for services furnished beginning in CY 2000. A methodology for establishing resource-based malpractice RVUs was included in the November 1999 final rule and implemented January 1, 2000. In addition, based on concerns expressed by commenters, updated premium data used under this methodology were obtained and used to calculate malpractice RVUs for CY 2001.

Since resource-based malpractice RVUs were recently implemented, and resource-based practice expenses are in the final phase of transition to a fully resource-based system, these components are not being included in this 5-year review. However, as stated above we expect to publish our annual physician fee schedule proposed rule that will propose continuing refinements to resource-based practice expense RVUs.

5. Nature and Format of Comments on Work RVUs

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

III. Collection of Information Requirements

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

IV. Response to Comments

Because of the large number of 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 comment received by the date and time specified in the DATES section of this preamble, and we will respond to the comments in the physician fee schedule final rule.

V. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this proposed notice as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 9, 1980 Public Law 96-354). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity).

A regulatory impact analysis must be prepared for major rules with economically significant effects ($100 million or more annually). While the changes in the Medicare physician fee schedule due to the 5-year review are budget neutral, they do involve a redistribution of Medicare spending among procedures that will exceed $100 million. For this reason, we are considering this to be a major rule. We estimate that the aggregate amount of payments being redistributed among specialties as a result of the 5-year review will be over $200 million.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations and government agencies. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $7.5 million or less annually for physicians and $5 million or less for other practitioners. For purposes of the RFA and based on small business administration data for 1997 we estimate that there are 162,000 physician organizations that meet the definition of a small entity. There are about 700,000 physicians and other practitioners who receive Medicare payment under the physician fee schedule. Individuals and States are not included in the definition of a small entity.

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 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any one year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. We have determined that this rule has no consequential effect on State, local or tribal governments. We believe the private sector costs of this rule will fall below this threshold as well.

For purposes of Executive Order 12866 and the RFA, 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 proposed notice, details the costs and benefits of the proposed notice, analyzes alternatives, and presents the measures we considered to minimize burden on small entities. Section 1848(c)(2)(B) of the Act requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustments to preserve budget neutrality. This year, budget-neutrality adjustments will be required for changes in work relative value units resulting from the 5-year refinement. Revisions in payment policies, including the establishment of interim and final relative value units for coding changes that will be announced later this year, may result in additional budget-neutrality adjustments.

We considered making the statutorily required budget-neutrality adjustments to account for the 5-year review of physician work by reducing all work RVUs. We estimate that all work RVUs would have to be reduced by 0.7 percent under this option. Alternatively, we considered making an adjustment to the physician fee schedule CF to meet the provisions of section 1848(c)(2)(B) of the Act. This option would require an estimated 0.3 percent reduction in the CF. For the 5-year review, we are proposing to reduce the CF by 0.3 percent to meet the provisions of section 1848(c)(2)(B) of the Act.

Table 3.—Percent Change in Total Payments by Specialty Resulting From the 5 Year Review of Work

Specialty	Allowed charges (billions)	Percent change in total payments from increase in work	Percent change in total payments from change in PE	Total percent change in payments from 5 year review
Anesthesiology	1.5	1	0	1
Cardiac Surgery	0.3	5	1	6
Cardiology	4.2	0	−1	−1
Chiropractor	0.4	0	0	0
Clinics	1.6	0	0	0
Dermatology	1.4	0	0	0
Emergency Medicine	1.0	0	0	0
Family Practice	3.3	0	0	0
Gastroenterology	1.2	0	0	0
General Practice	1.0	0	0	0
General Surgery	2.0	3	1	4
Hematology Oncology	0.6	0	−1	−1
Internal Medicine	7.1	0	0	0
Nephrology	1.0	0	0	0
Neurology	0.9	0	0	0
Neurosurgery	0.4	0	0	0
Nonphysician Practitioner	1.2	0	0	0
Obstetrics/Gynecology	0.4	0	0	0
Ophthalmology	3.9	0	0	0
Optometrist	0.5	0	0	0
Orthopedic Surgery	2.3	0	0	0
Other Physician	1.6	0	0	0
Otolaryngology	0.6	0	0	0
Pathology	0.6	0	0	0
Plastic Surgery	0.2	0	0	0
Podiatry	1.1	0	0	0
Psychiatry	1.1	0	0	0
Pulmonary	1.1	0	0	0
Radiation Oncology	0.7	0	−1	−1
Radiology	3.3	0	−1	−1
Rheumatology	0.3	0	0	0
Suppliers	0.5	0	0	−1
Thoracic Surgery	0.5	4	1	5
Urology	1.3	0	0	0
Vascular Surgery	0.3	2	0	2
Note: This table incorporates two separate budget neutrality adjustments. The increase in practice expense relative value units is incorporated through a rescaling of all practice expense RVUs. In addition, all physician fee schedule payments (not the work RVUs) are reduced to make the increase in physician work RVUs budget neutral.

The table above shows the specialty level payment impact of changes in work and practice expense relative values resulting from the 5-year review. The table includes the effect of budget-neutrality adjustments applied to the physician fee schedule CF. Since the practice expense RVUs are based, in part, on physician work, the table also reflects changes in practice expense RVUs that will result from the 5-year review of physician work. The changes in practice expense RVUs resulting from the changes in physician work RVUs were made budget neutral by rescaling all practice expense RVUs. This table shows the impact on payments per service at the specialty level that would result only from the 5-year review of physician work RVUs.

We are in the process of developing our annual physician fee schedule proposed rule that will make refinements in practice expense RVUs and other policies that will affect payment for physician fee schedule services in CY 2002. As part of the physician fee schedule proposed rule, we expect to use revised physician times submitted to us by the RUC in the methodology for determining practice expense RVUs. The RUC is recommending that we use new time data for codes in which they recommended a change in work RVUs. In addition, the RUC is recommending a revision of the time data for many other codes. For some specialties, we expect that use of the revised times will change the impacts shown here.

In particular, it appears that the revised times submitted to us by the RUC are less than the times included in our database for many heart and chest procedures. Our expectation is that use of the RUC recommended times will result in a reduction in the practice expense RVUs for these services that are predominantly performed by cardiac and thoracic surgeons. This means that our expectation is that the total payment increase shown here for these specialties will be less when the revised times are used to determine the practice expense RVUs. In addition, there may be other refinements to the practice expense RVUs or other changes in policies that may result in a specialty level payment impact for 2002 that we will announce in our proposed rule. We will show the combined payment impact by specialty, as a result of the revised times and other proposed policy changes, in our notice of proposed rulemaking that we expect to be published shortly.

We will show the combined impact of all policy changes affecting physician fee schedule payments in 2002 in one final rule that we expect to be published no later than November 1, 2001.

Federalism: Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have determined that this rule will not impose substantial direct requirement costs on State and local governments, preempt State law, or otherwise have Federalism implications.

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

(42 U.S.C. 1395k(a)(2)(F) and 1395l(i)(1) and (2)); 42 CFR 416.120, 416.125, and 416.130)

(Catalog of Federal Domestic Assistance Programs No. 93.774, Medicare—Supplementary Medical Insurance Program)

Dated: April 17, 2001.

Michael McMullan,

Acting Deputy Administrator, Health Care Financing Administration.

Dated: April 23, 2001.

Tommy G. Thompson,

Secretary.

—————————— ¹ All CPT codes and descriptors copyright 2000 American Medical Association

Addendum—Codes Subject to Comment

CPT/HCPCS code 1	Mod	Descriptor	Proposed work RVU
G0127		Trim nail(s)	0.11
11055		Trim skin lesion	0.27
11056		Trim skin lesion, 2 to 4	0.39
11057		Trim skin lesions, over 4	0.50
11402		Removal of skin lesion	1.61
11642		Removal of skin lesion	2.93
11642		Removal of skin lesion	2.93
11719		Trim nail(s)	0.11
12001		Repair superficial wound(s)	1.70
12002		Repair superficial wound(s)	1.86
12011		Repair superficial wound(s)	1.76
13101		Repair of wound or lesion	3.92
13131		Repair of wound or lesion	3.79
13132		Repair of wound or lesion	5.95
15000		Skin graft	4.00
15001		Skin graft add-on	1.00
15100		Skin split graft	9.05
15101		Skin split graft add-on	1.72
15120		Skin split graft	9.83
15121		Skin split graft add-on	2.67
15350		Skin homograft	4.00
15351		Skin homograft add-on	1.00
15400		Skin heterograft	4.00
15401		Skin heterograft add-on	1.00
19000		Drainage of breast lesion	0.84
19100		Biopsy of breast	1.27
19125		Excision, breast lesion	6.06
19160		Removal of breast tissue	5.99
19162		Remove breast tissue, nodes	13.53
19240		Removal of breast	16.00
20205		Deep muscle biopsy	2.35
20245		Bone biopsy, excisional	7.78
21740		Reconstruction of sternum	16.50
21800		Treatment of rib fracture	0.96
23076		Removal of shoulder lesion	7.63
23472		Reconstruct shoulder joint	21.10
23485		Revision of collar bone	13.43
23585		Treat scapula fracture	8.96
23615		Treat humerus fracture	9.35
23630		Treat humerus fracture	7.35
23680		Treat dislocation/fracture	10.06
24076		Remove arm/elbow lesion	6.30
24435		Repair humerus with graft	13.17
24545		Treat humerus fracture	10.46
25076		Removal of forearm lesion	4.92
26562		Repair of web finger	15.00
27048		Remove hip/pelvis lesion	6.25
27075		Extensive hip surgery	35.00
27077		Extensive hip surgery	40.00
27216		Treat pelvic ring fracture	15.19
27217		Treat pelvic ring fracture	14.11
27218		Treat pelvic ring fracture	20.15
27226		Treat hip wall fracture	14.91
27236		Treat thigh fracture	15.60
27280		Fusion of sacroiliac joint	13.39
27282		Fusion of pubic bones	11.34
27284		Fusion of hip joint	23.45
27328		Removal of thigh lesion	5.57
27472		Repair/graft of thigh	17.72
27513		Treatment of thigh fracture	17.92
27536		Treat knee fracture	15.65
27590		Amputate leg at thigh	12.03
27619		Remove lower leg lesion	8.40
27724		Repair/graft of tibia	18.20
27822		Treatment of ankle fracture	11.00
27823		Treatment of ankle fracture	13.00
27828		Treat lower leg fracture	16.23
28299		Correction of bunion	9.18
28322		Repair of metatarsals	8.34
28420		Treat/graft heel fracture	16.64
28445		Treat ankle fracture	15.62
28705		Fusion of foot bones	18.80
29450		Application of leg cast	2.08
29450		Application of leg cast	2.08
29883		Knee arthroscopy/surgery	11.05
29889		Knee arthroscopy/surgery	16.00
29889		Knee arthroscopy/surgery	16.00
31600		Incision of windpipe	7.18
31622		Dx bronchoscope/wash	2.78
31622		Dx bronchoscope/wash	2.78
31625		Bronchoscopy with biopsy	3.37
31645		Bronchoscopy, clear airways	3.16
32000		Drainage of chest	1.54
32000		Drainage of chest	1.54
32005		Treat lung lining chemically	2.19
32020		Insertion of chest tube	3.98
32035		Exploration of chest	8.67
32095		Biopsy through chest wall	8.36
32100		Exploration/biopsy of chest	15.24
32110		Explore/repair chest	23.00
32220		Release of lung	24.00
32225		Partial release of lung	13.96
32320		Free/remove chest lining	24.00
32440		Removal of lung	25.00
32440		Removal of lung	25.00
32480		Partial removal of lung	23.75
32480		Partial removal of lung	23.75
32482		Bilobectomy	25.00
32491		Lung volume reduction	21.25
32500		Partial removal of lung	22.00
32520		Remove lung & revise chest	21.68
32602		Thoracoscopy, diagnostic	5.96
32651		Thoracoscopy, surgical	12.91
32652		Thoracoscopy, surgical	18.66
32655		Thoracoscopy, surgical	13.10
32657		Thoracoscopy, surgical	13.65
33234		Removal of pacemaker system	7.82
33235		Removal of pacemaker electrode	9.40
33400		Repair of aortic valve	28.50
33405		Replacement of aortic valve	35.00
33406		Replacement of aortic valve	37.50
33410		Replacement of aortic valve	32.46
33411		Replacement of aortic valve	36.25
33412		Replacement of aortic valve	42.00
33413		Replacement of aortic valve	43.50
33415		Revision, subvalvular tissue	27.15
33425		Repair of mitral valve	27.00
33426		Repair of mitral valve	33.00
33427		Repair of mitral valve	40.00
33430		Replacement of mitral valve	33.50
33468		Revision of tricuspid valve	30.12
33475		Replacement, pulmonary valve	33.00
33506		Repair artery, translocation	35.50
33510		CABG, vein, single	29.00
33511		CABG, vein, two	30.00
33512		CABG, vein, three	31.80
33513		CABG, vein, four	32.00
33514		CABG, vein, five	32.75
33516		Cabg, vein, six or more	35.00
33517		CABG, artery-vein, single	2.57
33518		CABG, artery-vein, two	4.85
33519		CABG, artery-vein, three	7.12
33521		CABG, artery-vein, four	9.40
33522		CABG, artery-vein, five	11.67
33523		Cabg, art-vein, six or more	13.95
33530		Coronary artery, bypass/reop	5.86
33533		CABG, arterial, single	30.00
33534		CABG, arterial, two	32.20
33535		CABG, arterial, three	34.50
33536		Cabg, arterial, four or more	37.50
33611		Repair double ventricle	34.00
33612		Repair double ventricle	35.00
33615		Repair, simple fontan	34.00
33617		Repair, modified fontan	37.00
33619		Repair single ventricle	45.00
33641		Repair heart septum defect	21.39
33660		Repair of heart defects	30.00
33670		Repair of heart chambers	35.00
33681		Repair heart septum defect	30.61
33694		Repair of heart defects	34.00
33697		Repair of heart defects	36.00
33730		Repair heart-vein defect(s)	34.25
33750		Major vessel shunt	21.41
33767		Major vessel shunt	24.50
33770		Repair great vessels defect	37.00
33778		Repair great vessels defect	40.00
33780		Repair great vessels defect	41.75
33786		Repair arterial trunk	39.00
33820		Revise major vessel	16.29
33840		Remove aorta constriction	20.63
33860		Ascending aortic graft	38.00
33861		Ascending aortic graft	42.00
33863		Ascending aortic graft	45.00
33870		Transverse aortic arch graft	44.00
33875		Thoracic aortic graft	33.06
33877		Thoracoabdominal graft	42.60
33917		Repair pulmonary artery	24.50
33919		Repair pulmonary atresia	40.00
33945		Transplantation of heart	42.10
34101		Removal of artery clot	10.00
34111		Removal of arm artery clot	10.00
34151		Removal of artery clot	25.00
34151		Removal of artery clot	25.00
34201		Removal of artery clot	10.03
34201		Removal of artery clot	10.03
34203		Removal of leg artery clot	16.50
34203		Removal of leg artery clot	16.50
34401		Removal of vein clot	25.00
34401		Removal of vein clot	25.00
34421		Removal of vein clot	12.00
34421		Removal of vein clot	12.00
34451		Removal of vein clot	27.00
34451		Removal of vein clot	27.00
34490		Removal of vein clot	9.86
34501		Repair valve, femoral vein	16.00
34510		Transposition of vein valve	18.95
34520		Cross-over vein graft	17.95
34530		Leg vein fusion	16.64
35011		Repair defect of artery	18.00
35011		Repair defect of artery	18.00
35013		Repair artery rupture, arm	22.00
35013		Repair artery rupture, arm	22.00
35045		Repair defect of arm artery	17.57
35045		Repair defect of arm artery	17.57
35081		Repair defect of artery	28.01
35082		Repair artery rupture, aorta	38.50
35082		Repair artery rupture, aorta	38.50
35092		Repair artery rupture, aorta	45.00
35092		Repair artery rupture, aorta	45.00
35103		Repair artery rupture, groin	40.50
35103		Repair artery rupture, groin	40.50
35111		Repair defect of artery	25.00
35111		Repair defect of artery	25.00
35112		Repair artery rupture, spleen	30.00
35112		Repair artery rupture, spleen	30.00
35121		Repair defect of artery	30.00
35121		Repair defect of artery	30.00
35122		Repair artery rupture, belly	35.00
35122		Repair artery rupture, belly	35.00
35131		Repair defect of artery	25.00
35131		Repair defect of artery	25.00
35132		Repair artery rupture, groin	30.00
35132		Repair artery rupture, groin	30.00
35141		Repair defect of artery	20.00
35141		Repair defect of artery	20.00
35142		Repair artery rupture, thigh	23.30
35142		Repair artery rupture, thigh	23.30
35151		Repair defect of artery	22.64
35151		Repair defect of artery	22.64
35152		Repair artery rupture, knee	25.62
35152		Repair artery rupture, knee	25.62
35182		Repair blood vessel lesion	30.00
35184		Repair blood vessel lesion	18.00
35189		Repair blood vessel lesion	28.00
35190		Repair blood vessel lesion	12.75
35201		Repair blood vessel lesion	16.14
35201		Repair blood vessel lesion	16.14
35206		Repair blood vessel lesion	13.25
35221		Repair blood vessel lesion	24.39
35221		Repair blood vessel lesion	24.39
35226		Repair blood vessel lesion	14.50
35226		Repair blood vessel lesion	14.50
35231		Repair blood vessel lesion	20.00
35231		Repair blood vessel lesion	20.00
35236		Repair blood vessel lesion	17.11
35236		Repair blood vessel lesion	17.11
35246		Repair blood vessel lesion	26.45
35246		Repair blood vessel lesion	26.45
35251		Repair blood vessel lesion	30.20
35251		Repair blood vessel lesion	30.20
35256		Repair blood vessel lesion	18.36
35261		Repair blood vessel lesion	17.80
35261		Repair blood vessel lesion	17.80
35266		Repair blood vessel lesion	14.91
35266		Repair blood vessel lesion	14.91
35276		Repair blood vessel lesion	24.25
35276		Repair blood vessel lesion	24.25
35281		Repair blood vessel lesion	28.00
35281		Repair blood vessel lesion	28.00
35286		Repair blood vessel lesion	16.16
35311		Rechanneling of artery	27.00
35311		Rechanneling of artery	27.00
35321		Rechanneling of artery	16.00
35321		Rechanneling of artery	16.00
35331		Rechanneling of artery	26.20
35331		Rechanneling of artery	26.20
35351		Rechanneling of artery	23.00
35351		Rechanneling of artery	23.00
35355		Rechanneling of artery	18.50
35355		Rechanneling of artery	18.50
35361		Rechanneling of artery	28.20
35361		Rechanneling of artery	28.20
35363		Rechanneling of artery	30.20
35363		Rechanneling of artery	30.20
35371		Rechanneling of artery	14.72
35371		Rechanneling of artery	14.72
35372		Rechanneling of artery	18.00
35372		Rechanneling of artery	18.00
35381		Rechanneling of artery	15.81
35511		Artery bypass graft	21.20
35511		Artery bypass graft	21.20
35518		Artery bypass graft	21.20
35518		Artery bypass graft	21.20
35521		Artery bypass graft	22.20
35521		Artery bypass graft	22.20
35526		Artery bypass graft	29.95
35526		Artery bypass graft	29.95
35531		Artery bypass graft	36.20
35531		Artery bypass graft	36.20
35533		Artery bypass graft	28.00
35533		Artery bypass graft	28.00
35536		Artery bypass graft	31.70
35536		Artery bypass graft	31.70
35541		Artery bypass graft	25.80
35546		Artery bypass graft	25.54
35551		Artery bypass graft	26.67
35556		Artery bypass graft	21.76
35556		Artery bypass graft	21.76
35558		Artery bypass graft	21.20
35558		Artery bypass graft	21.20
35560		Artery bypass graft	32.00
35560		Artery bypass graft	32.00
35563		Artery bypass graft	24.20
35563		Artery bypass graft	24.20
35565		Artery bypass graft	23.20
35565		Artery bypass graft	23.20
35571		Artery bypass graft	24.06
35571		Artery bypass graft	24.06
35582		Vein bypass graft	27.13
35587		Vein bypass graft	24.75
35587		Vein bypass graft	24.75
35621		Artery bypass graft	20.00
35621		Artery bypass graft	20.00
35623		Bypass graft, not vein	24.00
35623		Bypass graft, not vein	24.00
35626		Artery bypass graft	27.75
35626		Artery bypass graft	27.75
35631		Artery bypass graft	34.00
35631		Artery bypass graft	34.00
35636		Artery bypass graft	29.50
35636		Artery bypass graft	29.50
35641		Artery bypass graft	24.57
35646		Artery bypass graft	25.81
35650		Artery bypass graft	19.00
35650		Artery bypass graft	19.00
35654		Artery bypass graft	25.00
35654		Artery bypass graft	25.00
35661		Artery bypass graft	19.00
35661		Artery bypass graft	19.00
35663		Artery bypass graft	22.00
35663		Artery bypass graft	22.00
35665		Artery bypass graft	21.00
35665		Artery bypass graft	21.00
35666		Artery bypass graft	22.19
35666		Artery bypass graft	22.19
35671		Artery bypass graft	19.33
35671		Artery bypass graft	19.33
35701		Exploration, carotid artery	8.50
35701		Exploration, carotid artery	8.50
35721		Exploration, femoral artery	7.18
35741		Exploration popliteal artery	8.00
35840		Explore abdominal vessels	9.77
35860		Explore limb vessels	5.55
35905		Excision, graft, thorax	31.25
35905		Excision, graft, thorax	31.25
35907		Excision, graft, abdomen	35.00
35907		Excision, graft, abdomen	35.00
36400		Drawing blood	0.18
36405		Drawing blood	0.18
36406		Drawing blood	0.18
36489		Insertion of catheter, vein	2.50
36489		Insertion of catheter, vein	2.50
36520		Plasma and/or cell exchange	1.74
36533		Insertion of access device	5.32
36534		Revision of access device	2.80
36535		Removal of access device	2.27
36620		Insertion catheter, artery	1.15
36625		Insertion catheter, artery	2.11
36822		Insertion of cannula(s)	5.42
37565		Ligation of neck vein	10.88
37565		Ligation of neck vein	10.88
37600		Ligation of neck artery	11.25
37600		Ligation of neck artery	11.25
37605		Ligation of neck artery	13.11
37605		Ligation of neck artery	13.11
37609		Temporal artery procedure	3.00
37609		Temporal artery procedure	3.00
37615		Ligation of neck artery	5.73
37615		Ligation of neck artery	5.73
37617		Ligation of abdomen artery	22.06
37618		Ligation of extremity artery	4.84
37650		Revision of major vein	7.80
37660		Revision of major vein	21.00
37700		Revise leg vein	3.73
37720		Removal of leg vein	5.66
37730		Removal of leg veins	7.33
37735		Removal of leg veins/lesion	10.53
37760		Revision of leg veins	10.47
37785		Revision secondary varicosity	3.84
38100		Removal of spleen, total	14.50
38100		Removal of spleen, total	14.50
38101		Removal of spleen, partial	15.31
38115		Repair of ruptured spleen	15.82
38300		Drainage, lymph node lesion	1.99
38305		Drainage, lymph node lesion	6.00
38308		Incision of lymph channels	6.45
38500		Biopsy/removal, lymph nodes	3.75
38500		Biopsy/removal, lymph nodes	3.75
38510		Biopsy/removal, lymph nodes	6.43
38520		Biopsy/removal, lymph nodes	6.67
38525		Biopsy/removal, lymph nodes	6.07
38530		Biopsy/removal, lymph nodes	7.98
38571		Laparoscopy, lymphadenectomy	12.38
38572		Laparoscopy, lymphadenectomy	16.59
38740		Remove armpit lymph nodes	10.02
38745		Remove armpit lymph nodes	13.00
38746		Remove thoracic lymph nodes	4.89
38760		Remove groin lymph nodes	12.94
38765		Remove groin lymph nodes	19.98
38780		Remove abdomen lymph nodes	16.59
39010		Exploration of chest	11.79
39220		Removal chest lesion	17.42
39400		Visualization of chest	5.61
39503		Repair of diaphragm hernia	34.85
42205		Reconstruct cleft palate	13.29
43107		Removal of esophagus	40.00
43112		Removal of esophagus	43.50
43117		Partial removal of esophagus	40.00
43122		Parital removal of esophagus	40.00
43215		Esophagus endoscopy	2.60
43217		Esophagus endoscopy	2.90
43219		Esophagus endoscopy	2.80
43228		Esoph endoscopy, ablation	3.77
43239		Upper GI endoscopy, biopsy	2.69
43239		Upper GI endoscopy, biopsy	2.87
43244		Upper GI endoscopy/ligation	4.59
43246		Place gastrostomy tube	4.33
43246		Place gastrostomy tube	4.33
43247		Operative upper GI endoscopy	3.39
43249		Esoph endoscopy, dilation	2.90
43251		Operative upper GI endoscopy	3.70
43255		Operative upper GI endoscopy	4.40
43258		Operative upper GI endoscopy	4.55
43259		Endoscopic ultrasound exam	4.89
43263		Endo cholangiopancreatograph	6.19
43265		Endo cholangiopancreatograph	8.90
43269		Endo cholangiopancreatograph	6.04
43310		Repair of esophagus	25.39
43312		Repair esophagus and fistula	28.42
43320		Fuse esophagus & stomach	19.93
43324		Revise esophagus & stomach	20.57
43325		Revise esophagus & stomach	20.06
43326		Revise esophagus & stomach	19.74
43330		Repair of esophagus	19.77
43331		Repair of esophagus	20.13
43340		Fuse esophagus & intestine	19.61
43341		Fuse esophagus & intestine	20.85
43350		Surgical opening, esophagus	15.78
43351		Surgical opening, esophagus	18.35
43352		Surgical opening, esophagus	15.26
43360		Gastrointestinal repair	35.70
43361		Gastrointestinal repair	40.50
43400		Ligate esophagus veins	21.20
43401		Esophagus surgery for veins	22.09
43405		Ligate/staple esophagus	20.01
43410		Repair esophagus wound	13.47
43415		Repair esophagus wound	25.00
43420		Repair esophagus opening	14.35
43425		Repair esophagus opening	21.03
43500		Surgical opening of stomach	11.05
43501		Surgical repair of stomach	20.04
43502		Surgical repair of stomach	23.13
43510		Surgical opening of stomach	13.08
43520		Incision of pyloric muscle	9.99
43605		Biopsy of stomach	11.98
43610		Excision of stomach lesion	14.60
43611		Excision of stomach lesion	17.84
43620		Removal of stomach	30.04
43621		Removal of stomach	30.73
43622		Removal of stomach	32.53
43631		Removal of stomach, partial	22.59
43632		Removal of stomach, partial	22.59
43633		Removal of stomach, partial	23.10
43634		Removal of stomach, partial	25.12
43638		Removal of stomach, partial	29.00
43638		Removal of stomach, partial	29.00
43639		Removal of stomach, partial	29.65
43640		Vagotomy & pylorus repair	17.02
43641		Vagotomy & pylorus repair	17.27
43651		Laparoscopy, vagus nerve	10.15
43652		Laparoscopy, vagus nerve	12.15
43800		Reconstruction of pylorus	13.69
43810		Fusion of stomach and bowel	14.65
43820		Fusion of stomach and bowel	15.37
43825		Fusion of stomach and bowel	19.22
43830		Place gastrostomy tube	9.53
43832		Place gastrostomy tube	15.60
43840		Repair of stomach lesion	15.56
43842		Gastroplasty for obesity	18.47
43843		Gastroplasty for obesity	18.65
43846		Gastric bypass for obesity	24.05
43847		Gastric bypass for obesity	26.92
43848		Revision gastroplasty	29.39
43850		Revise stomach-bowel fusion	24.72
43855		Revise stomach-bowel fusion	26.16
43860		Revise stomach-bowel fusion	25.00
43865		Revise stomach-bowel fusion	26.52
43870		Repair stomach opening	9.69
43880		Repair stomach-bowel fistula	24.65
44005		Freeing of bowel adhesion	16.23
44010		Incision of small bowel	12.52
44020		Exploration of small bowel	13.99
44021		Decompress small bowel	14.08
44025		Incision of large bowel	14.28
44050		Reduce bowel obstruction	14.03
44050		Reduce bowel obstruction	14.03
44055		Correct malrotation of bowel	22.00
44110		Excision of bowel lesion(s)	11.81
44111		Excision of bowel lesion(s)	14.29
44120		Removal of small intestine	17.00
44125		Removal of small intestine	17.54
44130		Bowel to bowel fusion	14.49
44130		Bowel to bowel fusion	14.49
44140		Partial removal of colon	21.00
44140		Partial removal of colon	21.00
44143		Partial removal of colon	22.99
44144		Partial removal of colon	21.53
44144		Partial removal of colon	21.53
44145		Partial removal of colon	26.42
44146		Partial removal of colon	27.54
44147		Partial removal of colon	20.71
44150		Removal of colon	23.95
44151		Removal of colon/ileostomy	26.88
44151		Removal of colon/ileostomy	26.88
44152		Removal of colon/ileostomy	27.83
44153		Removal of colon/ileostomy	30.59
44155		Removal of colon/ileostomy	27.86
44156		Removal of colon/ileostomy	30.79
44156		Removal of colon/ileostomy	30.79
44160		Removal of colon	18.62
44200		Laparoscopy, enterolysis	14.44
44300		Open bowel to skin	12.11
44310		Ileostomy/jejunostomy	15.95
44312		Revision of ileostomy	8.02
44314		Revision of ileostomy	15.05
44316		Devise bowel pouch	21.09
44320		Colostomy	17.64
44340		Revision of colostomy	7.72
44345		Revision of colostomy	15.43
44346		Revision of colostomy	16.99
44388		Colon endoscopy	2.82
44389		Colonoscopy with biopsy	3.13
44390		Colonoscopy for foreign body	3.83
44391		Colonoscopy for bleeding	4.32
44392		Colonoscopy and polypectomy	3.82
44393		Colonoscopy, lesion removal	4.84
44394		Colonoscopy w/snare	4.43
44394		Colonoscopy w/snare	4.43
44602		Suture, small intestine	16.03
44603		Suture, small intestine	18.66
44604		Suture, large intestine	16.03
44605		Repair of bowel lesion	19.53
44615		Intestinal stricturoplasty	15.93
44620		Repair bowel opening	12.20
44625		Repair bowel opening	15.05
44626		Repair bowel opening	25.36
44640		Repair bowel-skin fistula	21.65
44650		Repair bowel fistula	22.57
44660		Repair bowel-bladder fistula	21.36
44661		Repair bowel-bladder fistula	24.81
44680		Surgical revision, intestine	15.40
44700		Suspend bowel w/prosthesis	16.11
44800		Excision of bowel pouch	11.23
44820		Excision of mesentery lesion	12.09
44850		Repair of mesentery	10.74
44900		Drain app abscess, open	10.14
44950		Appendectomy	10.00
44960		Appendectomy	12.34
44970		Laparoscopy, appendectomy	8.70
45000		Drainage of pelvic abscess	4.52
45020		Drainage of rectal abscess	4.72
45100		Biopsy of rectum	3.68
45108		Removal of anorectal lesion	4.76
45110		Removal of rectum	28.00
45111		Partial removal of rectum	16.48
45112		Removal of rectum	30.54
45113		Partial proctectomy	30.58
45114		Partial removal of rectum	27.32
45116		Partial removal of rectum	24.58
45119		Remove rectum w/reservoir	30.84
45120		Removal of rectum	24.60
45121		Removal of rectum and colon	27.04
45123		Partial proctectomy	16.71
45126		Pelvic exenteration	45.16
45130		Excision of rectal prolapse	16.44
45135		Excision of rectal prolapse	19.28
45160		Excision of rectal lesion	15.32
45170		Excision of rectal lesion	11.49
45190		Destruction, rectal tumor	9.74
45305		Proctosigmoidoscopy & biopsy	1.01
45309		Proctosigmoidoscopy	2.01
45330		Diagnostic sigmoidoscopy	0.96
45337		Sigmoidoscopy & decompress	2.36
45339		Sigmoidoscopy	3.14
45378		Diagnostic colonoscopy	3.70
45380		Colonoscopy and biopsy	4.01
45383		Lesion removal colonoscopy	5.87
45384		Colonoscopy	4.70
45385		Lesion removal colonoscopy	5.31
45505		Repair of rectum	7.58
45540		Correct rectal prolapse	16.27
45541		Correct rectal prolapse	13.40
45550		Repair rectum/remove sigmoid	23.00
45560		Repair of rectocele	10.58
45562		Exploration/repair of rectum	15.38
45563		Exploration/repair of rectum	23.47
45800		Repair rect/bladder fistula	17.77
45805		Repair fistula w/colostomy	20.78
45820		Repair rectourethral fistula	18.48
45825		Repair fistula w/colostomy	21.25
45900		Reduction of rectal prolapse	2.61
45905		Dilation of anal sphincter	2.30
45910		Dilation of rectal narrowing	2.80
45910		Dilation of rectal narrowing	2.80
45915		Remove rectal obstruction	3.14
46040		Incision of rectal abscess	4.96
46045		Incision of rectal abscess	4.32
46060		Incision of rectal abscess	5.69
46083		Incise external hemorrhoid	1.40
46083		Incise external hemorrhoid	1.40
46221		Ligation of hemorrhoid(s)	2.04
46230		Removal of anal tabs	2.57
46250		Hemorrhoidectomy	3.89
46255		Hemorrhoidectomy	4.60
46257		Remove hemorrhoids & fissure	5.40
46258		Remove hemorrhoids & fistula	5.73
46258		Remove hemorrhoids & fistula	5.73
46260		Hemorrhoidectomy	6.37
46261		Remove hemorrhoids & fissure	7.08
46262		Remove hemorrhoids & fistula	7.50
46270		Removal of anal fistula	3.72
46275		Removal of anal fistula	4.56
46280		Removal of anal fistula	5.98
46288		Repair anal fistula	7.13
46320		Removal of hemorrhoid clot	1.61
46320		Removal of hemorrhoid clot	1.61
46700		Repair of anal stricture	9.13
46705		Repair of anal stricture	6.90
46715		Repair of anovaginal fistula	7.20
46716		Repair of anovaginal fistula	15.07
46730		Construction of absent anus	26.75
46735		Construction of absent anus	32.17
46740		Construction of absent anus	30.00
46742		Repair of imperforated anus	35.80
46744		Repair of cloacal anomaly	52.63
46746		Repair of cloacal anomaly	58.22
46748		Repair of cloacal anomaly	64.21
46750		Repair of anal sphincter	10.25
46753		Reconstruction of anus	8.29
46754		Removal of suture from anus	2.20
46760		Repair of anal sphincter	14.43
46761		Repair of anal sphincter	13.84
46762		Implant artificial sphincter	12.71
46900		Destruction, anal lesion(s)	1.91
46910		Destruction, anal lesion(s)	1.86
46916		Cryosurgery, anal lesion(s)	1.86
46917		Laser surgery, anal lesions	1.86
46922		Excision of anal lesion(s)	1.86
46924		Destruction, anal lesion(s)	2.76
46924		Destruction, anal lesion(s)	2.76
46934		Destruction of hemorrhoids	3.51
46935		Destruction of hemorrhoids	2.43
46936		Destruction of hemorrhoids	3.69
46940		Treatment of anal fissure	2.32
46942		Treatment of anal fissure	2.04
46945		Ligation of hemorrhoids	1.84
46946		Ligation of hemorrhoids	2.58
47010		Open drainage, liver lesion	16.01
47015		Inject/aspirate liver cyst	15.11
47100		Wedge biopsy of liver	11.67
47120		Partial removal of liver	35.50
47122		Extensive removal of liver	55.13
47125		Partial removal of liver	49.19
47130		Partial removal of liver	53.35
47134		Partial removal, donor liver	39.15
47300		Surgery for liver lesion	15.08
47350		Repair liver wound	19.56
47360		Repair liver wound	26.92
47361		Repair liver wound	47.12
47362		Repair liver wound	18.51
47400		Incision of liver duct	32.49
47420		Incision of bile duct	19.88
47425		Incision of bile duct	19.83
47460		Incise bile duct sphincter	18.04
47480		Incision of gallbladder	10.82
47562		Laparoscopic cholecystectomy	11.09
47563		Laparoscopic cholecystectomy	11.94
47564		Laparo cholecystectomy/explr	14.23
47570		Laparo cholecystoenterostomy	12.58
47600		Removal of gallbladder	13.58
47605		Removal of gallbladder	14.69
47610		Removal of gallbladder	18.82
47612		Removal of gallbladder	18.78
47620		Removal of gallbladder	20.64
47701		Bile duct revision	27.81
47711		Excision of bile duct tumor	23.03
47712		Excision of bile duct tumor	30.24
47715		Excision of bile duct cyst	18.80
47716		Fusion of bile duct cyst	16.44
47720		Fuse gallbladder & bowel	15.91
47721		Fuse upper gi structures	19.12
47740		Fuse gallbladder & bowel	18.48
47741		Fuse gallbladder & bowel	21.34
47760		Fuse bile ducts and bowel	25.85
47765		Fuse liver ducts & bowel	24.88
47780		Fuse bile ducts and bowel	26.50
47785		Fuse bile ducts and bowel	31.18
47800		Reconstruction of bile ducts	23.30
47801		Placement, bile duct support	15.17
47802		Fuse liver duct & intestine	21.55
47900		Suture bile duct injury	19.90
48000		Drainage of abdomen	28.07
48001		Placement of drain, pancreas	35.45
48005		Resect/debride pancreas	42.17
48020		Removal of pancreatic stone	15.70
48100		Biopsy of pancreas	12.23
48120		Removal of pancreas lesion	15.85
48140		Partial removal of pancreas	22.94
48145		Partial removal of pancreas	24.02
48146		Pancreatectomy	26.40
48148		Removal of pancreatic duct	17.34
48150		Partial removal of pancreas	48.00
48150		Partial removal of pancreas	48.00
48152		Pancreatectomy	43.75
48153		Pancreatectomy	47.89
48154		Pancreatectomy	44.10
48155		Removal of pancreas	24.64
48180		Fuse pancreas and bowel	24.72
48500		Surgery of pancreas cyst	15.28
48510		Drain pancreatic pseudocyst	14.31
48520		Fuse pancreas cyst and bowel	15.59
48540		Fuse pancreas cyst and bowel	19.72
48545		Pancreatorrhaphy	18.18
48547		Duodenal exclusion	25.83
49000		Exploration of abdomen	11.68
49002		Reopening of abdomen	10.49
49010		Exploration behind abdomen	12.28
49020		Drain abdominal abscess	22.84
49040		Drain, open, abdom abscess	13.52
49060		Drain, open, retrop abscess	15.86
49085		Remove abdomen foreign body	12.14
49200		Removal of abdominal lesion	10.25
49201		Removal of abdominal lesion	14.84
49215		Excise sacral spine tumor	33.50
49215		Excise sacral spine tumor	33.50
49220		Multiple surgery, abdomen	14.88
49255		Removal of omentum	11.14
49320		Diag laparo separate proc	5.10
49321		Laparoscopy; biopsy	5.40
49322		Laparoscopy; aspiration	5.70
49421		Insert abdominal drain	5.54
49422		Remove perm cannula/catheter	6.25
49425		Insert abdomen-venous drain	11.37
49426		Revise abdomen-venous shunt	9.63
49428		Ligation of shunt	6.06
49429		Removal of shunt	7.40
49495		Repair inguinal hernia, init	5.89
49495		Repair inguinal hernia, init	5.89
49496		Repair inguinal hernia, init	8.79
49496		Repair inguinal hernia, init	8.79
49500		Repair inguinal hernia	5.48
49501		Repair inguinal hernia, init	8.88
49505		Repair inguinal hernia	7.60
49505		Repair inguinal hernia	7.60
49507		Repair inguinal hernia	9.57
49520		Rerepair inguinal hernia	9.63
49521		Repair inguinal hernia, rec	11.97
49525		Repair inguinal hernia	8.57
49540		Repair lumbar hernia	10.39
49550		Repair femoral hernia	8.63
49553		Repair femoral hernia, init	9.44
49555		Repair femoral hernia	9.03
49557		Repair femoral hernia, recur	11.15
49560		Repair abdominal hernia	11.57
49561		Repair incisional hernia	14.25
49565		Rerepair abdominal hernia	11.57
49566		Repair incisional hernia	14.40
49570		Repair epigastric hernia	5.69
49572		Repair epigastric hernia	6.73
49580		Repair umbilical hernia	4.11
49582		Repair umbilical hernia	6.65
49585		Repair umbilical hernia	6.23
49587		Repair umbilical hernia	7.56
49590		Repair abdominal hernia	8.54
49605		Repair umbilical lesion	22.66
49606		Repair umbilical lesion	18.60
49650		Laparo hernia repair initial	6.27
49651		Laparo hernia repair recur	8.24
49900		Repair of abdominal wall	12.28
49905		Omental flap	6.55
50200		Biopsy of kidney	2.63
50230		Removal of kidney	22.07
51595		Remove bladder/revise tract	37.14
51596		Remove bladder/create pouch	39.52
56515		Destruction, vulva lesion(s)	2.76
56740		Remove vagina gland lesion	4.57
57100		Biopsy of vagina	1.20
57130		Remove vagina lesion	2.43
57292		Construct vagina with graft	13.09
57307		Fistula repair & colostomy	15.93
57410		Pelvic examination	1.75
57505		Endocervical curettage	1.14
58150		Total hysterectomy	15.24
58152		Total hysterectomy	20.60
58260		Vaginal hysterectomy	12.98
58262		Vaginal hysterectomy	14.77
58263		Vaginal hysterectomy	16.06
58267		Hysterectomy & vagina repair	17.04
58270		Hysterectomy & vagina repair	14.26
58275		Hysterectomy/revise vagina	15.76
58280		Hysterectomy/revise vagina	17.01
58285		Extensive hysterectomy	22.26
58323		Sperm washing	0.23
58400		Suspension of uterus	6.36
58600		Division of fallopian tube	5.60
58605		Division of fallopian tube	5.00
58611		Ligate oviduct(s) add-on	1.45
58700		Removal of fallopian tube	12.05
58740		Revise fallopian tube(s)	14.00
58805		Drainage of ovarian cyst(s)	5.88
58820		Drain ovary abscess, open	4.22
58825		Transposition, ovary(s)	10.98
58920		Partial removal of ovary(s)	11.36
58950		Resect ovarian malignancy	16.93
58951		Resect ovarian malignancy	22.38
59150		Treat ectopic pregnancy	11.67
59151		Treat ectopic pregnancy	11.49
59812		Treatment of miscarriage	4.01
59870		Evacuate mole of uterus	6.01
60100		Biopsy of thyroid	1.56
60220		Partial removal of thyroid	11.90
60220		Partial removal of thyroid	11.90
60252		Removal of thyroid	20.57
60254		Extensive thyroid surgery	26.99
60260		Repeat thyroid surgery	17.47
60270		Removal of thyroid	20.27
60271		Removal of thyroid	16.83
60540		Explore adrenal gland	17.03
60545		Explore adrenal gland	19.88
62263		Lysis epidural adhesions	6.14
62310		Inject spine c/t	1.91
62311		Inject spine l/s (cd)	1.54
62318		Inject spine w/cath, c/t	2.04
62319		Inject spine w/cath l/s (cd)	1.87
65855		Laser surgery of eye	3.85
66180		Implant eye shunt	14.55
66986		Exchange lens prosthesis	12.28
67028		Injection eye drug	2.52
67218		Treatment of retinal lesion	18.53
67904		Repair eyelid defect	6.26
69990		Microsurgery add-on	3.47
72275		Epidurography	0.76
76005		Fluoroguide for spine inject	0.60
76065		X-rays, bone evaluation	0.70
76090		Mammogram, one breast	0.70
76091		Mammogram, both breasts	0.87
76095		Stereotactic breast biopsy	1.59
88170		Fine needle aspiration	1.27
88171		Fine needle aspiration	1.27
90901		Biofeedback train, any meth	0.41
90911		Biofeedback peri/uro/rectal	0.89
90935		Hemodialysis, one evaluation	1.22
90937		Hemodialysis, repeated eval	2.11
90945		Dialysis, one evaluation	1.28
90947		Dialysis, repeated eval	2.16
90989		Dialysis training, complete	0.00
90993		Dialysis training, incompl	0.00
90997		Hemoperfusion	1.84
92018		New eye exam & treatment	2.50
93350		Echo transthoracic	1.48
94640		Airway inhalation treatment	0.00
94664		Aerosol or vapor inhalations	0.00
94665		Aerosol or vapor inhalations	0.00
96100		Psychological testing	0.00
96105		Assessment of aphasia	0.00
96110		Developmental test, lim	0.00
96115		Neurobehavior status exam	0.00
96117		Neuropsych test battery	0.00
97542		Wheelchair mngmnt training	0.45
99233		Subsequent hospital care	1.51
99273		Confirmatory consultation	1.19
99274		Confirmatory consultation	1.73
99291		Critical care, first hour	4.00
99291		Critical care, first hour	4.00
99291		Critical care, first hour	4.00
99292		Critical care, addl 30 min	2.00
99292		Critical care, addl 30 min	2.00
99292		Critical care, addl 30 min	2.00
99295		Neonatal critical care	16.00
99296		Neonatal critical care	8.00
99297		Neonatal critical care	4.00
99298		Neonatal critical care	2.75
99436		Attendance, birth	1.50
99440		Newborn resuscitation	2.93
1 All CPT codes and descriptors copyright 2000 American Medical Association