[Federal Register: November 15, 2004 (Volume 69, Number 219)]
[Rules and Regulations]
[Page 66235-66915]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr15no04-29]
[[Page 66235]]
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Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 403, 405, 410, et al.
Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule for Calendar Year 2005; Final Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 403, 405, 410, 411, 414, 418, 424, 484, and 486
[CMS-1429-FC]
RIN 0938-AM90
Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule for Calendar Year 2005
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule with comment period.
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SUMMARY: This final rule refines the resource-based practice expense
relative value units (RVUs) and makes other changes to Medicare Part B
payment policy. These policy changes concern: supplemental survey data
for practice expense; updated geographic practice cost indices for
physician work and practice expense; updated malpractice RVUs; revised
requirements for supervision of therapy assistants; revised payment
rules for low osmolar contrast media; changes to payment policies for
physicians and practitioners managing dialysis patients; clarification
of care plan oversight requirements; revised requirements for
supervision of diagnostic psychological testing services;
clarifications to the policies affecting therapy services; revised
requirements for assignment of Medicare claims; addition to the list of
telehealth services; and, several coding issues. We are making these
changes to ensure that our payment systems are updated to reflect
changes in medical practice and the relative value of services.
This final rule also addresses the following provisions of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(Pub. L. 108-17) (MMA): coverage of an initial preventive physical
examination; coverage of cardiovascular (CV) screening blood tests;
coverage of diabetes screening tests; incentive payment improvements
for physicians in shortage areas; payment for covered outpatient drugs
and biologicals; payment for renal dialysis services; coverage of
routine costs associated with certain clinical trials of category A
devices as defined by the Food and Drug Administration; hospice
consultation service; indexing the Part B deductible to inflation;
extension of coverage of intravenous immune globulin (IVIG) for the
treatment in the home of primary immune deficiency diseases; revisions
to reassignment provisions; and, payment for diagnostic mammograms,
physicians' services associated with drug administration services and
coverage of religious nonmedical health care institution items and
services to the beneficiary's home.
In addition, this rule updates the codes subject to the physician
self-referral prohibition, discusses payment for set-up of portable x-
ray equipment, discusses the third five-year refinement of work RVUs,
and solicits comments on potentially misvalued work RVUs.
We are also finalizing the calendar year (CY) 2004 interim RVUs and
are issuing interim RVUs for new and revised procedure codes for CY
2005.
As required by the statute, we are announcing that the physician
fee schedule update for CY 2005 is 1.5 percent, the initial estimate
for the sustainable growth rate for CY 2005 is 4.3, and the conversion
factor for CY 2005 is $37.8975.
DATES: Effective Date: These regulations are effective on January 1,
2005.
Applicability Date: Section 623 of the MMA, that is, the case-mix
portion of the revised composite payment methodology and the budget
neutrality adjustment required by the MMA, is applicable on April 1,
2005.
Comment Date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on January 3, 2005.
ADDRESSES: In commenting, please refer to file code CMS-1429-FC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of three ways (no duplicates,
please):
1. Electronically. You may submit electronic comments on specific
issues in this regulation to http://www.cms.hhs.gov/regulations/ecomments.
(Attachments should be in Microsoft Word, WordPerfect, or
Excel; however, we prefer Microsoft Word.)
2. By mail. You may mail written comments (one original and two
copies) to the following address ONLY: Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Attention: CMS-1429-
FC, P.O. Box 8012, Baltimore, MD 21244-8012.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to one of the following addresses. If you
intend to deliver your comments to the Baltimore address, please call
telephone number 800-743-3951 in advance to schedule your arrival with
one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200
Independence Avenue, SW., Washington, DC 20201; or 7500 Security
Boulevard, Baltimore, MD 21244-1850.
(Because access to the interior of the HHH Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for persons wishing to retain a proof of filing by stamping
in and retaining an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
Submission of comments on paperwork requirements. You may submit
comments on this document's paperwork requirements by mailing your
comments to the addresses provided at the end of the ``Collection of
Information Requirements'' section in this document.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Pam West (410) 786-2302 (for issues related to Practice Expense,
Respiratory Therapy Coding, and Therapy Supervision).
Rick Ensor (410) 786-5617 (for issues related to Geographic
Practice Cost Index (GPCI) and malpractice RVUs).
Craig Dobyski (410) 786-4584 (for issues related to list of
telehealth services or payments for physicians and practitioners
managing dialysis patients).
Bill Larson or Tiffany Sanders (410) 786-7176 (for issues related
to coverage of an initial preventive physical examination).
Cathleen Scally (410) 786-5714 (for issues related to payment of an
initial preventive physical examination).
Joyce Eng (410) 786-7176 (for issues related to coverage of
cardiovascular screening tests).
Betty Shaw (410) 786-7176 (for issues related to coverage of
diabetes screening tests).
Anita Greenberg (410) 786-0548 (for issues related to payment of
cardiovascular and diabetes screening tests).
David Worgo (410) 786-5919, (for issues related to incentive
payment
[[Page 66237]]
improvements for physicians practicing in shortage areas).
Angela Mason or Jennifer Fan (410) 786-0548 (for issues related to
payment for covered outpatient drugs and biologicals).
David Walczak (410) 786-4475 (for issues related to reassignment
provisions).
Henry Richter (410) 786-4562 (for issues related to payments for
ESRD facilities).
Steve Berkowitz (410) 786-7176 (for issues related to coverage of
routine costs associated with certain clinical trials of category A
devices).
Terri Deutsch (410) 786-9462 (for issues related to hospice
consultation services).
Karen Daily (410) 786-7176 (for issues related to clinical
conditions for payment of covered items of durable medical equipment).
Dorothy Shannon (410) 786-3396 (for issues related to outpatient
therapy services performed ``incident to'' physicians' services).
Roberta Epps (410) 786-5919 (for issues related to low osmolar
contrast media or supervision of diagnostic psychological testing
services).
Gail Addis (410) 786-4522 (for issues related to care plan
oversight).
Jean-Marie Moore (410) 786-3508 (for issues related to religious
nonmedical health care institution services).
Diane Milstead (410) 786-3355 or Gaysha Brooks (410) 786-9649 (for
all other issues).
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on the
following issues: interim RVUs for selected procedure codes identified
in Addendum C; zip code areas for Health Professional Shortage Areas
(HPSAs); the coverage of religious nonmedical health care institution
items and services to the beneficiary's home; the physician self
referral designated health services listed in tables 20 and 21; the
third five-year refinement of work RVUs for services furnished
beginning January 1, 2007; and, potentially misvalued work RVUs for all
services in the CY 2005 physician fee schedule. You can assist us by
referencing the file code CMS-1429-FC and the specific ``issue
identifier'' that precedes the section on which you choose to comment.
Inspection of Public Comments: Comments received timely will be
available for public inspection as they are processed, generally
beginning approximately 3 weeks after publication of a document, at the
headquarters of the Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view
public comments, call 800-743-3951.
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 (or toll-free at 1-888-293-
6498) or by faxing to (202) 512-2250. The cost for each copy is $10. As
an alternative, you can view and photocopy the Federal Register
document at most libraries designated as Federal Depository Libraries
and at many other public and academic libraries throughout the country
that receive the Federal Register.
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 web site address is: http://www.access.gpo.gov/nara/index.html
.
Information on the physician fee schedule can be found on the CMS
homepage. You can access this data by using the following directions:
1. Go to the CMS homepage (http://www.cms.hhs.gov).
2. Place your cursor over the word ``Professionals'' in the blue
area near the top of the page. Select ``physicians'' from the drop-down
menu.
3. Under ``Policies/Regulations'' select ``Physician Fee
Schedule.''
To assist readers in referencing sections contained in this
preamble, we are providing the following table of contents. Some of the
issues discussed in this preamble affect the payment policies but do
not require changes to the regulations in the Code of Federal
Regulations. Information on the regulation's impact appears throughout
the preamble and is not exclusively in section VII.
Table of Contents
I. Background
A. Legislative History
B. Published Changes to the Fee Schedule
C. Components of the Fee Schedule Payment Amounts
D. Development of the Relative Value System
II. Provisions of the Proposed Regulation Related to the Physician
Fee Schedule
A. Resource-Based Practice Expense Relative Value Units
1. Resource-Based Practice Expense Legislation
2. Current Methodology
3. Practice Expense Proposals for Calendar Year 2005
B. Geographic Practice Cost Indices (GPCIs)
C. Malpractice RVUs
D. Coding Issues
III. Provisions Related to the Medicare Modernization Act of 2003
A. Section 611--Preventive Physical Examination
B. Section 613--Diabetes Screening
C. Section 612--Cardiovascular Screening
D. Section 413--Incentive Payment for Physician Scarcity
E. Section 303--Payment for Covered Outpatient Drugs and
Biologicals
F. Section 952--Revision to Reassignment Provisions
G. Section 642--Extension of Coverage of IVIG for the Treatment
in the Home of Primary Immune Deficiency Diseases
H. Section 623--Payment for Renal Dialysis Services
I. Section 731--Coverage of Routine Costs for Category A
Clinical Trials
J. Section 629--Part B Deductible
K. Section 512--Hospice Consultation Service
L. Section 302--Clinical Conditions for Coverage of Durable
Medical Equipment (DME)
M. Section 614--Payment for Certain Mammography Services
N. Section 305--Payment for Inhalation Drugs
O. Section 706 Coverage of Religious Nonmedical Health Care
Institution Services Furnished in the Home
IV. Other Issues
A. Provisions Related to Therapy Services
1. Outpatient Therapy Services Performed ``Incident to''
Physicians' Services
2. Qualification Standards and Supervision Requirements in
Therapy Private Practice Settings
3. Other Technical Revisions
B. Low Osmolar Contrast Media
C. Payments for Physicians and Practitioners Managing Patients
on Dialysis
D. Technical Revision--Sec. 411.404
E. Diagnostic Psychological Tests
F. Care Plan Oversight
G. Assignment of Medicare Claims-Payment to the Supplier
H. Additional Issues Raised by Commenters
V. Refinement of Relative Value Units for Calendar Year 2004 and
Response to Public Comments on Interim Relative Value Units for 2003
VI. Five-Year Refinement of Relative Value Units VII. Update to the
Codes for Physician Self-Referral Prohibition
VIII. Physician Fee Schedule Update for Calendar Year 2005
IX. Allowed Expenditures for Physicians' Services and the
Sustainable Growth Rate
X. Anesthesia and Physician Fee Schedule Conversion Factors for CY
2005
XI. Telehealth Originating Site Facility Fee Payment Amount Update
XII. Provisions of the Final Rule
XIII. Waiver of Proposed Rulemaking
XIV. Collection of Information Requirements
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XV. Response to Comments
XVI. Regulatory Impact Analysis
Addendum A--Explanation and Use of Addendum B.
Addendum B--2005 Relative Value Units and Related Information Used
in Determining Medicare Payments for 2005.
Addendum C--Codes With Interim RVUs
Addendum D--2005 Geographic Practice Cost Indices by Medicare
Carrier and Locality
Addendum E--2006 Geographic Practice Cost Indices by Medicare
Carrier and Locality
Addendum F--Comparison of 2004 GAFs to 2005 GAFs
Addendum G--Comparison of 2004 GAFs to 2006 GAFs
Addendum H--Specialty Care PSA Zip Codes
Addendum I--2005 Primary Care HSPA Zip Codes
Addendum J--Primary Care PSA Zip Codes
Addendum K--Mental Health HPSA Zip Codes
Addendum L--Updated List of CPT/HCPCS Codes Used To Describe Certain
Designated Health Services Under the Physician Self-Referral
Provision
In addition, because of the many organizations and terms to which
we refer by acronym in this final rule, we are listing these acronyms
and their corresponding terms in alphabetical order below:
AAA Abdominal aortic aneurysm
AAFP American Academy of Family Physicians
AAKP American Association of Kidney Patients
AANA American Association of Nurse Anesthetists
ABI Ankle brachial index
ABN Advanced beneficiary notice
ACC American College of Cardiology
ACLA American Clinical Laboratory Association
ACP American College of Physicians
ACPM American College of Preventative Medicine
ACR American College of Radiology
ADLs Activities of daily living
AFROC Association of Freestanding Radiation Oncology Centers
AGS American Geriatric Society
AHA American Heart Association
AMA American Medical Association
AOA American Osteopathic Association
APA Administrative Procedures Act
APTA American Physical Therapy Association
ASA American Society of Anesthesiologists
ASCP American Society for Clinical Pathology
ASN American Society of Nephrology
ASP Average sales price
ASTRO American Society for Therapeutic Radiation Oncology
ATA American Telemedicine Association
AWP Average wholesale price
BBA Balanced Budget Act of 1997
BBRA Balanced Budget Refinement Act of 1999
BIPA Benefits Improvement and Protection Act of 2000
BLS Bureau of Labor Statistics
BMI Body mass index
BSA Body surface area
CAH Critical access hospital
CAP College of American Pathologists
CAPD Continuous ambulatory peritoneal dialysis
CCPD Continuous cycling peritoneal dialysis
CDC Centers for Disease Control and Prevention
CF Conversion factor
CFR Code of Federal Regulations
CLIA Clinical Laboratory Improvement Amendment
CMA California Medical Association
CMS Centers for Medicare & Medicaid Services
CNMs Certified nurse midwives
CNS Clinical nurse specialist
COPD Chronic obstructive pulmonary disease
CORF Comprehensive outpatient rehabilitation facilities
CPEP Clinical Practice Expert Panel
CPI Consumer Price Index
CPO Care Plan Oversight
CPT [Physicians'] Current Procedural Terminology [4th Edition, 2002,
copyrighted by the American Medical Association]
CRNAs Certified Registered Nurse Anesthetists
CT Computed tomography
CV Cardiovascular
CY Calendar year
DEXA Dual energy x-ray absorptiometry
DHS Designated health services
DME Durable medical equipment
DMEPOS Durable medical equipment, prosthetics, orthotics, and
supplies
DMERC Durable medical equipment regional carrier
DOI Departments of Insurance
DRE Digital rectal exam
DRG Diagnosis-related groups
DVT Deep venous thrombosis
EKG Electrocardiogram
E/M Evaluation and management
EPO Erythropoeitin
ESRD End-stage renal disease
FAX Facsimile
FMR Fair market rental
FQHC Federally qualified healthcare center
FR Federal Register
FY Fiscal year
GAF Geographic adjustment factor
GPCI Geographic practice cost index
GTT Glucose tolerance test
HBO Hyperbaric oxygen
HCPAC Health Care Professional Advisory Committee
HCPCS Healthcare Common Procedure Coding System
HHA Home health agency
HHS [Department of] Health and Human Services
HIPAA Health Insurance Portability and Accountability Act of 1996
HOCM High osmolar contrast media
HPSA Health professional shortage area
HRSA Health Resources and Services Administration
HsCRP high sensitivity C-reactive protein
HUD Housing and Urban Development
IDTFs Independent diagnostic testing facilities
IMRT Intensity modulated radiation therapy
IOM Internet Only Manual
IPD Intermittent peritoneal dialysis
IPPE Initial preventive physical examination
IPPS Inpatient prospective payment system
ISO Insurance Services Office
IVIG Intravenous immune globulin
JUAs Joint underwriting associations
KCP Kidney Care Partners
KECC Kidney Epidemiology and Cost Center
LCD Local coverage determination
LMRP Local medical review policies
LOCM Low osmolar contrast media
LUPA Low utilization payment adjustment
MCM Medicare Carrier Manual
MCP Monthly capitation payment
MedPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MGMA Medical Group Management Association
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003
MPFS Medicare physician fee schedule
MSA Metropolitan statistical area
NAMCS National Ambulatory Medical Care Survey
NCD National coverage determination
NCIPC National Center for Injury Prevention and Control
NDC National drug code
NIH National Institutes of Health
NP Nurse practitioner
NPP Nonphysician practitioners
OASIS Outcome and Assessment Information Set
OBRA Omnibus Budget Reconciliation Act
OIG Office of Inspector General
OMB Office of Management and Budget
OPPS Outpatient prospective payment system
OT Occupational therapy
OTA Occupational therapist assistant
OTPP Occupational therapists in private practice
PA Physician assistant
PAD Peripheral arterial disease
PC Professional component
PCF Patient compensation fund
PD Peritoneal dialysis
PEAC Practice Expense Advisory Committee
PET Positron emission tomography
PFS Physician Fee Schedule
PHSA Public Health Services Act
PIAA Physician Insurers Association of America
PIN Provider identification number
PLI Professional liability insurance
POS Prosthetics, orthotics and supplies
PPI Producer price index
PPS Prospective payment system
PRA Paperwork Reduction Act
PSA Physician scarcity area
PT Physical therapy
PTA Physical therapist assistant
PTPP Physical therapists in private practice
PVD Peripheral vascular disease
RFA Regulatory Flexibility Act
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RHC Rural health clinic
RHHI Regional home health intermediary
RIA Regulatory impact analysis
RN Registered nurse
RNHCI Religious nonmedical health care institution
RPA Renal Physicians Association
RT Respiratory therapy
RTs Respiratory therapists
RUC [AMA's Specialty Society] Relative [Value] Update Committee
RUCA Rural-Urban commuting area
RVU Relative value unit
SAF Standard analytic file
SCHIP State Child Health Insurance Program
SGR Sustainable growth rate
SHIPs State Health Insurance Assistance Programs
SIR Society for Interventional Radiology
SLP Speech language pathology
SMR Standardized mortality ratio
SMS [AMA's] Socioeconomic Monitoring System
SNF Skilled nursing facility
TC Technical component
UAF Update adjustment factor
URR Urea reduction ratios
USPSTF U.S. Preventive Services Task Force
I. Background
A. Legislative History
Medicare has paid for physicians' services under section 1848 of
the Social Security Act (the Act), ``Payment for Physicians' Services''
since January 1, 1992. The Act requires that payments under the fee
schedule be based on national uniform relative value units (RVUs)
reflecting 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 adjustments to RVUs cause expenditures to change by more than
$20 million, we must make adjustments to ensure that they do not
increase or decrease by more than $20 million.
B. Published Changes to the Fee Schedule
The July 2000 and August 2003 proposed rules ((65 FR 44177) and (68
FR 49030), respectively), include a summary of the final physician fee
schedule rules published through February 2003.
In the November 7, 2003 final rule, we refined the resource-based
practice expense RVUs and made other changes to Medicare Part B payment
policy. The specific policy changes concerned: the Medicare Economic
Index; practice expense for professional component services; definition
of diabetes for diabetes self-management training; supplemental survey
data for practice expense; geographic practice cost indices; and
several coding issues. In addition, this rule updated the codes subject
to the physician self-referral prohibition. We also made revisions to
the sustainable growth rate and the anesthesia conversion factor.
Additionally, we finalized the CY 2003 interim RVUs and issued interim
RVUs for new and revised procedure codes for CY 2004.
As required by the statute, we announced that the physician fee
schedule update for CY 2004 was -4.5 percent; that the initial estimate
of the sustainable growth rate for CY 2004 was 7.4 percent; and that
the conversion factor for CY 2004 was $35.1339.
Subsequent to the November 7, 2003 final rule, the Congress enacted
the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (Pub. L. 108-17) (MMA). On January 7, 2004, an interim final rule
was published to implement provisions of the MMA applicable in 2004 to
Medicare payment for covered drugs and physician fee schedule services.
These provisions included--
Revising the current payment methodology for Medicare Part
B covered drugs and biologicals that are not paid on a cost or
prospective payment basis;
Making changes to Medicare payment for furnishing or
administering drugs and biologicals;
Revising the geographic practice cost indices;
Changing the physician fee schedule conversion factor.
(Note: The 2004 physician fee schedule conversion factor is $37.3374);
and
Extending the ``opt-out'' provisions of section
1802(b)(5)(3) of the Act to dentists, podiatrists, and optometrists.
The information contained in the January 7, 2004 interim final rule
concerning payment under the physician fee schedule superceded
information contained in the November 7, 2003 final rule to the extent
that the two are inconsistent.
C. Components of the Fee Schedule Payment Amounts
Under the formula set forth in section 1848(b)(1) of the Act, the
payment amount for each service paid under the physician fee schedule
is the product of three factors: (1) A nationally uniform relative
value unit (RVU) for the service; (2) a geographic adjustment factor
(GAF) for each physician fee schedule area; and (3) a nationally
uniform conversion factor (CF) for the service. The CF converts the
relative values into payment amounts.
For each physician fee schedule service, there are three relative
values: (1) An RVU for physician work; (2) an RVU for practice expense;
and (3) an RVU for malpractice expense. For each of these components of
the fee schedule, there is a geographic practice cost index (GPCI) for
each fee schedule area. The GPCIs reflect the relative costs of
practice expenses, malpractice insurance, and physician work in an area
compared to the national average for each component.
The general formula for calculating the Medicare fee schedule
amount for a given service in a given fee schedule area can be
expressed as:
Payment = [(RVU work x GPCI work) + (RVU practice expense x GPCI
practice expense) + (RVU malpractice x GPCI malpractice)] x CF
The CF for calendar year (CY) 2005 appears in section X. The RVUs
for CY 2005 are in Addendum B. The GPCIs for CY 2005 can be found in
Addendum D.
Section 1848(e) of the Act requires us to develop GAFs for all
physician fee schedule areas. The total GAF for a fee schedule area is
equal to a weighted average of the individual GPCIs for each of the
three components of the service. In accordance with the statute,
however, the GAF for the physician's work reflects one-quarter of the
relative cost of physician's work compared to the national average.
D. Development of the Relative Value System
1. Work Relative Value Units
Approximately 7,500 codes represent services included in the
physician fee schedule. The work RVUs established for the
implementation of the fee schedule in January 1992 were developed with
extensive input from the physician community. A research team at the
Harvard School of Public Health developed the original work RVUs for
most codes in a cooperative agreement with us. In constructing the
vignettes for the original RVUs, Harvard worked with expert panels of
physicians and obtained input from physicians from numerous
specialties.
The RVUs for radiology services were based on the American College
of Radiology (ACR) relative value scale, which we integrated into the
overall physician fee schedule. The RVUs for anesthesia services were
based on RVUs from a uniform relative value guide. We established a
separate CF for anesthesia services, and we continue to recognize
[[Page 66240]]
time as a factor in determining payment for these services. As a
result, there is a separate payment system for anesthesia services.
2. Practice Expense and Malpractice Expense Relative Value Units
Section 1848(c)(2)(C) of the Act requires that the practice expense
and malpractice expense RVUs equal the product of the base allowed
charges and the practice expense and malpractice percentages for the
service. Base allowed charges are defined as the national average
allowed charges for the service furnished during 1991, as estimated
using the most recent data available. For most services, we used 1989
charge data aged to reflect the 1991 payment rules, because those were
the most recent data available for the 1992 fee schedule.
Section 121 of the Social Security Act Amendments of 1994 (Pub. L.
103-432), enacted on October 31, 1994, required us to develop a
methodology for a resource-based system for determining practice
expense RVUs for each physician's service. As amended by the Balanced
Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on August 5, 1997,
section 1848(c) required the new payment methodology to be phased in
over 4 years, effective for services furnished in 1999, with resource-
based practice expense RVUs becoming fully effective in 2002. The BBA
also required us to implement resource-based malpractice RVUs for
services furnished beginning in 2000.
II. Provisions of the Proposed Rule Related to the Physician Fee
Schedule
In response to the publication of the August 5, 2004 proposed rule
(69 FR 47488), we received approximately 9,302 comments. We received
comments from individual physicians, health care workers, professional
associations and societies, and beneficiaries. The majority of the
comments addressed the proposals related to ``incident to'' therapy
services, GPCI, diagnostic psychological testing, and drug issues
including average sales price (ASP).
The proposed rule discussed policies that affected the number of
RVUs on which payment for certain services would be based. The proposed
rule also discussed policies related to implementation of the MMA. RVU
changes implemented through this final rule are subject to the $20
million limitation on annual adjustments contained in section
1848(c)(2)(B)(ii)(II) of the Act.
After reviewing the comments and determining the policies we would
implement, we have estimated the costs and savings of these policies
and discuss in detail the effects of these changes in the Regulatory
Impact Analysis in section XIV.
For the convenience of the reader, the headings for the policy
issues correspond to the headings used in the August 5, 2004 proposed
rule. More detailed background information for each issue can be found
in the August 5, 2004 proposed rule.
A. Resource-Based Practice Expense Relative Value Units
1. Resource-Based Practice Expense Legislation
Section 121 of the Social Security Act Amendments of 1994 (Pub. L.
103-432), enacted on October 31, 1994, amended section
1848(c)(2)(C)(ii) of the Social Security Act (the Act) and required us
to develop a methodology for a resource-based system for determining
practice expense RVUs for each physician's service beginning in 1998.
Until that time, physicians' practice expenses were established based
on historical allowed charges.
In developing the methodology, we were to consider the staff,
equipment, and supplies used in providing medical and surgical services
in various settings. The legislation specifically required that, in
implementing the new system of practice expense RVUs, we apply the same
budget-neutrality provisions that we apply to other adjustments under
the physician fee schedule.
Section 4505(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L.
105-33), enacted on August 5, 1997, amended section 1848(c)(2)(C)(ii)
of the Act and delayed the effective date of the resource-based
practice expense RVU system until January 1, 1999. In addition, section
4505(b) of the BBA provided for a 4-year transition period from charge-
based practice expense RVUs to resource-based RVUs.
Further legislation affecting resource-based practice expense RVUs
was included in the Medicare, Medicaid and State Child Health Insurance
Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L.
106-113) enacted on November 29, 1999. Section 212 of the BBRA amended
section 1848(c)(2)(C)(ii) of the Act by directing us to establish a
process under which we accept and use, to the maximum extent
practicable and consistent with sound data practices, data collected or
developed by entities and organizations. These data would supplement
the data we normally collect in determining the practice expense
component of the physician fee schedule for payments in CY 2001 and CY
2002. (The 1999 and 2003 final rules (64 FR 59380 and 68 FR 63196,
respectively, extended the period during which we would accept
supplemental data.)
2. Current Methodology for Computing the Practice Expense Relative
Value Unit System
In the November 2, 1998 final rule (63 FR 58910), effective with
services furnished on or after January 1, 1999, we established at 42
CFR 414.22(b)(5) a new methodology for computing resource-based
practice expense RVUs that used the two significant sources of actual
practice expense data we have available--the Clinical Practice Expert
Panel (CPEP) data and the American Medical Association's (AMA)
Socioeconomic Monitoring System (SMS) data. The CPEP data were
collected from panels of physicians, practice administrators, and
nonphysicians (for example registered nurses) nominated by physician
specialty societies and other groups. The CPEP panels identified the
direct inputs required for each physicians service in both the office
setting and out-of-office setting. The AMA's SMS data provided
aggregate specialty-specific information on hours worked and practice
expenses. The methodology was based on an assumption that current
aggregate specialty practice costs are a reasonable way to establish
initial estimates of relative resource costs for physicians' services
across specialties. The methodology allocated these aggregate specialty
practice costs to specific procedures and, thus, can be seen as a
``top-down'' approach.
Also in the November 2, 1998 final rule, in response to comments,
we discussed the establishment of the Practice Expense Advisory
Committee (PEAC) of the AMA's Specialty Society Relative Value Update
Committee (RUC), which would review code'specific CPEP data during the
refinement period. This committee would include representatives from
all major specialty societies and would make recommendations to us on
suggested changes to the CPEP data.
As directed by the BBRA, we also established a process (see 65 FR
65380) under which we would accept and use, to the maximum extent
practicable and consistent with sound data practices, data collected by
entities and organizations to supplement the data we normally collect
in determining the practice expense component of the physician fee
schedule.
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a. Major Steps
A brief discussion of the major steps involved in the determination
of the practice expense RVUs follows. (Please see the November 1, 2001
final rule (66 FR 55249) for a more detailed explanation of the top-
down methodology.)
Step 1--Determine the specialty specific practice expense
per hour of physician direct patient care. We used the AMA's SMS survey
of actual aggregate cost data by specialty to determine the practice
expenses per hour for each specialty. We calculated the practice
expenses per hour for the specialty by dividing the aggregate practice
expenses for the specialty by the total number of hours spent in
patient care activities.
Step 2--Create a specialty-specific practice expense pool
of practice expense costs for treating Medicare patients. To calculate
the total number of hours spent treating Medicare patients for each
specialty, we used the physician time assigned to each procedure code
and the Medicare utilization data. The primary sources for the
physician time data were surveys submitted to the AMA's RUC and surveys
done by Harvard for the establishment of the work RVUs. We then
multiplied the physician time assigned per procedure code by the number
of times that code was billed by each specialty, and summed the
products for each code, by specialty, to get the total physician hours
spent treating Medicare patients for that specialty. We then calculated
the specialty-specific practice expense pools by multiplying the
specialty practice expenses per hour (from step 1) by the total
Medicare physician hours for the specialty.
Step 3--Allocate the specialty-specific practice expense
pool to the specific services (procedure codes) performed by each
specialty. For each specialty, we divided the practice expense pool
into two groups based on whether direct or indirect costs were involved
and used a different allocation basis for each group.
(i) Direct costs--For direct costs (which include clinical labor,
medical supplies, and medical equipment), we used the procedure-
specific CPEP data on the staff time, supplies, and equipment as the
allocation basis. For the separate practice expense pool for services
without physician work RVUs, we have used, on an interim basis, 1998
practice expense RVUs to allocate the direct cost pools.
(ii) Indirect costs--To allocate the cost pools for indirect costs,
including administrative labor, office expenses, and all other
expenses, we used the total direct costs, or the 1998 practice expense
RVUs, in combination with the physician fee schedule work RVUs. We
converted the work RVUs to dollars using the Medicare CF (expressed in
1995 dollars for consistency with the SMS survey years).
Step 4--The direct and indirect costs are then added
together to attain the practice expense for each procedure, by
specialty. For procedures performed by more than one specialty, the
final practice expense allocation was a weighted average of practice
expense allocations for the specialties that perform the procedure,
based on the frequency with which each specialty performs the procedure
on Medicare patients.
b. Other Methodological Issues
i. Nonphysician Work Pool
As an interim measure, until we could further analyze the effect of
the top-down methodology on the Medicare payment for services with
physician work RVUs equal to zero (including the technical components
of radiology services and other diagnostic tests), we created a
separate practice expense pool. We first used the average clinical
staff time from the CPEP data and the ``all physicians'' practice
expense per hour to create the pool. In the December 2002 final rule,
we changed this policy and now use the total clinical staff time and
the weighted average specialty-specific practice expense per hour for
specialties with services in this pool. In the next step, we used the
adjusted 1998 practice expense RVUs to allocate this pool to each
service. Also, for all radiology services that are assigned physician
work RVUs, we used the adjusted 1998 practice expense RVUs for
radiology services as an interim measure to allocate the direct
practice expense cost pool for radiology.
A specialty society may request that its services be removed from
the nonphysician work pool. We have removed services from the
nonphysician work pool if the requesting specialty predominates
utilization of the service.
ii. Crosswalks for Specialties Without Practice Expense Survey Data
Since many specialties identified in our claims data did not
correspond exactly to the specialties included in the SMS survey data,
it was necessary to crosswalk these specialties to the most appropriate
SMS specialty.
iii. Physical Therapy Services
Because we believe that most physical therapy services furnished in
physicians' offices are performed by physical therapists, we
crosswalked all utilization for therapy services in the CPT 97000
series to the physical and occupational therapy practice expense pool.
3. Practice Expense Proposals for Calendar Year 2005
a. Supplemental Practice Expense Surveys
i. Survey Criteria and Submission Dates
As required by the BBRA, we established criteria to evaluate survey
data collected by organizations to supplement the SMS survey data used
in the calculation of the practice expense component of the physician
fee schedule. The deadline for submission of supplemental data to be
considered in CY 2006 is March 1, 2005.
ii. Survey by the College of American Pathologists (CAP)
In the August 5, 2004 rule, we proposed to incorporate the CAP
survey data into the practice expense methodology and to implement a
change to the practice expense methodology to calculate the technical
component RVUs for pathology services as the difference between the
global and professional component RVUs. (This technical change was
proposed in the June 28, 2002 Federal Register (67 FR 43849), but, at
the specialty's request, we delayed implementation of this change for
pathology services to permit evaluation of the combined effects of the
use of the new survey data along with this technical change to the
methodology.) We proposed to use the following practice expense per
hour figures for specialty 69--Independent Laboratory.
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[GRAPHIC] [TIFF OMITTED] TR15NO04.487
Comment: Specialty organizations representing clinical laboratories
and pathologists expressed support for the use of the CAP supplemental
survey data and urged us to finalize this proposal.
Response: We will incorporate the CAP survey data into the practice
expense methodology and implement the proposed change to the practice
expense methodology to calculate the technical component RVUs for
pathology services as the difference between the global and
professional component RVUs.
iii. Submission of Supplemental Surveys
We received surveys from the American College of Cardiology (ACC),
the American College of Radiology (ACR), and the American Society for
Therapeutic Radiation Oncology (ASTRO). Our contractor, The Lewin
Group, evaluated the data and recommended that we accept the data from
the ACC and the ACR, but indicated that the survey from ASTRO did not
meet the precision criteria established for supplemental surveys and,
thus, did not recommend using the ASTRO survey results at this time. We
agreed with these recommendations. However, as explained in the August
5, 2004 proposed rule, the ACR and the ACC requested that we not use
the data until we have a stable and global solution that is workable
for all specialties that are currently paid using the nonphysician work
pool. We agreed with these requests and proposed delaying use of these
supplemental surveys until issues related to the nonphysician work pool
can be addressed.
Comment: The ACR expressed appreciation for our acceptance of the
supplemental data and for our proposal to delay implementation until
next year, as they had requested, to allow further time to examine the
issue of the nonphysician work pool. The Society for Interventional
Radiology (SIR) also expressed support for the use of the ACR data and
the delay in implementation.
Response: We look forward to working with these and other
specialties as we seek a permanent solution to practice expense issues
associated with the nonphysician work pool.
Comment: ASTRO stated that they appreciate the opportunity to
submit data and, that they understand we will not be using the data in
2005. ASTRO further commented that, due to the specific practice
patterns and practice environment of radiation oncology, new data,
regardless of the response rate, may not meet the criteria. ASTRO
further stated that they will continue to work with CMS and with the
Lewin Group as this issue is analyzed. The Association of Freestanding
Radiation Oncology Centers (AFROC) expressed concern that freestanding
centers that have higher costs than hospital-based centers were
underrepresented by the ASTRO survey. They also expressed concern about
the reference in the Lewin Group report to crosswalking radiation
oncology costs from another specialty. In addition, AFROC argued that
we should not average costs associated with freestanding centers with
those that are hospital-based, because the costs would be understated.
They urged us to ensure that any assumption regarding
representativeness of any survey data is justified.
Response: We will take these comments into consideration as we
continue to work with these groups concerning the supplemental survey
data. We currently have no plans to propose a practice expense
crosswalk for radiation oncology.
Comment: The ACC expressed appreciation that we are not eliminating
the nonphysician workpool until methodologic issues are addressed.
While they support the delay in implementing their supplemental survey
data, they believe that the contractor's suggestion that the ACC survey
data could be blended with the existing SMS survey data is invalid for
two reasons: (1) The suggestion that similar changes to physician
practice (for example, increased use of technology) may have occurred
throughout all physician services is an unfounded speculation because
few other specialties are as technologically driven as cardiology; and
(2) other supplemental data has not been blended and all specialties
must be treated consistently.
Response: We will take these comments into consideration as part of
the evaluation and discussion of the cardiology survey data in next
year's proposed rule.
Comment: The American Urological Association requested that, as we
explore alternate sources of data and consider how to incorporate new
practice expense data into the methodology, we find a way to
incorporate recently collected specialty supplemental data into the new
efforts. They also requested that we clarify whether we would apply the
budget neutrality exemption to any increases in drug administration PE
RVUs that result from the use of urology survey data that will be
submitted under the supplemental survey process.
Response: We anticipate that we would incorporate all accepted
supplemental survey data into any comprehensive changes to the
nonphysician work pool.
As we explained in the January 7, 2004 Federal Register (69 FR 1093
through 1094), section 303(a)(1) of the MMA modifies section
1848(c)(2)(B) of the Act to provide an exemption from the budget
neutrality requirements in 2006 for further increases in the practice
expense RVUs for drug administration that may result from using survey
data from specialties meeting certain criteria. The survey must include
expenses for the administration of drugs and biologicals and be
submitted by a specialty that receives more than 40 percent of its 2002
Medicare revenues from drugs. Urology received more than 40 percent of
its 2002 Medicare revenues from drugs. Therefore, if we were to receive
a practice expense survey of urologists by March 1, 2005
[[Page 66243]]
that included expenses for the administration of drugs and biologicals
and the survey met the criteria we have established (and those of
section 1848(c)(2)(I)(ii) of the Act), we would exempt the change in
the practice expense RVUs for drug administration services from the
budget neutrality requirements of section 1848(c)(2)(B) of the Act.
b. Practice Expense Advisory Committee (PEAC)
Recommendations on CPEP Inputs for 2005
CPEP Refinement Process.
In the August 5, 2004 proposed rule, we included the PEAC
recommendations from meetings held in March and August 2003 and January
and March 2004, which accounted for over 2,200 codes from many
specialties. We also stated that future practice expense issues,
including the refinement of the remaining codes not addressed by the
PEAC, would be handled by the RUC.
Comment: We received comments from the AMA that future practice
expense issues, including the refinement of the remaining codes not
addressed by the PEAC, would be handled by the RUC with the help of a
new ad hoc committee, now termed the Practice Expense Review Committee
(PERC), comprised of former PEAC members. The RUC also noted that their
Practice Expense Subcommittee remains committed to reviewing
improvements to the practice expense methodology.
The AMA and the RUC, as well as the specialty society representing
neurological surgeons, noted their appreciation of our continued
efforts to improve the direct practice expense data and to establish a
reasonable methodology for determining practice expense relative
values.
Response: We look forward to our continuing work with the AMA, the
RUC and all the specialty societies on the refinement of the remaining
codes and with ongoing practice expense issues.
Comment: The National Association for the Support of Long Term Care
expressed concern about the dissolution of the PEAC and requested that
we require the RUC to expand its membership to include a broad array of
providers who are reimbursed under the physician fee schedule.
Response: Because the RUC is an independent committee, we are not
in a position to set the requirements for RUC membership. However, we
are confident that the RUC and the Health Care Professional Advisory
Committee, which also sends practice expense recommendations directly
to us, together represent two broad ranges of practitioners, both
physician and nonphysician.
Comment: A specialty society suggested that there should be a
process for fixing minor errors that are identified outside of the
refinement process. The commenter also suggested that there should be a
system to address individual exceptions to PEAC standard packages.
Response: If we have made errors, major or minor, in any part of
our calculation of practice expense RVUs in this final rule, inform us
as soon as possible so that we are able to correct them in the
physician fee schedule correction notice. Any other revisions would
have to be made in the next physician fee schedule rule. If a specialty
society believes that a RUC decision is not appropriate, the society
can always request that the decision be revisited or can discuss the
issue with us at any time. For the concern with the standard packages
adopted by the PEAC, it is our understanding that all presenters at the
RUC have the opportunity to demonstrate that something other than the
standard would be more appropriate.
PEAC Recommendations.
We proposed to adopt nearly all of the PEAC recommendations.
However, we disagreed with the PEAC recommendation for clinical labor
time for CPT code 99183, Physician attendance and supervision of
hyperbaric oxygen therapy, per session, and proposed a total clinical
labor time of 112 minutes for this service.
Comment: Specialty societies representing interventional radiology
and neurological surgeons, as well as the AMA, expressed appreciation
for our acceptance of well over 2,000 PEAC refinements in this rule.
However, the specialty society representing orthopaedic surgeons
commented that some of our proposals appeared to be circumventing the
PEAC process, in that we changed the PEAC recommendation for hyperbaric
oxygen (HBO) therapy and proposed in-office inputs for two services
rather than referring these to the RUC.
Response: We appreciate the hard work and perseverance on the part
of the PEAC and the specialty societies that produced the recommended
refinements for so many services. In addition, we do not believe that
we circumvented the PEAC process in any way. We have the greatest
respect for the PEAC and RUC recommendations that we received. However,
we do have the final responsibility for all payments made under the
physician fee schedule, and this can lead to disagreement with a
specific recommendation. The RUC itself has always demonstrated its
understanding and respect for our responsibility in this regard. With
regard to the two services that we priced in the office, we stated
explicitly in the proposed rule that we were requesting that the RUC
review the practice expense inputs.
Comment: The specialty society representing family physicians
disagreed with our proposed changes to the PEAC recommendations for the
clinical labor time for CPT code 99183, Physician attendance and
supervision of hyperbaric oxygen therapy, per session. The commenter
contended that a physician providing this service would probably have
multiple hyperbaric oxygen chambers; therefore, staff would not be in
constant attendance. However, the specialty society representing
podiatrists supported this change in clinical staff time.
Response: Based on our concern that the PEAC recommendation of 20
minutes of clinical staff time during the intra-service period
undervalued the clinical staff time, we proposed increasing this time
to 90 minutes in the proposed rule. This was, of course, subject to
comment. We believe there is some merit to the claim that the clinical
staff may be monitoring more than one chamber at a time. Therefore, we
are adjusting the time for the intra-service period from the proposed
90 minutes to 60 minutes in recognition of this point. We will continue
our examination of this issue and entertain ongoing dialog with all
interested organizations and individuals familiar with this service to
assure the accuracy of the intra-service time.
Comment: The Cardiac Event Monitoring Provider Group Coalition
expressed concern about the PEAC recommendations that would
substantially reduce the clinical staff time associated with cardiac
monitoring services. Of particular concern to the Coalition was the 70
percent reduction in time for CPT code 93271, the code for cardiac
event monitoring, receipt of transmissions, and analysis. Although all
these services are currently priced in the nonphysician work pool and
this decrease in the staff times has no immediate impact, the commenter
was concerned that, when the nonphysician work pool is eliminated,
these services will be undervalued. The commenter also believed that
the PEAC recommendations may not have reflected all the supplies and
equipment utilized in these services and included a complete list of
necessary supplies
[[Page 66244]]
and equipment. The American College of Cardiology (ACC) presented these
services at the PEAC meeting and commented they had been unable to
collect sufficient data so that the PEAC could make an appropriate
recommendation.
Response: It is clear from the Coalition and ACC comments that more
information is needed in order to ensure that the appropriate practice
expense inputs are assigned to these services in the event that they
are removed from the nonphysician work pool. We would be glad to work
with the Coalition and the specialty society so that they can make a
new presentation to the RUC this coming year.
Adjustments To Conform With PEAC Standards
We also reviewed those codes that are currently unrefined or that
were refined early in the PEAC process to apply some of the major PEAC-
agreed standards. For the unrefined 10-day global services, we proposed
to substitute for the original CPEP times the PEAC-agreed standard
post-service office visit clinical staff times used for all 90-day and
refined 10-day global services. We also proposed to eliminate the
discharge day management clinical staff time from all but the 10 and
90-day global codes, substituting one post-service phone call if not
already in the earlier data. Lastly, we proposed to delete any extra
clinical staff time for post-visit phone calls for 10 and 90-day global
service because that time is already included in the time allotted for
the visits.
Comment: A specialty society representing family physicians
supported the elimination of the discharge day management time assigned
in the facility setting for all 0-day global services, as well as all
the other adjustments we made to apply PEAC standards. However, several
specialty societies representing gastroenterology and orthopaedics, as
well as the American College of Physicians, did not agree with the
deletion of the discharge day management time. These groups requested
restoration of the six minutes allocated to the discharge day
management for 0-day global services and argued that most 0-day
services require as much staff time as do many 10-day global services
performed in the outpatient setting. One of these commenters did not
believe a rationale was provided for this change. Another commenter,
although recommending that any future refinements take into account all
of the PEAC standards, expressed concern regarding all of the above
changes, suggesting that this could lead to additional anomalies and
recommending that the revisions should be reviewed by the RUC.
Response: The PEAC recommended that the discharge day management
time apply only to 10-day and 90-day global services and we were
complying with this recommendation. We also believe that this PEAC
recommendation is reasonable; it is hard to imagine what tasks a
physician's clinical staff back in the office is performing for a
patient during the period that the patient is undergoing a same-day
procedure in the hospital outpatient department. However, the point
made about 10-day global procedures is pertinent. We would suggest that
the RUC reconsider whether the discharge day management clinical staff
time should apply only to services that are typically performed in the
inpatient setting. We also believe that it was appropriate to apply the
PEAC standards to codes that were not refined or that were refined
before the standards were developed. The application of these standards
is not only fair, but can also help to avoid the possible rank order
anomalies cited by the commenter.
Methacholine Chloride
The PEAC recommendations for CPT codes 91011 and 91052 included a
supply input for methacholine chloride as the injected stimulant for
these two services. In discussions with representatives from the
gastroenterology specialty society subsequent to receipt of the PEAC
recommendations, we learned this is incorrect. For the esophageal
motility study, CPT code 91011, we proposed to include edrophonium as
the drug typically used in this procedure. For the gastric analysis
study, CPT code 91052, we were unable to identify the single drug that
is most typically used with this procedure. We requested that
commenters provide us with information on the drug that is most
typically used for CPT code 91052, including drug dosage and price, so
that it could be included in the practice expense database.
Comment: Several specialty societies representing allergists,
pulmonologists and chest physicians, as well as the AMA, requested that
the additional cost of methacholine be reflected in the RVUS for the
bronchial challenge test, CPT code 95070. As an alternative, the
specialty society representing allergists suggested that a HCPCS code
could be created so that methacholine could be billed separately.
In response to our request for information about the supply inputs
for CPT codes 91011 and 91052, the American Gastroenterological
Association (AGA) indicated that edrophonium may be an appropriate
supply proxy for CPT code 91011, but, in practice, other agents are
more commonly used. However, they provided no additional information
regarding these other agents. AGA also stated that the most commonly
used drug for CPT code 91052 is pentagastrin, but betazole or histamine
may also be used. Again, they did not provide further specific
information.
Response: Because CPT code 95070 is valued in the nonphysician work
pool, the PEAC's addition of methacholine to this procedure could not
be captured by the practice expense RVUs. However, a J-code was
established, J7674, Methacholine chloride administered as inhalation
solution through nebulizer, per 1mg, so that this drug can be billed
separately. Accordingly, we have deleted methacholine from the practice
expense database.
For CPT code 91011, we have retained the drug edrophonium, and our
proposed price of $4.67 per ml, as a supply in the practice expense
database. However, we were not able to include a price for pentagastrin
in the supply practice expense database for CPT code 91052. We will be
happy to work with the specialty societies involved with both of these
procedures to obtain accurate drug pricing for the 2006 fee schedule.
Nursing Facility and Home Visits.
We proposed to adopt the direct practice expense input
recommendations from the March 2003 PEAC meeting for CPT codes 99348
and 99350, two E/M codes for home visits, as well as the March 2004
PEAC recommendations for E/M codes for nursing home services (CPT codes
99301 through 99316).
Comment: A specialty group representing family physicians supported
the acceptance of the PEAC recommendations for nursing facility visits,
even though this resulted in a decrease for these services. The
commenter stated that the decrease occurred because the original CPEP
data was flawed and the clinical staff times were too high. The
commenter also stated that the payments in the facility setting will
increase for these services and that setting has the higher volume of
visits. Other commenters representing long term care physicians,
geriatricians and podiatrists expressed disappointment in these PEAC
recommendations and stated that, while the PEAC did consider the views
of long term care physicians, the PEAC failed to accept these views
even though they were supported by data. These commenters believe the
PEAC did not
[[Page 66245]]
recommend an appropriate increase based on a false assumption that the
nursing home provides the staff. Another commenter contended that the
new values do not adequately account for work performed by the
physician's clinical staff. The commenter stated that the pre- and
post-times for these codes are less than for the comparable office
visit codes, even though it is clear that more clinical staff time is
required for the nursing facility resident. One commenter suggested
that these concerns would need to be addressed within the framework of
the 5-year review. The specialty society representing homecare
physicians also commented that, rather than challenging a flawed
system, they will use the 5-year review process to have work and
practice expense re-valuated for the home visit codes.
Response: While sympathetic to the concerns expressed by the long-
term care physicians regarding the overall decrease in clinical staff
time in the nursing facility E/M procedures, we believe the PEAC
recommendations for these services to be reasonable. We also agree with
commenters regarding the upcoming 5-year review process as a means to
address the physician work component of these codes. To the extent that
there is overlap between the physician time and the clinical labor
practice expenses involved in a particular procedure, the 5-year review
process can be utilized to address these issues. We encourage the home
care physicians and the long-term care physicians to consider using the
5-year review process for these codes.
Suggested Corrections to the CPEP Data.
Comment: The RUC and American Podiatric Medical Association
identified a number of PEAC refinements from the August 2003 meeting
that were not reflected in the practice expense database and asked that
these be implemented. The RUC also asked us to correct the equipment
times for all of the 90-day global services to correspond with the
PEAC-refined clinical staff times for these codes.
Response: We have made the recommended corrections to our practice
expense database.
Comment: The specialty society representing hematology noted the
supply items missing from the practice expense database for CPT codes
36514 through 36516 that had been included in the CMS-accepted PEAC
refinements.
Response: We regret the error. These items are incorporated into
the practice expense database.
Comment: The specialty society representing pediatrics as well as
the RUC commented that the PEAC recommendations also included a
recommendation for a change in the global period for CPT code 54150,
Circumcision, using clamp or other device; newborn, from a 10-day
global to an ``xxx'' designation, which would mean the global period
does not apply. This issue was not discussed in the proposed rule and
the commenters requested that this change be reflected in the final
rule.
Response: As stated by the commenters, this request was included in
the PEAC recommendations but was inadvertently omitted from the
proposed rule. We agree that the 10-day global period currently
assigned to this procedure may not be appropriate because the physician
performing the procedure most likely does not see the infant for a
post-procedure visit. However, we believe that a 0-day global period
rather than ``xxx'' should be assigned to this procedure. We generally
use the ``xxx'' designation for diagnostic tests and no surgical
procedure currently is designated as an ``xxx'' global service. We
believe this will accomplish the same end because most any other
service performed at the same time as the circumcision could be billed
with the appropriate modifier. We are adjusting the practice expense
database to delete any staff time, supplies and equipment associated
with the post-procedure office visit.
Comment: Specialty societies representing dermatology stated that
there was an error in the nonfacility practice expense RVUS for the
Mohs micrographic surgery service, CPT code 17307, due to the omission
of clinical staff time from the practice expense database.
Response: We have corrected the practice expense database to
reflect the appropriate clinical staff time.
Comment: We received comments from the American College of
Radiology (ACR) and Society of Nuclear Medicine noting that some of the
codes used by their specialty were omitted from the listing of PEAC-
refined codes that appeared in Addendum C in our proposed rule. They
submitted a complete list of the codes that had gone through PEAC
refinement, beginning at the first PEAC meeting in April 1999, and
asked that we include these codes on the Addendum.
Response: We appreciate the specialty societies bringing to our
attention that some of their codes were omitted from Addendum C and we
have reviewed the codes on their submitted list. Addendum C was meant
to list only those codes that were refined in this year's rule, and
thus, only listed those refined by the PEAC from March and August 2003
and January and March 2004. However, it does appear that there is some
confusion regarding what codes were refined during this period,
particularly from the March 2004 meeting. We will work with all medical
societies and the RUC to clarify the status of all the codes in
question.
Other Issues.
Comment: The RUC requested that we publish practice expense RVUs
for all Medicare noncovered services for which the RUC has recommended
direct inputs. We also received a request from the American Academy of
Pediatrics to publish work and practice expense RVUs for the noncovered
nasal or oral immunization services (CPT codes 90473 and 90474) and the
visual acuity test (CPT code 99173).
Response: In the past, we have published the practice expense RVUs
for only a small number of noncovered codes which are listed in our
national payment files that can be accessed via our physician web page
under ``Medicare Payment Systems'' as part of the public use files at
http://www.cms.hhs.gov/physicians/. Because we have not yet established a
consistent policy regarding the publication of RVUs for noncovered
services, we will need to examine this issue further to carefully weigh
the pros and cons of publishing these RVUs for noncovered services.
Comment: The American Speech-Language Hearing Association (ASHA)
and the American Academy of Audiology (AAA), expressed concern about
the reduction of practice expense RVUs for CPT code 92547, Use of
vertical electrodes (List separately in addition to code for primary
procedure), which resulted after the PEAC refinement. The commenters
asked for our assistance to clarify a CPT instruction regarding this
procedure because they believe it prevents the multiple billings of CPT
92547 in a given patient encounter.
Response: While we are sympathetic to the concerns expressed by
ASHA and AAA, we also want to note that CPT code descriptors and
accompanying coding instructions are proprietary to CPT. We would
encourage these organizations to discuss this issue directly with the
CPT editorial committee.
Comment: A specialty society representing vascular surgery
expressed concern about the wide variations in practice expense RVUs
that are sometimes derived under the current methodology. The commenter
suggested that some outliers require additional focus to determine
whether these are errors in the direct inputs or if they
[[Page 66246]]
reflect problems inherent in the methodology. According to the
commenter, it would appear that some of the extreme variation is due to
the high costs of certain disposable supplies in the office setting as
well as high scaling factors. A few examples of outlier codes were
provided. The commenter suggested that we consider an alternative
methodology for payment of high-priced single-use items in the
nonfacility setting.
Response: We agree with the commenter that the issue raised is one
worth study and analysis. Unfortunately, this is not a task that can be
accomplished in time for discussion in this final rule. We will be very
willing to work with the specialty society and with the Practice
Expense Subcommittee of the RUC, as well as any other interested
parties, to work further on this issue that will only be magnified as
more complex procedures are moved into the office setting.
Comment: A provider of radiology services questioned the reductions
in practice expense for CPT code 77370, Special medical radiation
physics consultation.
Response: The practice expense RVUs for CPT code 77370 decreased by
0.02 RVUs between last year's final rule and this year's proposed rule.
This small decrease is due to the normal fluctuations resulting from
updating our practice expense data.
c. Repricing of Clinical Practice Expense Inputs--Equipment
We use the practice expense inputs (the clinical staff, supplies,
and equipment assigned to each procedure) to allocate the specialty-
specific practice expense cost pools to the procedures performed by
each specialty. The costs of the original equipment inputs assigned by
the CPEP panels were determined in 1997 by our contractor, Abt
Associates, based primarily on list prices from equipment suppliers.
Subsequent to the CPEP panels, equipment has also been added to the
CPEP data, with the costs of the inputs provided by the relevant
specialty society. We only include equipment with costs equal to or
exceeding $500 in our practice expense database because the cost per
use for equipment costing less than $500 would be negligible. We also
consider the useful life of the equipment in establishing an equipment
cost per minute of use.
We contracted with a consultant to assist in obtaining the current
price for each equipment item in our CPEP database. The consultant was
able to determine the current prices for most of the equipment inputs
and clarified the specific composition of each of the various packaged
and standardized rooms or ophthalmology ``lanes'' currently identified
in the equipment practice expense database (for example, mammography
room or exam lane). We proposed to delete the current ``room''
designation for the radiopharmaceutical receiving area and, in its
place, list separately the equipment necessary for each procedure as
individual line items.
Also, we proposed to replace all surgical packs and trays in the
practice expense database with the appropriate standardized packs that
were recommended by the PEAC, either the basic instrument pack or the
medium pack.
The useful life for each equipment item was also updated as
necessary, primarily based on the AHA's ``Estimated Useful Lives of
Depreciable Hospital Assets'' (1998 edition). We noted in the August 5,
2004 proposed rule that AHA would be publishing updated guidelines this
summer and that we would reflect any updates in our final rule.
In addition, we proposed the following database revisions:
Assignment of Equipment Categories
We proposed that equipment be assigned to one of the following six
categories: documentation, laboratory, scopes, radiology, furniture,
rooms-lanes, and other equipment. These categories would also be used
to establish a new numbering system for equipment that would more
clearly identify them for practice expense purposes.
Consolidation and Standardization of Item Descriptions
We proposed combining items that appeared to be duplicative. For
example, for two cervical endoscopy procedures, our contractor
identified that the price of the LEEP system includes a smoke
evacuation system but that system is also listed separately. We
proposed to merge these two line items and reflect both prices in the
price of the LEEP system.
These changes were reflected in Addendum D of the proposed rule.
Additionally, there were specific equipment items for which a
source was not identified or for which pricing information was not
found that were included in Table 2 of the August 5 proposed rule.
Items that we proposed to delete from the database were also identified
in this table. We requested that commenters, particularly the relevant
specialty groups, provide us with the needed pricing information,
including appropriate documentation. Also, we stated that if we were
not able to obtain any verified pricing information for an item, we
might eliminate it from the database.
Comment: The Society of Nuclear Medicine agreed with the deletion
of the current room designation for radiopharmaceutical area and
designation of categories for equipment. However, the society
recommended that the category designation of ``radiology'' be changed
to ``imaging equipment'' and ``other equipment'' be changed to ``non-
imaging equipment'' to be inclusive of these modalities. The American
College of Radiology also concurred with the elimination of the current
room designation for radiopharmaceutical area.
Response: We agree that the term ``imaging equipment'' rather than
the term ``radiology'' more accurately reflects current practice and
have changed the practice expense database accordingly. However, it
would be inappropriate to change the ``other equipment'' category to
``non-imaging equipment'' because there are items in other categories
that would not be encompassed in the proposed title change.
Comment: The Society of Nuclear Medicine supplied information on
the equipment item E51076 with the requested documentation.
Response: We have revised the practice expense database to reflect
the information provided.
Comment: The American Society for Therapeutic Radiology and
Oncology (ASTRO) submitted information and the requested documentation
for fifteen items, often supplying two or more pricing sources.
Response: We greatly appreciate the information and have revised
the practice expense database to reflect the information provided.
Comment: Commenters representing manufacturers and providers
expressed concern about the reduction in payment (9 percent) for
external counterpulsation (ECP), G0166. The commenters questioned the
proposed change made to the life of the ECP equipment, from seven to
five years, used for this service. Commenters did not believe this was
supported by the AHA information (which indicated that similar
diagnostic cardiovascular equipment has an equipment life of five
years) and requested that this timeframe be applied to the ECP
equipment for this service. The American College of Cardiology also
questioned the change to the ECP equipment life. The commenters also
questioned the allocation for maintenance and indirect costs applied
under the practice expense methodology
[[Page 66247]]
as well as the time allocated for this service. As a final point, some
of the commenters requested that we adjust the work RVUs assigned to
this G-code to that of an echocardiogram (CPT code 93307) and include
it in the nonphysician work pool.
Response: Based upon review of the information provided we have
revised the equipment life to five years. The methodology used for the
allocation for maintenance and indirect costs is consistent with our
methodology. For the request to adjust the work RVUs for this service,
we refer the commenters to section VI of this final rule where we are
soliciting comments on services where the physician work may be
misvalued.
Comment: The College of American Pathologists provided information
on items listed in table 2: the DNA image analyzer (ACIS), and image
analyzer (CAS system) code E13652. They noted that the CAS system is no
longer marketed and that the ACIS system would be used in its place.
Thus, they provided documentation on the price for the ACIS system.
Response: We appreciate the information and have made the necessary
changes to the database.
Comment: The American College of Cardiology (ACC) agreed with the
pricing for the ambulatory blood pressure monitor, provided prices for
the ECG signal averaging system (E55035), but provided no documentation
for these prices. They stated that the echocardiography digital
acquisition ultrasound referenced in table 2 was no longer in the
marketplace and that a digital workstation was now typically used. They
requested that an appropriate equipment code be available for this item
and provided a price range for this item (although without the
supporting documentation). ACC also recommended that the pacemaker
programmer (E55013) be removed from the equipment list because it is
provided at no cost to the physician. Removal of this item from the PE
database was also supported by a manufacturer that commented on the
rule.
Response: We have removed the pacemaker programmer from the
practice expense database. We will temporarily retain other items and
prices for the 2005 physician fee schedule and request that ACC forward
the documentation as soon as possible.
Comment: The American College of Radiology (ACR) provided partial
information for the CAD processor unit and software. ACR also submitted
information regarding the computer workstation for MRA and the
mammography reporting software, but with insufficient documentation.
For the various equipment items ACR listed for the mammography room,
updated information was provided for a few of the items. ACR noted that
they would submit documentation for all outstanding pieces of equipment
when it is available. ACR did not agree with the room price for MRI and
CT that was referenced in Addendum D and requested an extension so that
they can work with us to accurately price these items.
Response: We will maintain current pricing for all equipment items
and the mammography room on an interim basis, until sufficient
documentation is provided.
Comment: The American Ophthalmology Association (AOA) and American
Optometric Association both supplied pricing information along with the
requested documentation for the computer, VDT, and software (E71013)
listed in table 2. AOA also provided pricing information for the
ophthalmology drill listed in this table, indicating a cost of $57.
They expressed their appreciation for the recategorization and
standardization of descriptions for equipment and supplies.
Response: We appreciate the documentation forwarded by these two
organizations and have incorporated into the practice expense database
the pricing information provided for the computer, VDT, and software.
Because the ophthalmology drill is less than $500 (the standard
established for equipment), we are removing it from the equipment list
for the practice expense database.
Comment: The American Gastroenterological Association (AGA)
expressed concern about the reduction in RVUs for CPT code 91065, a
breath hydrogen test. They believe that the newer equipment listed in
the practice expense database does not reflect the analyzer that is
typically used, which is more expensive, and noted that the costs for
the reagents have also increased.
Response: We are sympathetic to the concerns of the AGA regarding
the typical equipment used for CPT code 91065 and would like to work
with them to ascertain updated pricing information about the equipment
most physicians utilize for this service. However, the majority of the
decrease (76 percent) in practice expense RVUs for this procedure is
due to the PEAC refinement for the clinical labor time that was reduced
by nearly 50 percent.
Comment: The American Academy of Sleep Medicine indicated that most
typical CPAP/BiPAP remote unit is a bilevel positive airway pressure
unit and provided documentation for the price of this item.
Response: This price is reflected in the practice expense database.
Comment: The Society for Vascular Surgery (SVS), Society for
Vascular Ultrasound and Society of Diagnostic Medical Sonography all
expressed appreciation for the refinement to the inputs that apply to
vascular ultrasound services. However, the commenters requested that we
incorporate the requested refinements for the other ancillary equipment
present in a vascular ultrasound room into other similar procedures.
SVS specifically listed the following CPT codes: 93875-9 and 93990.
Response: In addition to the three new CPT codes for
cerebrovascular arterial studies CPT 93890, 93892 and 93893, we have
added the vascular ultrasound room to the codes indicated in the SVS
comment noted above.
Comment: The American Psychiatric Association provided
documentation for the cost of the ECT machine and the American
Psychological Association provided information on the neurobehavioral
status exam and testing, as well as the biofeedback equipment listed in
table 2, along with the requested documentation.
Response: We appreciate this information. The practice expense
database was revised to reflect this cost information.
Comment: The American Society of Clinical Oncology requested that
the biohazard hood be substituted for the ventilator and hood blower as
a practice expense input for the chemotherapy codes.
Response: We revised the database to reflect this change.
Comment: American Academy of Neurology supplied information and the
necessary documentation on several equipment items listed in table 2
associated with neurology services.
Response: We have made the revisions to the prices for the
ambulatory EEG recorder (E54008), ambulatory review station (E54009),
and portable digital EEG monitor based on the documentation provided.
Based on the documentation provided, we note that the price for the
ambulatory review station was substantially reduced ($44,950 to
$7,950).
Comment: The American Clinical Neurophysiology Society (ACNS)
stated that the payment for CPT code 95819, an EEG service, was
substantially reduced. The Society believes it is due to a price
reduction for the EEG equipment (E54006) used in this service that was
listed in Addendum D of the
[[Page 66248]]
proposed rule. The commenter indicated that the proposed price does not
include the review station and software which is needed for this
service and provided documentation for appropriately pricing this item.
Response: Based on the documentation provided, we have changed, on
an interim basis for the 2005 fee schedule, the price for this item and
note that this equipment price is associated only with CPT code 95819.
We would be happy to work with ACNS in order to resolve any issues
surrounding the RVUs for CPT code 95819. Reviewing the direct inputs
for this code, we note that the largest contributor to the reduction of
practice expense RVUs is the PEAC's refinement of this code's supply
items.
Comment: The National Association for Medical Direction of
Respiratory Care and the American College of Chest Physicians were in
agreement with the proposed prices for equipment except for the pulse
oximeter (including printer), E55003. The commenters referenced a price
that is $83 more than that listed in the table, but provided no
documentation.
Response: We appreciate the comments from these organizations
regarding the repricing of the equipment items in the practice expense
database. We have retained our price of $1,207 for the pulse oximeter
and note that it is an average from two different available sources.
Comment: We received a comment from a consumer regarding the price
of the electromagnetic therapy machine for HCPCS code G0329 with
concerns about the low payment for this modality. While no
documentation was submitted, the commenter noted that the cost for this
equipment ranged from $25,000 to $35,000.
Response: We appreciate the commenter's remarks about the price of
the electromagnetic therapy equipment, Diapulse. We have retained our
price of $25,000 in the practice expense database because we do not
have documentation that any higher-priced equipment is typically used.
Similar to other modalities used in rehabilitation, including those
used in wound care, we note that this procedure reflects comparable
practice expense values.
Comment: Several specialty organizations questioned our
substitution of the two standardized packs for previously PEAC-approved
packs and trays, as discussed in our proposed rule. One specialty
society suggested we consult with the AMA before proceeding on this
point.
Response: We uniformly applied the PEAC-approved values for the
packs and trays to all packs and trays, regardless of whether the codes
had previously been refined by the PEAC. To the extent that a specialty
society feels that it was disadvantaged by this policy, we would
encourage them to bring the specific codes that should be excluded from
this policy to the newly formed PERC (formerly PEAC) at the next RUC
meeting in February 2005.
Comment: Several specialty organizations indicated that they were
in the process of obtaining pricing information on equipment items and
would provide it as soon as possible. One commenter also asked that we
retain the items proposed for deletion as they are necessary in
providing their services, but provided no documentation.
Response: In the proposed rule, we noted that we might eliminate
those items from the database for which documented pricing information
was not received. Due to the number of outstanding equipment prices,
and the number of societies that are underway in their search for this
data, we have decided to extend the submission deadline. We would
encourage specialty societies to submit price information soon to help
ensure that it can be used to establish practice expense RVUs in next
year's proposed rule.
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d. Miscellaneous Practice Expense Issues
Pricing for Seldinger Needle.
We proposed to average two prices of this supply item to reflect a
cost of $5.175. We requested that, if commenters disagreed with this
change in price, the comment should provide documentation to support
the recommended price, as well as the specific type of needle that is
most commonly used.
Comment: Commenters were in agreement with the proposed pricing of
the seldinger needle.
Response: We will use the proposed price of $5.175 for this supply
item in the practice expense database.
[[Page 66255]]
Hysteroscopic Endometrial Ablation.
We proposed to assign, on an interim basis, the following direct
practice expense inputs in the nonfacility setting for CPT code 58563,
Hysteroscopy, surgical; with endometrial ablation. (Note: In the August
5, 2004 proposed rule this code was erroneously identified as 56853,
which does not exist.) We also stated we would request that the RUC
review these inputs as part of the practice expense refinement process.
+ Clinical Staff: RN/LPN/MTA--72 minutes (18 pre-service and 54
service)
+ Supplies: PEAC multispecialty visit supply package, pelvic exam
package, irrigation tubing, sterile impervious gown, surgical cap, shoe
cover, surgical mask with face shield, 3x3 sterile gauze (20), cotton
tip applicator, cotton balls (4), irrigation 0.9 percent sodium
chloride 500-1000 ml (3), maxi-pad, mini-pad, 3-pack betadine swab (4),
Monsel's solution (10 ml), lidocaine jelly (1000 ml), disposable
speculum, spinal needle, 18-24 g needle, 20 ml syringe, bupivicaine
0.25 percent (10 ml), 1 percent xylocaine (20 ml), cidex (10 ml),
Polaroid film-type 667 (2), endosheath, and hysteroscopic ablation
device kit.
+ Equipment: power table, fiberoptic exam light, endoscopic-rigid
hysteroscope, endoscopy video system, and hysteroscopic ablation
system.
Comment: Commenters, including many individual practitioners, were
supportive of this proposed change. The specialty society also stated
that they plan to present the inputs for this service at the RUC
meeting in February 2005
Response: With the exception of the post incision care kit that we
deleted because this procedure does not require an incision, we will
finalize these inputs as proposed.
Photopheresis.
We proposed to assign, on an interim basis, the following
nonfacility practice expense inputs for the photopheresis service, CPT
code 36522:
+ Clinical Staff: RN--223 minutes (treatment is for approximately 4
hours)
+ Supplies: multispecialty visit supply package, photopheresis
procedural kit, blood filter (filter iv set), IV blood administration
set, 0.9 percent irrigation sodium chloride 500-1000 ml (2), heparin
1,000 units-ml (10), povidone solution-betadine, methoxsalen (UVADEX)
sterile solution-10 ml vial, 1 percent-2 percent lidocaine-xylocaine,
paper surgical tape (12), 2x3 underpad (chux), nonsterile drapesheet 40
inches x 60 inches, nonsterile Kling bandage, bandage strip, 3x3
sterile gauze, 4x4 sterile gauze, alcohol swab pad (3), impervious
staff gown, 19-25 g butterfly needle, 14-24g angiocatheter, 18-27 g
needle, 20 ml syringe, 10-12 ml syringe, 1 ml syringe, 22-26 g syringe
needle-3 ml.
+ Equipment: plasma pheresis machine with ultraviolet light source,
medical recliner.
We also stated we would request that the RUC review these inputs.
Comment: One commenter supplied information on practice expense
inputs for this code and indicated that an oncology nurse should be
used, instead of an RN, to perform the procedure. A specialty society
also stated that they would be providing information on this service at
the September RUC meeting.
Response: We appreciate the information submitted by the
commenters. This code was discussed at the September RUC meeting and
recommended practice expense inputs for this service were provided to
us. We do not agree with the RUC recommended clinical staff procedure
(intra) time of 90 minutes. We believe that this time, which is half of
the proposed intra time, does not accurately reflect the total time
involved in performing this procedure. Our understanding is that the
filtration rate and the procedures performed by the nurse for
photopheresis are similar to those that are reflected in the selective
apheresis services, CPT code 36516, with a PEAC-approved intra time of
240 minutes. Based on this, and the absence of specialty representation
at the RUC familiar with the process, we are assigning 180 minutes for
the intra time, as proposed. We are also assigning the RN/LPN staff
type to this procedure, because we believe it is similar to other
apheresis procedures. We will continue our examination of this issue
and entertain ongoing dialog with all interested organizations and
individuals, including the AMA and the RUC, the industry, and those
physicians and individuals familiar with the photopheresis procedure in
order to assure the accuracy of the intra time.
Pricing of New Supply Items.
As part of last year's rulemaking process, we reviewed and updated
the prices for supply items in our practice expense database. During
subsequent meetings of both the PEAC and the RUC, supply items were
added that were not included in the supply pricing update. The August
5, 2004 proposed rule included Table 3 Proposed Practice Expense Supply
Item Additions for 2005, which listed supply items added as a result of
PEAC or RUC recommendations subsequent to last year's update of the
supply items and the proposed associated prices that we will use in the
practice expense calculation.
We also identified certain supply items for which we were unable to
verify the pricing information (see Table 4, Supply Items Needing
Specialty Input for Pricing, in the August 5, 2004 proposed rule). We
requested that commenters provide pricing information on these items
along with documentation to support the recommended price. In addition,
we also requested information on the specific contents of the listed
kits, so that we do not duplicate any supply items.
Comment: Several commenters representing providers of these
services stated that table 3 incorrectly associated ``gold markers''
with the brachtherapy intracavity codes. They were all in agreement
that these markers are typically used in external beam treatments and
payment is associated with unlisted procedure codes and should be paid
for at cost.
Response: We have deleted the gold markers from CPT codes 77761-
77763 and removed this supply from the practice expense database.
Comment: The American Urology Association noted that we should
exclude the vasotomy kit from CPT codes 55200 and 55250.
Response: We have deleted the vasotomy kit from CPT codes 55200 and
55250.
Comment: The American College of Chest Physicians agreed with
pricing of items used in their practices in table 3 and stated that the
bronchogram tray does not need to be included in the practice expense
database, as the procedure is seldom performed and, when it is, the
procedure is performed in a facility.
Response: We have deleted the bronchogram tray from the practice
expense database and corrected the direct inputs for CPT code 31708
accordingly.
Comment: We received comments from the American College of
Cardiology (ACC) that included price quotes and names of sources for
supply items listed on table 3.
Response: Unfortunately, ACC did not include the requested
sufficient documentation, such as invoices or catalog web page links.
We have asked ACC to forward this pricing documentation to us as soon
as possible because it will be required for supplies to remain valued
in the practice expense database. In the interim, for the 2005 fee
schedule, we will maintain the prices currently in the practice expense
database for the following supplies:
[[Page 66256]]
blood pressure recording form at $0.31, pressure bag (infuser) 500cc or
1000cc at $8.925, sterile, non-vented, tubing at $1.99.
Comment: Noting that a $15 supply item, needle-wire for
localization of lesions in the breast (used preoperatively in CPT codes
19290 and 19291) was no longer used, a manufacturer requested that we
replace this supply with an anchor-guide device valued at $245. The
commenters also stated that this device is used in over 70 offices and
imaging centers.
Response: We appreciate the comments from the manufacturer.
However, during last year's rulemaking process we repriced all of our
supplies, and the needle-wire price of $15 was an average of prices
from two different sources ($17 and $13). This price was proposed and
accepted by the medical specialty societies that we depend on to verify
typical items in our practice expense database. We have retained the
$15 needle-wire for localization because we believe it is typically
used for this procedure.
The following table lists the items on which we requested input,
the comments received, and the action taken.
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Addition of Supply Item to CPT 88365, Tissue In Situ
Hybridization.
We proposed to add, on an interim basis, a DNA probe to the CPEP
database for CPT 88365, tissue in situ hybridization, with the
understanding that the inclusion of the item would be subject to
forthcoming RUC review.
[[Page 66259]]
Comment: Commenters were supportive of this proposal. The College
of American Pathologists also encouraged us to include updated
information on practice expense inputs from the September RUC meeting,
while another commenter suggested that we run the information by the
specialty society.
Response: The direct practice expense inputs for this code and two
other codes in the same family were discussed at the September RUC
after a presentation made by the specialty society. We have reviewed
and accepted the RUC recommendations, and these practice expense inputs
will be included in the practice expense database.
Ophthalmology Equipment.
In cases where both the screening and exam lanes are included in
the equipment list for the same ophthalmology service, we proposed to
include only one lane because the patient could only be in one lane at
a time. We proposed defaulting to the exam lane and, thus, we proposed
deleting the screening lane from the practice expense inputs for these
procedures. For the services where a lane change was made, time values
were assigned to the exam lane in accordance with our established
standard procedure.
Comment: The American Academy of Ophthalmology requested that we
specifically identify the codes for which we deleted the screening
lane, so that they can ensure that the correct lane was deleted.
Response: This information can be obtained by comparing the direct
inputs in the practice expense database files for the 2004 and 2005 fee
schedules that are posted on our Web site (http://www.cms.hhs.gov/physicians/pfs
). However, we would be happy to work with the specialty
organization to verify the accuracy of the information.
Parathyroid Imaging, CPT code 78070.
Based on comments received from the RUC and the specialty society
representing nuclear medicine, we proposed to crosswalk the charge-
based RVUs from CPT 78306, Bone and/or joint imaging; whole body, to
CPT 78070, Parathyroid imaging.
Comment: Several specialty societies expressed appreciation for
this proposed change.
Response: We will finalize our proposal and crosswalk the charge-
based RVUs from CPT code 78306 to CPT code 78070.
Additional PE concerns.
Comment: We received information from the American Academy of
Ophthalmology that two biometry devices (a-scan ultrasonic biometry
unit and an optical coherence biometer) were listed as equipment for
the ophthalmic biometry service, CPT code 92136. Only the optical
coherence biometer should be included for this code.
Response: As requested by the specialty society, we have deleted
the a-scan biometry unit from the equipment list for CPT code 92136.
Comment: We received comments from manufacturers, specialty
societies representing renal physicians and vascular surgeons, and
individual providers questioning the decrease in nonfacility practice
expense RVUS for CPT code 36870, Percutaneous thrombectomy,
arteriovenous fistula, autogenous or nonautogenous graft (includes
mechanical thrombus extraction and intra-graft thrombolysis. Some
commenters believe this reduction occurred because the supplies listed
in the database for this service reflect only one method of providing
this service. While commenters acknowledged that the database includes
the supplies used in approximately 50 percent of the instances this
procedure is performed, the commenters claimed that other supplies may
be used in the remaining occasions. Commenters requested that we add
these other specific supplies to the database.
Response: Because there are a variety of supplies and equipment
that can be used in performing a service, under the practice expense
methodology, the supplies and equipment that are used in determining
payment are those that are most typical for the procedure. Although
there may be alternative supplies used, the inputs in the database
reflect what is typically used (which is acknowledged by the
commenters) and thus we are not adding the requested supplies to the
practice expense database. However, we did note that the list of
equipment did not reflect the cost of the angiography room that is used
during the procedure, and this has been added to our database for this
code.
Comment: Societies representing dermatologic specialties expressed
concern about the reduction in practice expense RVUs for a photodynamic
therapy service, CPT code 96567. The commenters believe that this
reduction is due to the application of the dermatology scaling factor
based on updated practice expense utilization and requested that this
be reconsidered. These commenters also expressed appreciation that
there is now a separate HCPCS code to bill for levulan that is needed
for this procedure, but stated that there are two medical supplies that
need to be included in the practice expense database: bacitracin, and a
topical anesthetic cream.
Response: The practice expense RVUs for photodynamic therapy
decreased only slightly in this year's proposed rule due to the
proposed repricing of equipment. The decrease referred to by the
commenter occurred after the first year that the code was established.
At that time we obtained the utilization data that demonstrated that
dermatologists performed the service and we then applied the same
scaling factors to the code that we do for all dermatology services.
Therefore, the scaling factor we now apply is correct. We will add the
requested amount of bacitracin to the supply list for the code.
Unfortunately, the topical anesthetic requested is not in our database
and the commenters did not include pricing information so we are not
able to include the item in our practice expense calculation.
Comment: A society representing interventional pain physicians
expressed concern that the practice expense RVUs for CPT code 95990,
Refilling and maintenance of implantable pump or reservoir for drug
delivery, spinal (intrathecal, epidural) or brain (intraventricular),
are understated when compared to the RVUs for CPT code 95991, the same
service administered by a physician. According to the commenter, CPT
code 95991 includes a total of 47 minutes of nonphysician labor and 37
minutes of physician labor or total professional time of 84 minutes.
This is the total time spent with the patient before, during and after
the refill. The commenter requested that the number of minutes of
direct labor for CPT code 95990 should be a minimum of 84 minutes,
since the nonphysician practitioner would be performing all the
services associated with CPT code 95991 that are performed by both the
physician and clinical staff. In addition, the commenter stated that
CPT code 95990 should also be assigned physician work RVUs because
there is physician oversight of the service even when performed by
clinical staff. Two other commenters stated that both CPT codes 95990
and 95991 should be valued the same as the chemotherapy implanted pump
refill service, CPT code 96530. The commenters state that this was the
code originally used to report the above services, that CPT codes 95990
and 95991 originally were assigned higher RVUs than CPT code 96530 and
that the MMA adjustments that increased the payment for CPT code 96530
should be applied to CPT codes 95990 and 95991.
[[Page 66260]]
Response: The commenter is correct that the clinical staff times
for CPT codes 95990 and 95991 are the same (50 minutes of clinical
staff time), although the clinical staff is performing the procedure in
one case and assisting the physician in the other. However, the
assumption underlying these times is that, in the cases where it is
necessary for the physician to personally perform the procedure, the
nurse is assisting for the entire time. If this assumption is not
correct, then the clinical staff time for CPT code 95991 is overstated.
Because CPT codes 95990 and 95991 are not considered drug
administration codes under section 303 of the MMA, we will not apply
the adjustments made for CPT code 96530 to these services. Therefore,
we will not be revising the staff time for either code at this time,
but would suggest that the RUC look further at this issue. We would
also suggest that the society bring CPT code 95990 to the 5-year
review, if they wish to make the case that work RVUs should be
assigned.
Comment: The society representing interventional pain physicians
questioned the ``professional component only'' designation we assigned
to the codes for the analysis of an implanted intrathecal pump, CPT
codes 62367 and 62368, and the subsequent low RVUs for these services.
The commenter stated that if the payment is left as proposed, more
physicians would stop offering intrathecal pumps to patients.
Response: This was an inadvertent error on our part that we have
corrected for the final rule. These services are physicians' services
that do not have separate professional and technical components. We
thank the commenter for pointing out this error.
Comment: The Joint Council of Allergy, Asthma and Immunology
expressed concern about the reduction in the proposed rule in practice
expense RVUs for a number of allergy codes, in particular the venom
therapy CPT codes, 95145 through 95149. The commenter stated that
Medicare reimbursement for these services does not cover the
physician's supply expense, due to the expensive venom antigens that
are part of the service, and believes this is a result of the scaling
factor being used.
Response: We are sympathetic to the commenter's concern about the
high cost of the venom antigens and the specialty's low scaling factor.
We would be happy to work with JCAAI further to see if a remedy can be
identified regarding this subset of the allergy codes.
Comment: Two commenters stated that the practice expense RVUs for
HCPCS code G0329, Electromagnetic Therapy for ulcers, were too low and
supplied information on the supplies, equipment and clinical staff time
for this service.
Response: Based on the information provided by the commenters, we
added diapulse asetips and chux to the supplies in the practice expense
database for this service. We also increased the equipment time to 30
minutes.
Comment: We received comments from the North American Spine Society
(NASS) stating that the specific needle used for CPT codes 22520 and
22522, which was originally recommended by NASS, is the most expensive
needle and may not be the most typical. The specialty noted that
available needles range from $26 to $1,295, which represent the needle
(termed vertebroplasty kit) in the practice expense database. NASS
indicated that the specialties involved in performing these procedures
are conducting a survey to determine the most commonly used needles and
their costs.
Response: We appreciate the comments from NASS and look forward to
receiving the survey results. In the interim, we have averaged the
needle costs for the range indicated above by the specialty and have
entered this figure, $660.50, as a placeholder for the 2005 fee
schedule. Because of the large disparity between the lowest and highest
needle costs, it is not reasonable to consider $660.50 as a true
average cost for this supply item. We will continue to work with the
specialty organizations in order to ensure that the 2006 fee schedule
practice expense database reflects the value for the most typical
needle used in these procedures.
Comment: We received comments from two medical societies with
concerns about a decrease in practice expense RVUs for CPT code 95819,
which is part of the EEG sleep study series of codes. These two
organizations noted their willingness to bring this code to the
February 2005 RUC meeting in order to rectify the direct practice
expense inputs for this procedure.
Response: We have reviewed the family of EEG sleep-study codes and
believe that a rank order anomaly exists relating primarily to the 2004
PEAC recommendation to delete the 25 reusable electrodes from CPT code
95819. We support and encourage these organizations to bring the entire
EEG family of codes to the February 2005 RUC to ensure that this rank
order anomaly can be resolved and the correct direct inputs can be
identified for these procedures.
Comment: The Coalition for Advancement of Prosthetic Urology
expressed concern about the continuing decline in practice expense RVUs
for prosthetic urology procedures. They believe that this is due in
part to the number of post service visits assigned to these services.
They stated that information from a survey they conducted shows there
are typically four to five post service visits rather than three as
reflected in the database. The commenter also provided a copy of the
survey information.
Response: The number of post service visits for these services was
established based on recommendations from the RUC or by using the
Harvard data. If they believe that the information regarding the number
of post service visits for specific procedures is incorrect, the
Coalition must request that the codes be examined as part of the 5-year
refinement of work RVUs. An explanation of this process and the
information that must be provided is found in section VI. of this rule.
B. Geographic Practice Cost Indices (GPCIs)
We are required by section 1848(e)(1)(A) of the Act to develop
separate GPCIs to measure resource cost differences among localities
compared to the national average for each of the three fee schedule
components. While requiring that the practice expense and malpractice
GPCIs reflect the full relative cost differences, section
1848(e)(1)(A)(iii) of the Act requires that the physician work GPCIs
reflect only one-quarter of the relative cost differences compared to
the national average.
Section 1848(e)(1)(C) of the Act requires us to review and, if
necessary, to adjust the GPCIs at least every 3 years. This section of
the Act also requires us to phase-in the adjustment over 2 years and to
implement only one-half of any adjustment if more than 1 year has
elapsed since the last GPCI revision. The GPCIs were first implemented
in 1992. The first review and revision was implemented in 1995, the
second review was implemented in 1998, and the third review was
implemented in 2001. We reviewed and revised the malpractice GPCIs as
part of the November 7, 2003 (68 FR 63196) physician fee schedule final
rule. We were unable to revise the work and practice expense GPCIs at
the time of the publication of the November 2003 final rule because the
U.S. Census data, upon which the work and practice expense GPCIs are
based, were not yet available.
[[Page 66261]]
In addition, section 412 of the MMA amended section 1848(e)(1) of
the Act and established a floor of 1.0 for the work GPCI for any
locality where the GPCI would otherwise fall below 1.0. This 1.0 work
GPCI floor is used for purposes of payment for services furnished on or
after January 1, 2004 and before January 1, 2007. Section 602 of the
MMA further amended section 1848(e)(1) of the Act for purposes of
payment for services furnished in Alaska under the physician fee
schedule on or after January 1, 2004 and before January 1, 2006, and
sets the work, practice expense, and malpractice expense GPCIs at 1.67
if any GPCI would otherwise be less than 1.67.
In the August 5, 2004 proposed rule, we proposed to revise the work
and practice expense GPCIs for 2005 through 2007 based on updated U.S.
Census data and Department of Housing and Urban Development (HUD) fair
market rental (FMR) data. The same data sources and methodology used
for the development of the 2001 through 2003 GPCIs were used for the
proposed 2005 through 2007 work and practice expense GPCIs.
The relative respective weights for the 2004 work, practice expense
and malpractice GPCIs, as well as the proposed 2005 through 2007 GPCI
revisions, were derived using the same weights that were used in the
Medicare Economic Index (MEI) revision discussed in the November 2003
physician fee schedule final rule (68 FR 63245).
1. Work Geographic Practice Cost Indices
As explained in the August 5, 2004 proposed rule, we used data from
the 2000 decennial U.S. Census, by county, of seven professional
occupations (architecture and engineering; computer, mathematical, and
natural sciences; social scientists, social workers, lawyers;
education, library, training; registered nurses; pharmacists; writers,
artists, editors) in the development of the proposed work GPCIs.
Physicians' wages are not included because Medicare payments are
determinant of the physicians' earnings. Including physician wages in
the physician work GPCI would, in effect, make the index dependent upon
Medicare payments. Based on analysis performed by Health Economics
Research, we believe that, in the majority of instances, the earnings
of physicians will vary among areas to the same degree that the
earnings of other professionals vary.
The U.S. Census Bureau has very specific criteria that tabulations
must meet in order to be released to the public. To maximize the
accuracy and availability of the data collection, the nonphysician
professional wage data were aggregated by county and a median wage by
county was calculated for each occupational category. These median
wages were then weighted by the total RVUs associated with a given
county to ultimately arrive at locality-specific work GPCIs. This
geographic aggregation of Census data is the same methodology that was
used in previous updates to the GPCIs.
The proposed work GPCIs reflected one-fourth of the relative cost
differences, as required by statute, with the exception of those areas
where MMA requires that the GPCI be set at no lower than 1.00 and that
the Alaska GPCIs be set at 1.67.
2. Practice Expense GPCIs
As in the past, we proposed that the practice expense GPCI would be
comprised of several factors that represent the major expenses incurred
in operating a physician practice. The impact of each individual factor
on the calculation of the practice expense GPCI is based on the
relative weight for that factor consistent with the calculation of the
MEI. The specific factors included:
Employee Wage Indices--The employee wage index is based on
special tabulations of 2000 Census data and is designed to capture the
median wage by county of the professional labor force. The employee
wage index uses the median wages of four labor categories that are most
commonly present in a physician's private practice (administrative
support, registered nurses, licensed practical nurses, and health
technicians). Median wages for these occupations were aggregated by
county in the same manner as the data for the work GPCI.
Office Rent Indices--The HUD FMR data for the residential
rents were again used as the proxy for physician office rents as they
are in the current practice expense GPCIs. The proposed 2005 through
2007 practice expense GPCIs reflect the final fiscal year 2004 HUD FMR
data. We believe that the FMR data remain the best available source for
constructing the office rent index. The FMR data are available for all
areas, are updated annually, and retain consistency from area-to-area
and from year-to-year. A reduction in an area's rent index does not
necessarily mean that rents have gone down in that area since the last
GPCI update. Since the GPCIs measure area costs compared to the
national average, a decrease in an area's rent index means that that
area's rental costs are lower relative to the national average rental
costs. Addendum X illustrates the changes in the rental index based
upon the new FMR data.
Medical Equipment, Supplies, and other Miscellaneous
Expenses--The GPCIs assume that items such as medical equipment and
supplies have a national market and that input prices do not vary among
geographic areas. We were again unable to find any data sources that
demonstrated price differences by geographic areas. As mentioned in
previous updates, some price differences may exist, but these
differences are more likely to be based on volume discounts rather than
on geographic areas. The medical equipment, supplies, and miscellaneous
expense portion of the practice expense geographic index will continue
to be 1.000 for all areas in the proposed GPCIs, except for Alaska
which will have an overall practice expense GPCI set at 1.67 for 2005
and 2006.
3. Fee Schedule Payments
All three of the indices for a specific fee schedule locality are
based on the indices for the individual counties within the respective
fee schedule localities. As in the past, fee schedule RVUs are again
used to weight the county indices (to reflect volumes of services
within counties) when mapping to fee schedule areas and in constructing
the national average indices.
Fee schedule payments are the product of the RVUs, the GPCIs, and
the conversion factor. Updating the GPCIs changes the relative position
of fee schedule areas compared to the national average. Because the
changes represented by the GPCIs could result in total payments either
greater than or less than what would have been paid if the GPCIs were
not updated, it is necessary to apply scaling factors to the proposed
GPCIs to ensure budget neutrality (prior to applying the provisions of
MMA that change the work GPCIs to a minimum of 1.0 and increase the
Alaska GPCIs to 1.67 because these provisions are exempted from budget
neutrality). We determined that the proposed work and practice expense
GPCIs would have resulted in slightly higher total national payments.
Because the law requires that each individual component of the fee
schedule--work, practice expense, and malpractice expense--be
separately adjusted by its respective GPCI, we proposed to scale each
of the GPCIs separately. To ensure budget neutrality prior to applying
the MMA provisions, we have made the following adjustments:
Decreased the proposed work GPCI by 0.9965;
[[Page 66262]]
Decreased the proposed practice expense GPCI by 0.9930;
and
Increased the malpractice GPCIs that were published in the
November 7, 2003 final rule by 1.0021.
Because all geographic payment areas will receive the same
percentage adjustments, the adjustments do not change the new relative
positions among areas indicated by the proposed GPCIs. After the
appropriate scaling factors are applied, the MMA provision setting a
1.0 floor has been applied to all work GPCIs falling below 1.0.
Additionally, the GPCIs for Alaska have been set to 1.67 in accordance
with MMA.
Comment: A specialty society representing family physicians
recommended that we work with the Congress to eliminate the GPCIs or
set them all at 1.00. The society stated that they understand the
statutory requirement to apply the GPCIs, but that all geographic
adjustment factors should be eliminated from the physician fee
schedule, except for those designed to achieve a specific policy good,
such as adjustment to encourage physicians to practice in underserved
areas. The commenter contended that elimination of the GPCIs would have
a positive effect on the availability of medical care to rural
beneficiaries. Other commenters suggested that we should no longer
apply the work GPCI to the work RVUs.
We also received numerous comments on the subject of the source of
the data we use in the development of the GPCIs. Commenters suggested
that we find data sources other than Census Bureau data. They believe
the census data become obsolete very quickly and want us to use data
that reflect up-to-date prices for inputs. This would, they argue, make
the GPCI values more realistic.
A medical specialty group commented that the index is flawed
because--
It is based on the tenuous assumption that the relative
differences in the prices of the input proxies accurately reflect
relative changes in prices of corresponding physician practice cost
components; and,
It applies uniform weights to practice cost components,
despite evidence of geographic variation in component shares.
Several commenters had specific concerns about the proxies used for
the work and practice expense GPCIs, for example--
Using data for four employee classes to measure relative
compensation differences for all physicians' office staff which does
not reflect the changes in medical practice that have occurred since
the index was developed;
Using residential real estate prices to reflect relative
differences in physicians' office costs; and
Using nationally uniform prices for supplies, equipment,
and other expenses.
Another particular concern among commenters is the use of HUD
apartment rental data as the source of costs for physicians' rents.
Instead, they argue, we should find, or carry out, a national study of
retail and business rents.
Another commenter asserts that these indices have not been verified
by peer-reviewed published research since they were instituted and that
we should replace the indices with data from nationwide studies that
validate and update actual cost of practice data.
Response: As noted by a commenter, we are required by the Congress
to adjust for geographic differences in the operational cost of
physicians' practices by applying geographic price indices to each
component of the Physician Fee Schedule. However, we also believe it
appropriate in our resource based payment system to account for real
differences in physicians' costs in different geographical areas. We
share the concern about access to care for our rural beneficiaries and,
in this rule, we are finalizing our proposals on payment adjustments to
physicians in underserved areas through the HPSA Incentive Payment
Program. For the commenters who object to the GPCI adjustment to the
work RVUs, we would note that for 2005 and 2006 the floor for the work
GPCI will be 1.00.
With reference to the issue of the GPCI data source, we are always
open to suggestions about possible data sources; however, we believe
the most reliable source of national, comparable data at the county
level is the Census Bureau. Other data sources that we have examined
either fail to produce the data at the county level, cannot be compared
nationally, or offer no means of comparability over time.
We believe that the proxies, while not perfect, are the best tools
available for the development of the GPCIs. For example, if we were to
eliminate all proxies, we would have to collect actual physicians'
office data from a sufficiently large sample in each locality to
calculate the GPCIs. This would place a substantial burden on the
office staff and would be prohibitively expensive. Also, the benefits
from that approach would be uncertain.
The question of applying uniform weights to practice components is
an area where more research could lead to better information about the
variation attributable to case mix and the availability of other health
resources, input prices, and practice styles. However, it is important
to note that much of the variation associated with case and specialty
mix is accounted for by the varying RVUs for different services.
However, we are open to exploring this issue.
On the issue of which employee categories are included in the
employee wage index component of the practice expense GPCI calculation,
we included those that have been determined in the past to be most
commonly present in a physician's private practice. We are considering
the suggestion that we include a broader group of employment categories
in the future.
While we recognize that apartment rents are not a perfect proxy for
physician office rents, there are no existing national studies that
present reliable retail and business rentals data. We would welcome any
nationally consistent data that could be used for this purpose.
We noted in the proposed rule that we were unable to find any data
sources that demonstrate price differences by geographic areas for
medical equipment and supplies. Once again, however, we welcome any
nationally consistent data for this purpose.
We appreciate the concern expressed by the commenter who suggested
our GPCI methodology has not been subjected to peer-review validation
since its inception, but we are not aware of any currently available
data that could replace our methodology. Furthermore, we believe the
process of updating the GPCIs periodically through notice and comment
rulemaking affords an opportunity for a thorough review of the GPCI
calculation methodology.
Comment: A member of a medical society suggested that we make the
floor of 1.00 permanent for the work GPCI and incrementally increase
both the practice expense GPCI and the professional liability insurance
GPCI to 1.00 over the next ten years.
Response: We have no authority to extend the floor of the work
GPCI, or to create a 1.00 floor for the practice expense and
professi