[Federal Register: August 9, 2002 (Volume 67, Number 154)] [Proposed Rules] [Page 52141-52190] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr09au02-37] [[pp. 52141-52190]] Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2003 Payment Rates; and Changes to Payment Suspension for Unfiled Cost Reports [[Continued from page 52140]] [[Page 52141]] and we would not expect these procedures to be performed during the same operative session with a higher paying procedure with status indicator ``T.'' Therefore, we propose to continue our current policy of multiple procedure discounting. That is, when two or more APCS with status indicator ``T'' are billed together we propose to pay 100 percent for the highest cost APC and 50 percent for all other APCs with status indicator ``T.'' We propose not to adjust these payments to account for device costs in the APCs. F. Outpatient Billing For Dialysis Currently, hospitals are unable to bill for dialysis treatments furnished to End-Stage Renal Disease (ESRD) patients on an outpatient basis, unless the hospital also has a certified hospital-based ESRD facility. As a result of this policy, there has been an increase in denials by the PROs for inappropriate hospital admissions. When ESRD patients come to the hospital for a medical emergency or for problems with their access sites, they typically miss their regularly scheduled dialysis appointments. If the ESRD patient's usual facility is unable to reschedule the dialysis treatment, the beneficiary has to wait until the next scheduled dialysis appointment. CMS is concerned that by maintaining this policy, beneficiaries may be receiving interrupted care because there will be unnecessary lapses in treatment. The ESRD patient should not be prevented from receiving her or his normal dialysis because he or she experienced another unrelated medical situation. Therefore, we propose to allow payment for dialysis treatments for ESRD patients in the outpatient department of a hospital in specific situations. Payment would be limited to unscheduled dialysis for ESRD patients in exceptional circumstances. Outpatient dialysis for acute patients would not be included in this payment mechanism. We propose to limit this payment to medical situations in which the ESRD patient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility. Situations that we propose to allow are limited to: (1) dialysis performed following or in connection with a vascular access procedure; (2) dialysis performed following treatment for an unrelated medical emergency. For example, if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, we would allow the hospital to provide and bill Medicare for the dialysis treatment; and (3) emergency dialysis--Currently, the only mechanism available for payment in this situation is through an inpatient admission. We will maintain our policy that routine treatments in non-ESRD certified hospitals would not be payable under OPPS. We believe it is important to make this change in policy for two reasons: (1) to ensure that hospital outpatient departments are paid for providing this much needed service; and (2) to prevent dialysis patients from receiving interrupted care. Non-ESRD certified hospital outpatient facilities would bill Medicare using a new G code, G0GGG, ``Unscheduled or emergency treatment for dialysis for ESRD patient in the outpatient department of a hospital that does not have a certified ESRD facility.'' We propose that this new code will have status indicator ``S'' and be assigned to APC 0170. Payment would be roughly equivalent to the reimbursement rate for acute dialysis. We propose to implement this change effective January 1, 2003. Effective January 1, 2003, this would be the only way for non-ESRD certified hospital outpatient facilities to bill Medicare and be paid for providing outpatient dialysis to ESRD beneficiaries. CMS will be monitoring the use of this new code to ensure that (1) certified dialysis facilities are not incorrectly using this code; and (2) the same dialysis patient is not repeatedly using this code, which would indicate routine dialysis treatment. When ESRD patients receive outpatient dialysis in non-ESRD certified hospital outpatient facilities, the patient's home facility would be responsible for obtaining and reviewing the patient's medical records to ensure that appropriate care was provided in the hospital and that modifications are made, if necessary, to the patient's plan of care upon her or his return to the facility. This ensures continuity of care for the patient. IX. Summary of and Responses to MedPAC Recommendations The Medicare Payment Advisory Commission (MedPAC) in its March 2002 Report to the Congress: ``Medicare Payment Policy,'' makes a number of recommendations relating to the OPPS. This section provides responses to those recommendations. Recommendation: For calendar year 2003, the Secretary should increase the payment rates for services covered by the OPPS by the rate of increase in the hospital market basket. Response: Section 1833(t)(3)(C)(ii) of the Act requires the Secretary to update the conversion factor annually. Under section 1833(t)(3)(C)(iv) of the Act, the update is equal to the hospital market basket percentage increase applicable under the hospital inpatient PPS, minus one percentage point for the years 2000 and 2002. The Secretary has the authority under section 1833(t)(3)(C)(iv) of the Act to substitute a market basket that is specific to hospital outpatient services. In the September 8, 1998 proposed rule on the OPPS, we indicated that we were considering the option of developing an outpatient-specific market basket and invited comments on possible sources of data suitable for constructing one (63 FR 47579). We received no comments in response to this invitation, and we therefore announced in the April 7, 2000 final rule that we would update the conversion factor by the hospital inpatient market basket increase, minus one percentage point, for the years 2000, 2001, and 2002 (65 FR 18502). (As required by section 401(c) of the BIPA, we made payment adjustments effective April 1, 2001 under a special payment rule that had the effect of providing a full market basket update in 2001.) For 2003, we propose to increase payment rates by the rate of increase in the hospital market basket. Recommendation: The Congress should--Replace hospital-specific payments for pass-through devices with national rates. Give the Secretary authority to consider alternatives to average wholesale price (AWP) when determining payments for pass- through drugs and biologicals. Response: Regarding the pricing of transitional pass-through devices, we share the Commission's concern that the current methodology provides incentives for hospitals to inflate charges for transitional pass-through devices to increase payments. However, we believe that alternative approaches are not necessarily superior. Further, the salience of this problem should be much less in the future. At present, the payment for a transitional pass-through device is set, on a claim-by-claim basis, relative to the hospital's charge for that device. The charge is reduced to a measure of cost by application of a hospital-specific cost-to-charge ratio, and a subtraction is made to reflect the portion of device costs already recognized in the payment for the associated procedure APC. This procedure means that a higher charge by a hospital will result in a higher payment from Medicare. The Commission notes that this method embodies an incentive for hospitals, perhaps prompted by manufacturers, to increase charges as a means of [[Page 52142]] increasing payments. The Commission is concerned that this situation may lead to excessive payments and may bias the charges used to revise, from year to year, relative weights in the OPPS. In fact, the extent to which hospitals raising their charges on devices is problematic depends on the outcomes. In general, we anticipate that hospital charge structures, on average, reflect their costs; this assumption helps support the use of charge data to revise relative weights in hospital prospective payment systems. Accordingly, whether payments to hospitals for transitional pass-through devices might be considered excessive depends on whether hospitals inflate charges beyond the levels appropriate to recover their costs. Whether their behavior leads to biases in charge data depends on whether they set charges on transitional pass-through devices significantly differently than on other services. Moving to a fee schedule for transitional pass-through devices would remove the particular incentive problem that the Commission noted, which we agree would be desirable. However, the establishment of appropriate national rates would then become the focus. In the absence of field data on actual costs, we will be inevitably reliant on information that manufacturers provide. At present, manufacturers are asked for information about prices on applications for pass-through status. Anecdotal information suggests this information is not fully reliable as a measure of what hospitals actually pay. The Commission's report discusses the possibility of CMS setting the rate for a device based on analysis of the manufacturer's costs, including an appropriate rate of return on equity. This approach would confront a number of accounting, legal, and operational difficulties. First, it would take some time to complete the analysis for a new product, which could significantly delay establishment of a rate. The rate that would be used in the meantime, or whether billing would be permitted at all, would be open to question. Second, it appears that large firms with multiple product lines supply most devices, which would make determining the costs of a particular device difficult. This problem would be compounded when multiple enterprises are involved in bringing a product to market, which is not uncommon in the device industry, where invention and initial development may occur in one firm and final development, manufacturing, and marketing in another. Third, the government generally does not have access to manufacturers cost information. While legal authority could be enhanced, manufacturers would face incentives that raise questions about the reliability of information provided, and the need for government accounting and auditing resources would be high. Fourth, as the Commission's report notes, an appropriate rate of return on equity would have to be established. Fifth, devices are now paid, under BIPA, on the basis of categories. As a result, if a manufacturer brings to market a product that fits the description of a category, hospitals can bill for that manufacturer's product without any change in coding or notification of CMS. Consequently, we do not know what specific devices are actually being billed in these categories, or who manufactures them. Whatever rate might be established on the basis of an initial application for a category would presumably be based on the applicant's costs. Later entrants might have significantly different cost structures, but this information would not come into account unless a more elaborate process was implemented to include it. Finally, whether a rate set in this fashion would pay less or more than the current method is unclear. The current method is based on actual experience in the field, and it will reflect, though perhaps somewhat tenuously, whatever competitive market pressures exist. Any method that we use aimed at ensuring a more reliable price could yield a price that is too high, since it will not reflect market activity. Whether a rate set by ex ante analysis of this sort would produce superior results does not appear obvious. The Commission's report also mentions the possibility of using competitive bidding to set rates for transitional pass-through devices. While competitive bidding appears attractive as a means of setting a market-related price, it has not proven an easy process for Medicare to implement. Competitive bidding seems best suited for established products with multiple suppliers. However, transitional pass-through devices are by definition new to the market and will frequently have only one manufacturer, at least at the start of the 2 to 3 year transitional pass-through period. Even in those instances in which this technique would be possible, it involves a fair amount of administrative resources and time, and using it to establish a rate that will be used at the most for 3 years does not appear to be an effective use of resources. Both of the suggestions discussed above reflect procedures that involve relatively high overhead on the part of CMS and of other actors. It is not obvious whether either would produce results that are superior to those derived from the present method. While they would change incentives on hospitals, incentives of manufacturers would still be a source of concern. We agree with the Commission that further investigation would be necessary to determine a feasible alternative to cost-based pass-through payments. In considering the advantages of various approaches, it is important to keep the size of the problem in mind, especially when contemplating procedures for setting rates that would involve substantial administrative resources. As of July 1, 2002, the OPPS pays for 100 categories of devices. As is explained in section III.C of this preamble, we are proposing that 95 categories will lose pass-through status and be retired as of January 1, 2003.\3\ Since the initial categories were established in April 2001, we have added only three categories. While several applications are pending, given the extensiveness of the existing categories, it appears likely that the number of new categories to be established in future years will be small.\4\ The likely volume of claims represented by these new categories is of course speculative, but it also does not seem likely to be large relative to the size of the OPPS system. As discussed below, we developed criteria for the establishment of new categories that were specifically intended to limit future pass-through payments to devices that provide a substantial clinical improvement. --------------------------------------------------------------------------- \3\ In accord with the BBRA amendment that established the pass- through payment methodology, items are only eligible for pass- through payments for 2 to 3 years. After expiration of pass-through status, payments for devices described by these categories will be packaged into APC payments for the procedures with which they are used. \4\ If a new device arrives on the market that would have fit in a category formerly in use but subsequently retired, it will not be eligible for pass-through payment. --------------------------------------------------------------------------- Considering that the identified alternatives do not appear to be manifestly superior to the current system but do involve significantly more administrative resources, and given the anticipated small volume of transitional pass-through devices in the future, we think on balance it would be best to let more experience develop with the current system before making significant changes to the current method. However, we agree that it would be desirable to give the Secretary authority [[Page 52143]] to use alternatives to AWP when determining payments for pass-through drugs and biologicals. At present, total payment for these items is governed by the general rule (section 1842(o) of the Act) for Medicare pricing of drugs, which requires they be paid at 95 percent of AWP. This rule also covers most drugs delivered ``incident to'' physicians' services in physicians' offices and elsewhere. The Congress is at present considering various changes to the AWP as the basis for Medicare payment for drugs, and if a change is adopted to this standard, it may be an appropriate standard for transitional pass- through drugs and biologicals as well. Recommendation: The Secretary should do the following: Ensure additional payments are made only for new or substantially improved technologies that are expensive in relation to the applicable ambulatory payment classification rate. Avoid basing national rates only on reported costs. Ensure that the same broad principles guide payments for new technologies in the inpatient and outpatient payment systems. Response: We agree that additional payments should be limited to items that have the greatest merit and that have high costs not well captured in the existing payment structure. The Commission notes that limiting the number of transitional pass-through items limits the burdens on hospitals and us; reduces the likelihood of exceeding the statutory cap on aggregate pass-through payment, necessitating a uniform reduction in transitional pass-through payments; and limits the redistribution of funds across hospitals that are low versus high users of transitional pass-through items. We agree with these points. On November 2, 2001, we published an interim final rule with comment period in the Federal Register (66 FR 55850 to 55857) that set forth criteria we will use to evaluate whether to establish new categories of devices in the future. These criteria include tests of whether a device is new, whether it represents a substantial medical improvement for Medicare beneficiaries, and whether its costs are high relative to the payments that would otherwise be made. Section 1833(t)(6)(D) of the Act prescribes the method for setting payment for transitional pass-through drugs and devices. The issue of possible alternatives is discussed above. We agree that the same principles should govern payments for new technologies in the inpatient and outpatient prospective payment systems. Criteria governing extra new technology payments in the IPPS were established in a final rule published in the Federal Register (66 FR 46902 to 46925) on September 7, 2001. The criteria have the same general form as those for the OPPS. They differ in some particulars, largely traceable to the difference of the two payment systems. In particular, the IPPS system pays on the basis of an episode of care. As a result, the bundle of payment is generally larger and hospitals are better able to absorb minor cost differences. Considering the impact of new technology on all costs of the episode is also pertinent. Consequently, the criteria for special payment for inpatient new technologies require examination of the net effect on costs of the entire episode (not just the added costs of a new technology), and the relative cost standard we established is somewhat more stringent than for the OPPS. We believe it is premature to judge whether it will make sense to make these criteria even closer in the future, as the Commission's discussion suggests. X. Summary of Proposed Changes for 2003 A. Changes Required by Statute We are proposing the following changes to implement statutory requirements: Add APCs, delete APCs, and modify the composition of some existing APCs. Recalibrate the relative payment weights of the APCs. Update the conversion factor and the wage index. Revise the APC payment amounts to reflect the APC reclassifications, the recalibration of payment weights, and the other required updates and adjustments. Cease transitional pass-through payments for drugs and biologicals (including blood and blood products) and devices (including brachytherapy), that will, on January 1, 2003, have been paid under transitional pass-through methodology for at least 2 years. B. Additional Changes to OPPS and Payment Suspension Provisions We are proposing the following additional changes to the OPPS and Payment Suspension Provisions: Creation of new evaluation and management service codes for outpatient clinic and emergency department encounters for implementation no earlier than January 1, 2004. Changes to the list of services that we do not pay in outpatient departments because we define them as ``inpatient only'' procedures. Changes to our policy of nonpayment for procedures on the ``inpatient only'' list in special cases involving death or transfer before inpatient admission. Changes to our policy governing observation in cases of direct admission to observation. Changes to status indicators for HCPCS codes. Changes to our policies governing dialysis for ESRD patients and regarding partial hospitalization. In addition, we are making changes to payment suspension policies. C. Changes to the Regulations Text A. We propose to make the following changes to our regulations: Amend Sec. 410.43(b) to add clinical social worker services (for the diagnosis and treatment of mental illnesses) that meet the requirements of section 1861(hh)(2) of the Act to the specified professional services that are separately covered and not paid as partial hospitalization services. Amend Sec. 419.66(c)(1) to specify that we must establish a new category for a medical device if it is not described by any category previously in effect as well as an existing category. XI. Summary of Proposed Payment Suspension Provisions In this rule, we propose to revise Sec. 405.371 (c) to specify that we may suspend Medicare payments ``in whole or in part'' if a provider has failed to timely file an acceptable cost report. This provision is consistent with the existing provisions in Sec. 405.371(a) governing the suspension of Medicare payments ``in whole or in part'' under certain conditions. We believe the Medicare program would benefit because immediate complete payment suspension can be disruptive to providers and may negatively affect the care of Medicare patients. XII. Collection of Information Requirements Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: [[Page 52144]] The need for the information collection and its usefulness in carrying out the proper functions of our agency. The accuracy of our estimate of the information collection burden. The quality, utility, and clarity of the information to be collected. Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. This rule does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995. XIII. Response to Public Comments Because of the large number of items of correspondence we normally receive on a proposed rule, we are not able to acknowledge or respond to them individually. However, in preparing the final rule, we will consider all comments concerning the provisions of this proposed rule that we receive by the date and time specified in the DATES section of this preamble and respond to those comments in the preamble to that rule. XIV. Regulatory Impact Analysis The regulatory impact analysis for this proposed rule consists of an impact analysis for the OPPS provisions and a regulatory impact statement for the provision for payment suspension for unfiled cost reports. A. OPPS 1. General We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 16, 1980 Pub. L. 96-354). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more annually). We estimate the effects of the provisions that would be implemented by this proposed rule would result in expenditures exceeding $100 million in any 1 year. We estimate the total increase (from changes in the proposed rule as well as enrollment, utilization, and case mix changes) in expenditures under the OPPS for CY 2003 compared to CY 2002 to be approximately $1.372 billion. Therefore, this proposed rule is an economically significant rule under Executive Order 12866, and a major rule under 5 U.S.C. 804(2). The RFA requires agencies to determine whether a rule will have a significant economic impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations and government agencies. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6 to $29 million or less in any 1 year (see 65 FR 69432). For purposes of the RFA we have determined that approximately 37 percent of hospitals and 98 percent of mental health practitioners would be considered small entities according to the Small Business Administration (SBA) size standards. We do not have data available to calculate the percentages of entities in the pharmaceutical preparation manufacturing, biological products, or medical instrument industries. For the pharmaceutical preparation manufacturing industry (NAICS 325412), the size standard is 750 or fewer employees and $67.6 billion in annual sales (1997 business census). For biological products (except diagnostic) (NAICS 325414) $5.7 billion and medical instruments (NAICS 339112), with $18.5 billion in annual sales, the standard is 50 or fewer employees (see the standards web site at http://www.sba.gov/ regulations/siccodes/). Individuals and States are not included in the definition of a small entity. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area (MSA) and has fewer than 100 beds (or New England County Metropolitan Area (NECMA)). Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the OPPS, we classify these hospitals as urban hospitals. We believe that the changes in this proposed rule would affect both a substantial number of rural hospitals as well as other classes of hospitals and that the effects on some may be significant. Therefore, we conclude that this proposed rule has a significant impact on a substantial number of small entities. However, the statute provides for small rural hospitals (of less than 100 beds) to be held harmless by the law and to continue to be paid at cost; therefore this proposed rule has no impact on them. Unfunded Mandates Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in an expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. This proposed rule would not mandate any requirements for State, local, or tribal governments. This proposed rule imposes no unfunded mandates on the private sector. Federalism Executive Order 13132 establishes certain requirements that an agency must meet when it publishes a proposed rule (and subsequent final rule) that imposes substantial direct costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have examined this proposed rule in accordance with Executive Order 13132, Federalism, and have determined that it will not have an impact on the rights, roles, and responsibilities of State, local or tribal governments. The impact analysis (see table 10) shows that payments to governmental hospitals (including State, local and tribal governmental hospitals) would increase by 5 percent under the proposed rule. 2. Changes in this Proposed Rule We are proposing several changes to the OPPS that are required by the statute. We are required under section 1833(t)(3)(C)(ii) of the Act to update annually the conversion factor used to determine the APC payment rates. We are also required under section 1833(t)(9)(A) of the Act to revise, not less often than annually, the wage index and other adjustments. In addition, we must review the clinical integrity of payment groups and weights at least annually. Accordingly, in this proposed rule, we are updating the conversion factor and the wage index adjustment for hospital outpatient services furnished beginning January 1, 2003 as [[Page 52145]] we discuss in sections VI and IV, respectively, of this preamble. We are also proposing revisions to the relative APC payment weights based on claims data from January 1, 2001 through December 31, 2001. Finally, we are proposing to remove 95 devices and more than 200 drugs and biologicals from pass-through payment status. Under this proposed rule, the change to the conversion factor as provided by statute would increase total OPPS payments by 3.5 percent in 2003. The changes to the wage index and to the APC weights (which incorporates the cessation of pass-through payments for many drugs and devices) do not increase OPPS payments because the OPPS is budget neutral. However, the wage index and APC weight changes do change the distribution of payments within the budget neutral system as shown in Table 10 and described in more detail in this section. Alternatives Considered Alternatives to the changes we propose and the reason that we did not choose to propose them are discussed throughout this proposed rule. Below we discuss options we considered when analyzing methodologies to appropriately recognize the costs of former pass-through items. For a more detailed discussion, see section III.C.1 regarding the expiration of pass-through payment for devices and section III.C.2 regarding the expiration of pass-through payment for drugs and biologicals. Payment for Categories of Devices We considered establishing separate APCs for categories of devices and paying for them separately. We did not propose this option because we believe that to the extent possible, hospital payment for procedures and visits should include all of the costs required to provide the procedures and visits. A second option we considered involved (1) packaging some categories of devices into the procedures with which they were billed in 2001 and (2) paying the rest through separate APCs (as discussed in section III.C.). We did not propose this option because we believe that devices are routinely used in the services for which they are needed and therefore are consistently paid at the cost of providing the service. Furthermore, criteria that would provide a basis for some devices to be packaged and for others to be paid separately would have to be developed and approved, thereby further complicating an already complex payment system. Payment for Drugs and Biologicals We considered continuing to make separate payment for all drugs and biologicals through separate APCs. We did not propose to pay separately for all drugs through separate APCs because we believe that, to the extent possible, hospital payment for services should include all of the costs of the services. We believe that drugs should be packaged with the services in which they are furnished except when we determine that there is a valid reason to do otherwise. However, we recognize that (unlike the stability that exists with device usage with the applicable procedures) the use of drugs may vary widely depending upon patient and disease characteristics. Therefore, packaging payment for all drugs may, in some cases, provide inadequate payment for the services furnished. Where a hospital has a disproportionate share of patients who need greater amounts of expensive drugs, underpayment for the drugs needed by these patients could result in cessation of needed services. For the first year that we are ceasing transitional pass- through payment for drugs, we decided to proceed cautiously by proposing to pay separately for drugs when the cost per encounter was more than $150 or when special characteristics existed (for example, orphan drugs, blood products). We also considered packaging the costs of all drugs into the cost of the associated procedures with which they were billed in 2001. We did not package all payment for drugs into the payment for the procedures because, while this packaging is ultimately our goal, we believe, for the reasons indicated above, that we need to proceed cautiously to ensure that we do not inadvertently threaten access to needed care. Conclusion It is clear that the changes in this proposed rule would affect both a substantial number of rural hospitals as well as other classes of hospitals, and the effects on some may be significant. Therefore, the discussion below, in combination with the rest of this proposed rule, constitutes a regulatory impact analysis. The OPPS rates proposed for CY 2003 would have, overall, a positive effect for every category of hospital with the exception of children's hospitals, which are held harmless under the OPPS. The changes in the OPPS proposed for 2003 would result in an overall 3.5 percent increase in Medicare payments to hospitals, exclusive of outlier and transitional pass-through payments and transitional corridor payments. As described in the preamble, budget neutrality adjustments are made to the conversion factor and the weights to assure that the revisions in the wage index, APC groups, and relative weights do not affect aggregate payments. The impact of the wage and recalibration changes does vary somewhat by hospital group. Estimates of these impacts are displayed on Table 10. The overall projected increase in payments for urban hospitals is slightly lower (2.5 percent) than the average increase for all hospitals (3.5 percent) while the increase for rural hospitals is significantly greater (7.6 percent) than the average increase. Rural hospitals gain 2.3 percent from the wage index change, and also gain 1.6 percent from APC changes. A discussion of the distribution of outlier payments that we project under this proposed rule can be found under section D below. Table 11 presents the outlier distribution that we expect to see under this proposed rule. 3. Limitations of Our Analysis The distributional impacts represent the projected effects of the proposed policy changes, as well as statutory changes effective for 2003, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per service while holding all other payment policies constant. We use the best data available but do not attempt to predict behavioral responses to our policy changes. In addition, we do not make adjustments for future changes in variables such as service volume, service mix, or number of encounters. 4. Estimated Impacts of This Proposed Rule on Hospitals The OPPS is a budget neutral payment system under which the increase to the total payments made under OPPS is limited by the increase to the conversion factor set under the methodology in the statute. The impact tables show the redistributive effects of the wage index and APC changes. In some cases, under this proposed rule, hospitals would receive more total payment than in 2002 while in other cases they would receive less total payment than they received in 2002. The impact of this proposed rule would depend on a number of factors, most significant of which are the mix of services furnished by a hospital (for example, how the APCs for the hospital's most frequently furnished services would change) and the impact of the wage index changes on the hospital. Column 4 in Table 10 represents the full impact on each hospital group of all [[Page 52146]] the changes for 2003. Columns 2 and 3 in the table reflect the independent effects of the proposed change in the wage index and the APC reclassification and recalibration changes, respectively. We excluded critical access hospitals (CAHs) from the analysis of the impact of the proposed 2003 OPPS rates that is summarized in Table 10. For that reason, the total number of hospitals included in Table 10 (4,551) is lower than in previous years. CAHs are excluded from the OPPS. In general, the wage index changes favor rural hospitals, particularly the largest in bed size and volume. The only rural hospitals that would experience a negative impact due to wage index changes are those in Puerto Rico, a decrease of 2.8 percent. Conversely, the urban hospitals are generally negatively affected by wage index changes, with the largest decreases occurring in those with 300-499 beds (-0.7 percent) and those in the Middle Atlantic (-1.3 percent), Pacific (-.09 percent) and Puerto Rico Regions (-1.8 percent). However, this effect is somewhat lessened by the distribution of outlier payments as discussed in more detail below. The APC reclassification and recalibration changes also favor rural hospitals and have a negative effect on urban hospitals in excess of 200 beds. Specifically, urban hospitals with 200-299 beds (-0.5 percent decrease), urban hospitals with 300-499 beds (-2.0 percent decrease) and urban hospitals in excess of 500 beds (a -1.9 percent decrease) all show a decrease attributed to APC recalibration. We believe this occurs as a result of our folding 75 percent of estimated pass-through device costs into APC payments in the 2002 OPPS. Specifically, a comparison of the relative payment weights proposed for 2003, as listed in Addendum A, with the final 2002 relative payment weights in the March 1, 2002 final rule shows a decrease in the weights for certain APCs in 2002 that included a fold-in of 75 percent of estimated pass-through device costs. We relied on cost information supplied by device manufacturers in estimating the device costs to be folded in when calculating the median APC costs for the 2002 OPPS, whereas the proposed 2003 relative payment weights are based on actual hospital charges and utilization under the OPPS as reported by hospitals. We believe this downward tendency in the payment weights for APCs that include device costs, based on actual hospital experience, accounts in part for the lower positive effect of the proposed 2003 rates on urban hospitals and on teaching hospitals, which tend to perform a higher number of procedures involving costly new technology devices, in contrast with an increased positive effect in 2003 on rural and non-teaching hospitals, which tend to furnish a higher volume of clinic and preventive services than procedures associated with expensive new technology devices. In both urban and rural areas, hospitals that provide a lower volume of outpatient services are projected to receive a larger increase in payments than higher volume hospitals. In rural areas, hospitals with volumes of fewer than 5000 services are projected to experience a significant increase in payments (8.1 percent). The less favorable impact for the high volume urban hospitals is attributable to both wage index and APC changes. For example, urban hospitals providing more than 42,999 services are projected to gain a combined 1.6 percent due to these changes. Major teaching hospitals are projected to experience a smaller increase in payments (1.7 percent) than the aggregate for all hospitals (3.5 percent) due to negative impacts of the wage index (-0.5 percent) and recalibration (-1.2 percent). Hospitals with less intensive teaching programs are projected to experience an overall increase (2.0 percent) that is smaller than the average for all hospitals. There is little difference in impact among hospitals with that serve low-income patients. Table 10.--Impact of Changes for CY 2003 Hospital Outpatient Prospective Payment System [Percent change in total payment to hospitals (program and beneficiary); does not include the effects of outlier and transitional pass-through payments or of transitional corridor payments.] ---------------------------------------------------------------------------------------------------------------- Number of New wage APC All CY 2003 hospitals index \2\ changes)\3\ changes \4\ \1\ (1) (2) (3) (4) ---------------------------------------------------------------------------------------------------------------- ALL HOSPITALS.............................................. 4,551 0.0 0.0 3.5 NON-TEFRA HOSPITALS........................................ 4,002 0.0 -0.1 3.4 URBAN HOSPS................................................ 2,429 -0.6 -0.5 2.5 LARGE URBAN (GT 1 MILL.)............................... 1,398 -0.7 -0.1 2.6 OTHER URBAN (LE 1 MILL.)............................... 1,031 -0.4 -0.9 2.2 RURAL HOSPS................................................ 1,573 2.3 1.6 7.6 BEDS (URBAN): 0-99 BEDS.............................................. 554 -0.3 3.1 6.4 100-199 BEDS........................................... 882 -0.6 1.4 4.3 200-299 BEDS........................................... 488 -0.6 -0.5 2.3 300-499 BEDS........................................... 364 -0.7 -2.0 0.7 500+ BEDS.............................................. 141 -0.3 -1.9 1.3 BEDS (RURAL): 0-49 BEDS.............................................. 754 0.4 2.9 7.0 50-99 BEDS............................................. 479 1.5 2.3 7.6 100-149 BEDS........................................... 201 2.4 1.5 7.6 150-199 BEDS........................................... 73 5.5 0.1 9.5 200+ BEDS.............................................. 66 3.3 0.0 7.0 VOLUME (URBAN): LT 5,000............................................... 188 0.9 6.5 10.9 5,000-10,999........................................... 305 -0.8 5.1 7.9 11,000-20,999.......................................... 472 -0.7 2.6 5.5 21,000-42,999.......................................... 657 -0.8 0.3 3.0 GT 42,999.............................................. 807 -0.5 -1.4 1.6 VOLUME (RURAL): LT 5,000............................................... 326 0.2 4.2 8.1 5,000-10,999........................................... 446 0.6 4.4 8.7 [[Page 52147]] 11,000-20,999.......................................... 373 1.3 2.7 7.7 21,000-42,999.......................................... 290 1.9 1.4 6.9 GT 42,999.............................................. 138 4.3 -0.2 7.8 REGION (URBAN): NEW ENGLAND............................................ 127 -0.6 0.6 3.4 MIDDLE ATLANTIC........................................ 372 -1.3 0.2 2.3 SOUTH ATLANTIC......................................... 370 -0.2 -0.1 3.2 EAST NORTH CENT........................................ 413 -0.7 -1.4 1.4 EAST SOUTH CENT........................................ 153 -0.6 -1.0 1.9 WEST NORTH CENT........................................ 172 -0.3 -1.6 1.6 WEST SOUTH CENT........................................ 293 0.5 -0.7 3.3 MOUNTAIN............................................... 122 -0.4 -1.1 1.9 PACIFIC................................................ 368 -0.9 0.6 3.1 PUERTO RICO............................................ 39 -1.8 4.7 6.4 REGION (RURAL): NEW ENGLAND............................................ 40 1.6 1.3 6.5 MIDDLE ATLANTIC........................................ 63 2.2 1.3 7.2 SOUTH ATLANTIC......................................... 226 2.6 2.1 8.4 EAST NORTH CENT........................................ 213 1.2 -0.2 4.6 EAST SOUTH CENT........................................ 232 2.3 2.6 8.7 WEST NORTH CENT........................................ 271 2.0 0.9 6.6 WEST SOUTH CENT........................................ 278 1.8 3.2 8.8 MOUNTAIN............................................... 141 4.1 1.3 9.2 PACIFIC................................................ 104 5.6 2.7 12.1 PUERTO RICO............................................ 5 -2.8 10.4 11.1 TEACHING STATUS: NON-TEACHING........................................... 2,935 0.4 1.1 5.0 MINOR.................................................. 782 -0.4 -1.1 2.0 MAJOR.................................................. 284 -0.5 -1.2 1.7 DSH PATIENT PERCENT: 0..................................................... 11 4.9 10.1 19.4 GT 0-0.10.............................................. 982 -0.2 -0.4 3.0 0.10-0.16.............................................. 873 0.7 -0.8 3.4 0.16-0.23.............................................. 767 -0.6 -0.3 2.6 0.23-0.35.............................................. 756 -0.2 0.1 3.4 GE 0.35................................................ 613 -0.1 2.2 5.8 URBAN IME/DSH: IME & DSH.............................................. 982 -0.7 -1.2 1.6 IME/NO DSH............................................. 0 0.0 0.0 0.0 NO IME/DSH............................................. 1,441 -0.4 0.7 3.8 NO IME/NO DSH.......................................... 6 5.4 9.8 19.7 RURAL HOSP. TYPES: NO SPECIAL STATUS...................................... 610 0.7 2.7 7.1 RRC.................................................... 167 4.2 0.2 8.2 SCH/EACH............................................... 507 1.5 2.7 7.8 MDH.................................................... 199 0.8 2.1 6.6 SCH AND RRC............................................ 75 4.0 0.5 8.2 TYPE OF OWNERSHIP: VOLUNTARY.............................................. 2,440 -0.1 -0.4 3.1 PROPRIETARY............................................ 707 -0.6 0.9 3.8 GOVERNMENT............................................. 855 0.7 0.7 5.0 SPECIALTY HOSPITALS: EYE AND EAR............................................ 13 -1.4 11.5 13.7 TRAUMA................................................. 153 -0.3 -1.5 1.6 CANCER................................................. 10 0.5 -3.9 0.2 TEFRA HOSPITALS (NOT INCLUDED ON OTHER LINES): REHAB.................................................. 166 10.3 2.8 16.9 PSYCH.................................................. 198 0.1 15.9 20.1 LTC.................................................... 143 1.3 15.9 20.4 CHILDREN............................................... 42 -1.4 -2.8 -0.9 ---------------------------------------------------------------------------------------------------------------- Note: For CY 2003, under the OPPS transitional corridor policy, the following categories of hospitals are held harmless compared to their 1996 payment margin for these services: cancer and children's hospitals and rural hospitals with 100 or fewer beds. \1\ Some data necessary to classify hospitals by category were missing; thus, the total number of hospitals in each category may not equal the national total. \2\ This column shows the impact of updating the wage index used to calculate payment by applying the proposed FY 2003 hospital inpatient wage index after geographic reclassification by the Medicare Geographic Classification Review Board. The hospital inpatient proposed rule for FY 2003 was published in the Federal Register on May 9, 2002. \3\ This column shows the impact of changes resulting from the reclassification of HCPCS codes among APC groups and the recalibration of APC weights based on 2001 hospital claims data. [[Page 52148]] \4\ This column shows changes in total payment from CY 2002 to CY 2003, excluding outlier and pass-through payments. It incorporates all of the changes reflected in columns 2 and 3. In addition, it shows the impact of the proposed CY 2003 payment update. The sum of the columns may be different from the percentage changes shown here due to rounding. As stated elsewhere in this preamble, we propose to allocate 2 percent of the estimated 2003 expenditures to outlier payments. In Table 11 below, we provide a distribution by percentage of the total projected outlier payments for the categories of hospitals that we show in the impact table (Table 10). We project, based on the mix of services for the hospitals that will be paid under the OPPS in 2003, that most hospitals will receive outlier payments. It appears that, with the exception of some smaller bed hospitals, all Tax Equity & Fiscal Responsibility Act of 1982 (TEFRA) hospitals can be expected to receive outlier payments. This is because TEFRA hospitals provide an atypical mix of specialty services (which account for less than 1 percent of total OPPS payment before consideration of outliers). A greater percentage of non-TEFRA hospitals are not projected to receive outlier payments. The anticipated outlier payments for urban hospitals can be expected to ameliorate the impact of the wage index and APC changes on payments to urban hospitals. Table 11.--Distribution of Outlier Payments for CY 2003 Hospital Outpatient Prospective Payment System ---------------------------------------------------------------------------------------------------------------- Percent of Number of Percent of Number of total hosps total hosps hosps with outlier outliers payments ---------------------------------------------------------------------------------------------------------------- ALL HOSPITALS............................................... 4,551 100.00 4,306 100.00 NON-TEFRA HOSPITALS......................................... 4,002 88.00 3,987 99.40 URBAN HOSPS................................................. 2,429 53.40 2,420 83.20 LARGE URBAN (GT 1 MILL.)................................ 1,398 30.80 1,396 55.20 OTHER URBAN (LE 1 MILL.)................................ 1,031 22.60 1,024 28.00 RURAL HOSPS................................................. 1,573 34.60 1,567 16.00 BEDS (URBAN): 0-99 BEDS............................................... 554 12.20 550 6.80 100-199 BEDS............................................ 882 19.40 877 18.20 200-299 BEDS............................................ 488 10.80 488 16.20 300-499 BEDS............................................ 364 8.00 364 21.00 500+ BEDS............................................... 141 3.00 141 21.00 BEDS (RURAL): 0-49 BEDS............................................... 754 16.60 751 4.20 50-99 BEDS.............................................. 479 10.60 477 5.00 100-149 BEDS............................................ 201 4.40 200 2.60 150-199 BEDS............................................ 73 1.60 73 2.00 200+ BEDS............................................... 66 1.40 66 2.40 VOLUME (URBAN): LT 5,000................................................ 188 4.20 180 1.00 5,000-10,999............................................ 310 6.80 309 2.80 11,000-20,999........................................... 467 10.20 467 7.00 21,000-42,999........................................... 659 14.40 659 15.80 GT 42,999............................................... 805 17.60 805 56.60 VOLUME (RURAL): LT 5,000................................................ 326 7.20 321 1.00 5,000-10,999............................................ 447 9.80 446 2.60 11,000-20,999........................................... 372 8.20 372 3.80 21,000-42,999........................................... 290 6.40 290 4.20 GT 42,999............................................... 138 3.00 138 4.40 REGION (URBAN): NEW ENGLAND............................................. 127 2.80 126 6.20 MIDDLE ATLANTIC......................................... 372 8.20 371 22.80 SOUTH ATLANTIC.......................................... 370 8.20 369 11.00 EAST NORTH CENT......................................... 413 9.00 409 15.60 EAST SOUTH CENT......................................... 153 3.40 152 3.40 WEST NORTH CENT......................................... 172 3.80 172 4.40 WEST SOUTH CENT......................................... 293 6.40 292 8.20 MOUNTAIN................................................ 122 2.60 122 3.00 PACIFIC................................................. 368 8.00 368 8.60 PUERTO RICO............................................. 39 0.80 39 0.20 REGION (RURAL): NEW ENGLAND............................................. 40 0.80 40 1.00 MIDDLE ATLANTIC......................................... 63 1.40 63 1.00 SOUTH ATLANTIC.......................................... 226 5.00 223 3.00 EAST NORTH CENT......................................... 213 4.60 212 3.00 EAST SOUTH CENT......................................... 232 5.00 232 1.60 WEST NORTH CENT......................................... 271 6.00 270 2.40 WEST SOUTH CENT......................................... 278 6.20 278 1.60 MOUNTAIN................................................ 141 3.00 141 1.40 PACIFIC................................................. 104 2.20 103 1.20 PUERTO RICO............................................. 5 0.20 5 0.00 TEACHING STATUS: NON-TEACHING............................................ 2,935 64.40 2,920 39.80 [[Page 52149]] MINOR................................................... 782 17.20 782 27.20 MAJOR................................................... 284 6.20 284 32.20 DSH PATIENT PERCENT: 0....................................................... 11 0.20 10 0.00 GT 0--0.10.............................................. 982 21.60 978 24.80 0.10--0.16.............................................. 873 19.20 873 19.40 0.16--0.23.............................................. 767 16.80 765 17.60 0.23--0.35.............................................. 756 16.60 753 20.00 GE 0.35................................................. 613 13.40 608 17.40 URBAN IME/DSH: IME & DSH............................................... 982 21.60 982 57.20 IME/NO DSH.............................................. 0 0.00 0 0.00 NO IME/DSH.............................................. 1,441 31.60 1,433 26.00 NO IME/NO DSH........................................... 6 0.20 5 0.00 RURAL HOSP. TYPES: NO SPECIAL STATUS....................................... 621 13.60 617 5.20 RRC..................................................... 167 3.60 166 4.00 SCH/EACH................................................ 511 11.20 511 4.40 MDH..................................................... 199 4.40 198 1.00 SCH AND RRC............................................. 75 1.60 75 1.40 TYPE OF OWNERSHIP: VOLUNTARY............................................... 2,440 53.60 2,435 73.60 PROPRIETARY............................................. 707 15.60 702 10.40 GOVERNMENT.............................................. 855 18.80 850 15.20 SPECIALTY HOSPITALS: EYE AND EAR............................................. 13 0.20 13 0.20 TRAUMA.................................................. 153 3.40 153 15.00 CANCER.................................................. 10 0.20 10 3.80 TEFRA HOSPITALS (NOT INCLUDED ON OTHER LINES): REHAB................................................... 166 3.60 113 0.20 PSYCH................................................... 198 4.40 65 0.20 LTC..................................................... 143 3.20 100 0.20 CHILDREN................................................ 42 1.00 41 0.20 ---------------------------------------------------------------------------------------------------------------- 5. Estimated Impacts of This Proposed Rule on Beneficiaries For services for which the beneficiary pays a coinsurance of 20 percent of the payment rate, the beneficiary share of payment would increase for services for which OPPS payments would rise and would decrease for services for which OPPS payments would fall. For example for a mid level office visit (APC 0601), the minimum unadjusted copayment in 2002 was $9.67; under this proposed rule, the minimum unadjusted copayment would be $10.82 because the OPPS payment for the service would increase under this proposed rule. For some services (those services for which a national unadjusted copayment amount is shown in Addendum B), however, the beneficiary copayment is frozen based on historic data and would not change, therefore not presenting any potential impact on beneficiaries. However, in all cases, the statute limits beneficiary liability for copayment for a service to the inpatient hospital deductible for the applicable year. This amount was $812 for 2002, but is not yet determined for 2003. In general, the impact of this proposed rule on beneficiaries would vary based on the service the beneficiary receives and whether the copayment for the service is one that is frozen under the OPPS. B. Payment Suspension for Unfiled Cost Reports Overall Impact We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96- 354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. (A description of each of these requirements is stated above in section XIV.A.1.) We have determined that the proposed payment suspension provision does not have an economic impact on Medicare payments or other payments to providers. We are proposing to allow the Secretary flexibility in payment suspensions, but we are not altering the final payment determination in any way. With the implementation of the various prospective payment systems, the majority of the payment to providers is based on the PPS methodology and not on the cost report. Suspending all payments because the cost report is not timely filed negatively affects providers. Providing the Secretary with flexibility in payment suspension can lessen the financial impact on providers. For these reasons, we are not preparing analyses for either the RFA or section 1102(b) of the Act because we have determined, and we certify, that this rule would not have a significant economic impact on a substantial number of small entities or a significant impact on the operations of a substantial number of small rural hospitals. Under the requirement for Unfunded Mandates, this proposed rule will not have an economic effect on State, local, or tribal governments, in the aggregate, or on the private sector. Anticipated Effects 1. Effects on providers that file cost reports. The majority of providers that file cost reports comply with the timeliness provisions and will be unaffected by this proposed regulation. [[Page 52150]] In FY 2000, collectively 16 percent of hospitals, skilled nursing facilities, and home health agencies filed late cost reports. Of this 16 percent, 65 percent of those were only 1 day late. Currently, when a provider fails to file an acceptable cost report, the provider is placed on a complete payment suspension. Under this provision, for those providers who do not file timely, an immediate payment suspension less than the total suspension currently required might be imposed if the Secretary deemed it appropriate, which would allow the provider to more easily continue operations while completing and submitting the acceptable cost report. 2. Effects on other providers. The payment suspension provision does not affect other providers. 3. Effects on the Medicare Program. The provision would allow the Secretary to more effectively manage the Medicare program by imposing other than complete payment suspension when it is appropriate to do so. The Medicare program benefits because immediate complete payment suspension can be disruptive to providers and may negatively affect the care of Medicare patients. There are no costs to the Medicare program to doing so, because when the cost report is submitted, the suspended payments are returned to the provider. 4. Effects on Beneficiaries. We have determined that this provision has a potentially positive impact on beneficiaries. Under this proposed provision the Secretary will have the discretion to impose less than 100 percent payment suspension when a provider fails to timely file an acceptable cost report. Doing so will lessen the financial burden on the provider and thereby allow it to provide adequate services to its patient population as it works to complete and file an acceptable cost report. Alternatives Considered We considered not revising existing Sec. 405.371(c) to provide that payment suspension could be ``in whole or in part''. However, we did not choose this option because we believe the Secretary should have the discretion to impose partial payment suspensions when circumstances warrant in order to more effectively manage the Medicare program. Conclusion In conclusion, we have determined that the proposed payment suspension provision does not have an economic impact on Medicare payments. Federalism Since this regulation does not impose any costs on State or local governments, it will not have an effect on State or local governments. State or local governments will have no roles or responsibilities associated with this provision. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects 42 CFR Part 405 Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping requirements, Rural areas, X-rays. 42 CFR Part 410 Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting and recordkeeping requirements, Rural areas, X-rays. 42 CFR Part 419 Hospitals, Medicare, Reporting and recordkeeping requirements. For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as follows: PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Subpart C--Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans 1. The authority citation for subpart C continues to read as follows: Authority: Secs. 1102, 1815, 1833, 1842, 1866, 1870, 1871, 1879, and 1892 of the Social Security Act (42 U.S.C. 1302, 1395g, 1395l, 1395u, 1395cc, 1395gg, 1395hh, 1395pp, and 1395ccc) and 31 U.S.C. 3711. 2.Section 405.371(c) is revised to read as follows: Sec. 405.371 Suspension, offset and recoupment of Medicare payments to providers and suppliers of services. * * * * * (c) Suspension of payment in the case of unfiled cost reports. If a provider has failed to timely file an acceptable cost report, payment to the provider is immediately suspended in whole or in part until a cost report is filed and determined by the intermediary to be acceptable. In the case of an unfiled cost report, the provisions of Sec. 405.372 do not apply. (See Sec. 405.372(a)(2) concerning failure to furnish other information.) PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 1.The authority citation continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 2. In 410.43 republish the introductory text of paragraph (b), and add a new paragraph (b)(6) to read as follows: Sec. 410.43 Partial hospitalization services: Conditions and exclusions. * * * * * (b) The following services are separately covered and not paid as partial hospitalization services: * * * * * (6) Clinical social worker services that meet the requirements of section 1861(hh)(2) of the Act. PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES 1. The authority citation continues to read as follows: Authority: Secs. 1102, 1833(t), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395l(t), and 1395hh). Sec. 419.66 [Amended] 2. In Sec. 419.66, paragraph (c)(1) is amended by adding the phrase ``or by any category previously in effect'' after ``categories'' and before ``and'. Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: July 31, 2002. Thomas A. Scully, Administrator, Centers for Medicare & Medicaid Services. Approved: August 5, 2002. Tommy G. Thompson, Secretary. BILLING CODE 4120-01-P [[Page 52151]] Addendum A.--List of Ambulatory Payment Classifications (APCs) With Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts Calendar Year 2003 ---------------------------------------------------------------------------------------------------------------- National Minimum APC Group title Status indicator Relative Payment unadjusted unadjusted weight rate copayment copayment ---------------------------------------------------------------------------------------------------------------- 0620................ Critical Care........ S 10.25 $533.09 $150.55 $106.62 0656................ Transcatheter T 90.90 $4,927.70 .......... $985.54 Placement of Drug- Eluting Coronary Stents. 0657................ Placement of Tissue S 1.38 $71.77 .......... $14.35 Clips. 0658................ Percutaneous Breast T 5.57 $289.69 .......... $57.94 Biopsies. ---------------------------------------------------------------------------------------------------------------- Addendum A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts Calendar Year 2003 ---------------------------------------------------------------------------------------------------------------- National Minimum APC Group title Status Relative Payment rate unadjusted unadjusted indicator weight copayment copayment ---------------------------------------------------------------------------------------------------------------- 0001............. Level I S 0.43 $22.36 $7.88 $4.47 Photochemotherapy. 0002............. Fine needle Biopsy/ T 0.63 $32.77 $8.52 $6.55 Aspiration. 0003............. Bone Marrow Biopsy/ T 1.24 $64.49 $27.08 $12.90 Aspiration. 0004............. Level I Needle T 1.63 $84.77 $22.04 $16.95 Biopsy/Aspiration Except Bone Marrow. 0005............. Level II Needle T 3.02 $157.07 $69.11 $31.41 Biopsy /Aspiration Except Bone Marrow. 0006............. Level I Incision & T 1.89 $98.30 $25.56 $19.66 Drainage. 0007............. Level II Incision & T 9.44 $490.96 $103.10 $98.19 Drainage. 0008............. Level III Incision T 16.32 $848.79 ............ $169.76 and Drainage. 0009............. Nail Procedures.... T 0.68 $35.37 $8.34 $7.07 0010............. Level I Destruction T 0.70 $36.41 $10.56 $7.28 of Lesion. 0011............. Level II T 1.93 $100.38 $27.88 $20.08 Destruction of Lesion. 0012............. Level I Debridement T 0.76 $39.53 $10.67 $7.91 & Destruction. 0013............. Level II T 1.10 $57.21 $14.30 $11.44 Debridement & Destruction. 0015............. Level III T 1.43 $74.37 $18.59 $14.87 Debridement & Destruction. 0016............. Level IV T 2.57 $133.66 $56.14 $26.73 Debridement & Destruction. 0017............. Level VI T 16.46 $856.07 $227.84 $171.21 Debridement & Destruction. 0018............. Biopsy of Skin/ T 0.92 $47.85 $15.79 $9.57 Puncture of Lesion. 0019............. Level I Excision/ T 3.94 $204.92 $75.82 $40.98 Biopsy. 0020............. Level II Excision/ T 7.36 $382.79 $114.84 $76.56 Biopsy. 0021............. Level III Excision/ T 14.58 $758.29 $227.49 $151.66 Biopsy. 0022............. Level IV Excision/ T 18.10 $941.36 $367.13 $188.27 Biopsy. 0023............. Exploration T 2.38 $123.78 $40.37 $24.76 Penetrating Wound. 0024............. Level I Skin Repair T 2.00 $104.02 $37.45 $20.80 0025............. Level II Skin T 5.89 $306.33 $116.41 $61.27 Repair. 0027............. Level IV Skin T 15.73 $818.10 $343.60 $163.62 Repair. 0028............. Level I Breast T 17.44 $907.04 $303.74 $181.41 Surgery. 0029............. Level II Breast T 29.89 $1,554.55 $632.64 $310.91 Surgery. 0030............. Level III Breast T 40.23 $2,092.32 $763.55 $418.46 Surgery. 0032............. Insertion of T 7.14 $371.34 ............ $74.27 Central Venous/ Arterial Catheter. 0033............. Partial P 4.96 $257.96 ............ $51.59 Hospitalization. 0035............. Placement of T 0.24 $12.48 $3.74 $2.50 Arterial or Central Venous Catheter. 0041............. Level I Arthroscopy T 27.58 $1,434.41 $580.06 $286.88 0042............. Level II T 43.24 $2,248.87 $804.74 $449.77 Arthroscopy. 0043............. Closed Treatment T 1.68 $87.38 ............ $17.48 Fracture Finger/ Toe/Trunk. 0045............. Bone/Joint T 13.47 $700.56 $280.22 $140.11 Manipulation Under Anesthesia. 0046............. Open/Percutaneous T 29.03 $1,509.82 $535.76 $301.96 Treatment Fracture or Dislocation. 0047............. Arthroplasty T 29.59 $1,538.95 $537.03 $307.79 without Prosthesis. 0048............. Arthroplasty with T 36.93 $1,920.69 $633.83 $384.14 Prosthesis. 0049............. Level I T 19.45 $1,011.58 ............ $202.32 Musculoskeletal Procedures Except Hand and Foot. 0050............. Level II T 23.60 $1,227.41 ............ $245.48 Musculoskeletal Procedures Except Hand and Foot. 0051............. Level III T 34.03 $1,769.87 ............ $353.97 Musculoskeletal Procedures Except Hand and Foot. 0052............. Level IV T 42.37 $2,203.62 ............ $440.72 Musculoskeletal Procedures Except Hand and Foot. 0053............. Level I Hand T 14.76 $767.65 $253.49 $153.53 Musculoskeletal Procedures. 0054............. Level II Hand T 23.50 $1,222.21 $472.33 $244.44 Musculoskeletal Procedures. 0055............. Level I Foot T 18.28 $950.72 $355.34 $190.14 Musculoskeletal Procedures. 0056............. Level II Foot T 22.94 $1,193.09 $405.81 $238.62 Musculoskeletal Procedures. 0057............. Bunion Procedures.. T 23.87 $1,241.45 $496.58 $248.29 0058............. Level I Strapping S 1.09 $56.69 $14.74 $11.34 and Cast Application. 0060............. Manipulation S 0.36 $18.72 ............ $3.74 Therapy. [[Page 52152]] 0068............. CPAP Initiation.... S 1.59 $82.69 $45.48 $16.54 0069............. Thoracoscopy....... T 29.51 $1,534.79 $591.64 $306.96 0070............. Thoracentesis/ T 3.30 $171.63 ............ $34.33 Lavage Procedures. 0071............. Level I Endoscopy T 1.01 $52.53 $14.18 $10.51 Upper Airway. 0072............. Level II Endoscopy T 1.66 $86.33 $37.99 $17.27 Upper Airway. 0073............. Level III Endoscopy T 3.63 $188.79 $74.14 $37.76 Upper Airway. 0074............. Level IV Endoscopy T 12.84 $667.80 $295.70 $133.56 Upper Airway. 0075............. Level V Endoscopy T 20.41 $1,061.50 $445.92 $212.30 Upper Airway. 0076............. Endoscopy Lower T 9.30 $483.68 $189.92 $96.74 Airway. 0077............. Level I Pulmonary S 0.26 $13.52 $7.44 $2.70 Treatment. 0078............. Level II Pulmonary S 0.68 $35.37 $15.21 $7.07 Treatment. 0079............. Ventilation S 1.63 $84.77 $16.80 $16.95 Initiation and Management. 0080............. Diagnostic Cardiac T 35.64 $1,853.60 $838.92 $370.72 Catheterization. 0081............. Non-Coronary T 22.69 $1,180.08 ............ $236.02 Angioplasty or Atherectomy. 0082............. Coronary T 75.42 $3,922.52 $1,137.53 $784.50 Atherectomy. 0083............. Coronary T 47.83 $2,487.59 ............ $497.52 Angioplasty and Percutaneous Valvuloplasty. 0084............. Level I S 9.60 $499.29 ............ $99.86 Electrophysiologic Evaluation. 0085............. Level II T 31.77 $1,652.33 $363.51 $330.47 Electrophysiologic Evaluation. 0086............. Ablate Heart T 43.70 $2,272.79 $772.75 $454.56 Dysrhythm Focus. 0087............. Cardiac T 5.81 $302.17 ............ $60.43 Electrophysiologic Recording/Mapping. 0088............. Thrombectomy....... T 33.96 $1,766.23 $678.68 $353.25 0089............. Insertion/ T 108.92 $5,664.82 $1,642.80 $1,132.96 Replacement of Permanent Pacemaker and Electrodes. 0090............. Insertion/ T 77.15 $4,012.49 $1,444.50 $802.50 Replacement of Pacemaker Pulse Generator. 0091............. Level II Vascular T 27.03 $1,405.80 $348.23 $281.16 Ligation. 0092............. Level I Vascular T 24.97 $1,298.66 $505.37 $259.73 Ligation. 0093............. Vascular Repair/ T 26.29 $1,367.32 $277.34 $273.46 Fistula Construction. 0094............. Level I S 2.68 $139.38 $47.39 $27.88 Resuscitation and Cardioversion. 0095............. Cardiac S 0.66 $34.33 $16.73 $6.87 Rehabilitation. 0096............. Non-Invasive S 1.82 $94.66 $48.15 $18.93 Vascular Studies. 0097............. Cardiac and X 0.84 $43.69 $23.80 $8.74 Ambulatory Blood Pressure Monitoring. 0098............. Injection of T 1.90 $98.82 $20.88 $19.76 Sclerosing Solution. 0099............. Electrocardiograms. S 0.38 $19.76 ............ $3.95 0100............. Stress Tests and X 1.34 $69.69 $38.33 $13.94 Continuous ECG. 0101............. Tilt Table S 4.40 $228.84 $105.27 $45.77 Evaluation. 0103............. Miscellaneous T 11.26 $585.62 $210.82 $117.12 Vascular Procedures. 0104............. Transcatheter T 72.72 $3,782.09 ............ $756.42 Placement of Intracoronary Stents. 0105............. Revision/Removal of T 19.14 $995.45 $370.40 $199.09 Pacemakers, AICD, or Vascular. 0106............. Insertion/ T 29.23 $1,520.22 $410.46 $304.04 Replacement/Repair of Pacemaker and/ or Electrodes. 0107............. Insertion of T 181.51 $9,440.15 $2,076.83 $1,888.03 Cardioverter- Defibrillator. 0108............. Insertion/ T 232.69 $12,101.97 ............ $2,420.39 Replacement/Repair of Cardioverter- Defibrillator Leads. 0109............. Removal of T 7.68 $399.43 $131.49 $79.89 Implanted Devices. 0110............. Transfusion........ S 4.04 $210.12 ............ $42.02 0111............. Blood Product S 13.60 $707.32 $198.05 $141.46 Exchange. 0112............. Apheresis, S 39.40 $2,049.15 $612.47 $409.83 Photopheresis, and Plasmapheresis. 0113............. Excision Lymphatic T 19.75 $1,027.18 ............ $205.44 System. 0114............. Thyroid/ T 37.55 $1,952.94 $507.76 $390.59 Lymphadenectomy Procedures. 0115............. Cannula/Access T 23.48 $1,221.17 $439.62 $244.23 Device Procedures. 0116............. Chemotherapy S 0.85 $44.21 ............ $8.84 Administration by Other Technique Except Infusion. 0117............. Chemotherapy S 3.87 $201.27 $52.33 $40.25 Administration by Infusion Only. 0118............. Chemotherapy S 5.68 $295.41 $72.03 $59.08 Administration by Both Infusion and Other Technique. 0119............. Implantation of T 25.88 $1,345.99 ............ $269.20 Devices. 0120............. Infusion Therapy T 1.81 $94.14 $25.42 $18.83 Except Chemotherapy. 0121............. Level I Tube T 2.17 $112.86 $45.14 $22.57 changes and Repositioning. 0122............. Level II Tube T 3.89 $202.32 $46.53 $40.46 changes and Repositioning. 0123............. Bone Marrow S 4.86 $252.76 ............ $50.55 Harvesting and Bone Marrow/Stem Cell Transplant. 0124............. Revision of T 23.47 $1,220.65 ............ $244.13 Implanted Infusion Pump. 0125............. Refilling of T 1.73 $89.98 ............ $18.00 Infusion Pump. 0130............. Level I Laparoscopy T 31.99 $1,663.77 $659.53 $332.75 0131............. Level II T 42.44 $2,207.26 $1,001.89 $441.45 Laparoscopy. 0132............. Level III T 57.95 $3,013.92 $1,239.22 $602.78 Laparoscopy. 0140............. Esophageal Dilation T 5.84 $303.73 $107.24 $60.75 without Endoscopy. [[Page 52153]] 0141............. Upper GI Procedures T 7.82 $406.71 $150.48 $81.34 0142............. Small Intestine T 8.21 $426.99 $152.78 $85.40 Endoscopy. 0143............. Lower GI Endoscopy. T 8.37 $435.32 $186.06 $87.06 0146............. Level I T 3.47 $180.47 $64.40 $36.09 Sigmoidoscopy. 0147............. Level II T 7.30 $379.67 $83.53 $75.93 Sigmoidoscopy. 0148............. Level I Anal/Rectal T 3.61 $187.75 $67.59 $37.55 Procedure. 0149............. Level III Anal/ T 16.91 $879.47 $293.06 $175.89 Rectal Procedure. 0150............. Level IV Anal/ T 22.02 $1,145.24 $437.12 $229.05 Rectal Procedure. 0151............. Endoscopic T 18.23 $948.12 $245.46 $189.62 Retrograde Cholangio- Pancreatography (ERCP). 0152............. Percutaneous T 6.18 $321.42 $80.36 $64.28 Abdominal and Biliary Procedures. 0153............. Peritoneal and T 25.99 $1,351.71 $540.68 $270.34 Abdominal Procedures. 0154............. Hernia/Hydrocele T 26.98 $1,403.20 $491.12 $280.64 Procedures. 0155............. Level II Anal/ T 10.05 $522.69 $188.17 $104.54 Rectal Procedure. 0156............. Level II Urinary T 3.10 $161.23 $48.37 $32.25 and Anal Procedures. 0157............. Colorectal Cancer S 2.73 $141.98 $22.19 $28.40 Screening: Barium Enema. 0158............. Colorectal Cancer T 7.56 $393.19 ............ $98.30 Screening: Colonoscopy. 0159............. Colorectal Cancer S 2.48 $128.98 ............ $32.25 Screening: Flexible Sigmoidoscopy. 0160............. Level I T 6.44 $334.94 $105.06 $66.99 Cystourethroscopy and other Genitourinary Procedures. 0161............. Level II T 16.03 $833.70 $249.36 $166.74 Cystourethroscopy and other Genitourinary Procedures. 0162............. Level III T 21.50 $1,118.19 ............ $223.64 Cystourethroscopy and other Genitourinary Procedures. 0163............. Level IV T 24.77 $1,288.26 ............ $257.65 Cystourethroscopy and other Genitourinary Procedures. 0164............. Level I Urinary and T 1.18 $61.37 $18.41 $12.27 Anal Procedures. 0165............. Level III Urinary T 12.62 $656.35 ............ $131.27 and Anal Procedures. 0166............. Level I Urethral T 15.63 $812.90 $218.73 $162.58 Procedures. 0167............. Level III Urethral T 27.15 $1,412.04 $555.84 $282.41 Procedures. 0168............. Level II Urethral T 24.10 $1,253.42 $405.60 $250.68 Procedures. 0169............. Lithotripsy........ T 46.44 $2,415.30 $1,115.69 $483.06 0170............. Dialysis........... S 4.79 $249.12 ............ $49.82 0179............. Urinary T 81.28 $4,227.29 $1,817.73 $845.46 Incontinence Procedures. 0180............. Circumcision....... T 18.95 $985.57 $304.87 $197.11 0181............. Penile Procedures.. T 29.88 $1,554.03 $621.82 $310.81 0182............. Insertion of Penile T 83.80 $4,358.35 $1,438.26 $871.67 Prosthesis. 0183............. Testes/Epididymis T 22.19 $1,154.08 $448.94 $230.82 Procedures. 0184............. Prostate Biopsy.... T 3.66 $190.35 $95.18 $38.07 0187............. Miscellaneous X 4.19 $217.92 $94.96 $43.58 Placement/ Repositioning. 0188............. Level II Female T 1.12 $58.25 $11.95 $11.65 Reproductive Proc. 0189............. Level III Female T 1.63 $84.77 $18.60 $16.95 Reproductive Proc. 0190............. Surgical T 20.06 $1,043.30 $424.28 $208.66 Hysteroscopy. 0191............. Level I Female T 0.22 $11.44 $3.32 $2.29 Reproductive Proc. 0192............. Level IV Female T 2.94 $152.91 $42.81 $30.58 Reproductive Proc. 0193............. Level V Female T 14.57 $757.77 $171.13 $151.55 Reproductive Proc. 0194............. Level VI Female T 18.88 $981.93 $397.84 $196.39 Reproductive Proc. 0195............. Level VII Female T 24.37 $1,267.46 $483.80 $253.49 Reproductive Proc. 0196............. Dilation and T 16.32 $848.79 $338.23 $169.76 Curettage. 0197............. Infertility T 1.19 $61.89 $24.76 $12.38 Procedures. 0198............. Pregnancy and T 1.33 $69.17 $32.92 $13.83 Neonatal Care Procedures. 0199............. Vaginal Delivery... T 5.69 $295.93 $72.98 $59.19 0200............. Therapeutic T 14.49 $753.61 $307.83 $150.72 Abortion. 0201............. Spontaneous T 15.84 $823.82 $329.65 $164.76 Abortion. 0202............. Level VIII Female T 39.09 $2,033.03 $996.18 $406.61 Reproductive Proc. 0203............. Level IV Nerve T 10.96 $570.02 $256.51 $114.00 Injections. 0204............. Level I Nerve T 2.13 $110.78 $42.10 $22.16 Injections. 0206............. Level II Nerve T 4.89 $254.32 $75.55 $50.86 Injections. 0207............. Level III Nerve T 5.97 $310.49 $123.69 $62.10 Injections. 0208............. Laminotomies and T 39.95 $2,077.76 ............ $415.55 Laminectomies. 0209............. Extended EEG S 12.09 $628.79 $280.58 $125.76 Studies and Sleep Studies, Level II. 0212............. Nervous System T 3.53 $183.59 $84.45 $36.72 Injections. 0213............. Extended EEG S 3.38 $175.79 $70.41 $35.16 Studies and Sleep Studies, Level I. 0214............. Electroencephalogra S 2.37 $123.26 $61.63 $24.65 m. 0215............. Level I Nerve and S 0.60 $31.21 ............ $6.24 Muscle Tests. 0216............. Level III Nerve and S 3.06 $159.15 $71.62 $31.83 Muscle Tests. 0218............. Level II Nerve and S 1.06 $55.13 ............ $11.03 Muscle Tests. 0220............. Level I Nerve T 16.66 $866.47 ............ $173.29 Procedures. 0221............. Level II Nerve T 25.35 $1,318.43 $463.62 $263.69 Procedures. [[Page 52154]] 0222............. Implantation of T 140.56 $7,310.39 ............ $1,462.08 Neurological Device. 0223............. Implantation of T 20.30 $1,055.78 ............ $211.16 Pain Management Device. 0224............. Implantation of T 39.14 $2,035.63 $453.41 $407.13 Reservoir/Pump/ Shunt. 0225............. Implantation of T 44.47 $2,312.84 ............ $462.57 Neurostimulator Electrodes. 0226............. Implantation of T 44.20 $2,298.80 ............ $459.76 Drug Infusion Reservoir. 0227............. Implantation of T 128.03 $6,658.71 ............ $1,331.74 Drug Infusion Device. 0228............. Creation of Lumbar T 55.05 $2,863.10 $696.46 $572.62 Subarachnoid Shunt. 0229............. Transcatherter T 49.00 $2,548.44 $662.59 $509.69 Placement of Intravascular Shunts. 0230............. Level I Eye Tests & S 0.78 $40.57 $15.82 $8.11 Treatments. 0231............. Level III Eye Tests S 2.24 $116.50 $52.43 $23.30 & Treatments. 0232............. Level I Anterior T 4.91 $255.36 $112.36 $51.07 Segment Eye Procedures. 0233............. Level II Anterior T 13.43 $698.48 $266.33 $139.70 Segment Eye Procedures. 0234............. Level III Anterior T 21.45 $1,115.59 $535.48 $223.12 Segment Eye Procedures. 0235............. Level I Posterior T 5.62 $292.29 $81.84 $58.46 Segment Eye Procedures. 0236............. Level II Posterior T 20.62 $1,072.43 ............ $214.49 Segment Eye Procedures. 0237............. Level III Posterior T 35.09 $1,825.00 $818.54 $365.00 Segment Eye Procedures. 0238............. Level I Repair and T 3.04 $158.11 $58.96 $31.62 Plastic Eye Procedures. 0239............. Level II Repair and T 6.91 $359.38 $115.94 $71.88 Plastic Eye Procedures. 0240............. Level III Repair T 16.99 $883.63 $315.31 $176.73 and Plastic Eye Procedures. 0241............. Level IV Repair and T 21.89 $1,138.48 $384.47 $227.70 Plastic Eye Procedures. 0242............. Level V Repair and T 28.87 $1,501.50 $597.36 $300.30 Plastic Eye Procedures. 0243............. Strabismus/Muscle T 20.94 $1,089.07 $431.39 $217.81 Procedures. 0244............. Corneal Transplant. T 38.14 $1,983.62 $851.42 $396.72 0245............. Level I Cataract T 14.39 $748.41 $251.21 $149.68 Procedures without IOL Insert. 0246............. Cataract Procedures T 23.59 $1,226.89 $495.96 $245.38 with IOL Insert. 0247............. Laser Eye T 4.97 $258.48 $108.56 $51.70 Procedures Except Retinal. 0248............. Laser Retinal T 4.44 $230.92 $96.99 $46.18 Procedures. 0249............. Level II Cataract T 27.75 $1,443.25 $524.67 $288.65 Procedures without IOL Insert. 0250............. Nasal Cauterization/ T 1.68 $87.38 $30.58 $17.48 Packing. 0251............. Level I ENT T 1.92 $99.86 ............ $19.97 Procedures. 0252............. Level II ENT T 6.27 $326.10 $114.24 $65.22 Procedures. 0253............. Level III ENT T 14.79 $769.21 $284.61 $153.84 Procedures. 0254............. Level IV ENT T 21.89 $1,138.48 $352.93 $227.70 Procedures. 0256............. Level V ENT T 35.51 $1,846.84 ............ $369.37 Procedures. 0258............. Tonsil and Adenoid T 21.15 $1,099.99 $437.25 $220.00 Procedures. 0259............. Level VI ENT T 291.05 $15,137.22 $7,417.24 $3,027.44 Procedures. 0260............. Level I Plain Film X 0.81 $42.13 $23.17 $8.43 Except Teeth. 0261............. Level II Plain Film X 1.37 $71.25 $34.15 $14.25 Except Teeth Including Bone Density Measurement. 0262............. Plain Film of Teeth X 0.60 $31.21 $10.30 $6.24 0263............. Level I X 1.99 $103.50 $45.54 $20.70 Miscellaneous Radiology Procedures. 0264............. Level II X 2.75 $143.02 $77.23 $28.60 Miscellaneous Radiology Procedures. 0265............. Level I Diagnostic S 1.04 $54.09 $29.75 $10.82 Ultrasound Except Vascular. 0266............. Level II Diagnostic S 1.70 $88.42 $48.63 $17.68 Ultrasound Except Vascular. 0267............. Level III S 2.58 $134.18 $65.52 $26.84 Diagnostic Ultrasound Except Vascular. 0268............. Ultrasound Guidance S 1.48 $76.97 ............ $15.39 Procedures. 0269............. Level III S 3.42 $177.87 $92.49 $35.57 Echocardiogram Except Transesophageal. 0270............. Transesophageal S 5.65 $293.85 $146.79 $58.77 Echocardiogram. 0271............. Mammography........ S 0.69 $35.89 $16.80 $7.18 0272............. Level I Fluoroscopy X 1.38 $71.77 $38.64 $14.35 0274............. Myelography........ S 3.21 $166.95 $80.14 $33.39 0275............. Arthrography....... S 3.09 $160.71 $69.09 $32.14 0276............. Level I Digestive S 1.69 $87.90 $41.72 $17.58 Radiology. 0277............. Level II Digestive S 2.50 $130.02 $60.47 $26.00 Radiology. 0278............. Diagnostic S 2.65 $137.82 $66.07 $27.56 Urography. 0279............. Level II S 8.41 $437.40 $174.57 $87.48 Angiography and Venography except Extremity. 0280............. Level III S 15.51 $806.66 $353.85 $161.33 Angiography and Venography except Extremity. 0281............. Venography of S 5.23 $272.01 $115.16 $54.40 Extremity. 0282............. Miscellaneous S 1.76 $91.54 $44.51 $18.31 Computerized Axial Tomography. 0283............. Computerized Axial S 4.75 $247.04 ............ $49.41 Tomography with Contrast Material. 0284............. Magnetic Resonance S 7.74 $402.55 $201.02 $80.51 Imaging and Magnetic Resonance Angiography with Contrast Material. 0285............. Myocardial Positron S 16.73 $870.11 $374.15 $174.02 Emission Tomography (PET). 0286............. Myocardial Scans... S 6.94 $360.94 $198.52 $72.19 0287............. Complex Venography. S 7.13 $370.82 $114.51 $74.16 0288............. Bone Density:Axial S 1.38 $71.77 ............ $14.35 Skeleton. [[Page 52155]] 0289............. Needle Localization X 1.84 $95.70 $44.80 $19.14 for Breast Biopsy. 0290............. Level I Diagnostic S 2.16 $112.34 $56.17 $22.47 Nuclear Medicine Excluding Myocardial Scans. 0291............. Level II Diagnostic S 4.19 $217.92 $108.96 $43.58 Nuclear Medicine Excluding Myocardial Scans. 0292............. Level III S 4.53 $235.60 $117.80 $47.12 Diagnostic Nuclear Medicine Excluding Myocardial Scans. 0294............. Level II S 4.45 $231.44 $127.29 $46.29 Therapeutic Nuclear Medicine. 0295............. Level I Therapeutic S 3.86 $200.75 $110.41 $40.15 Nuclear Medicine. 0296............. Level I Therapeutic S 2.12 $110.26 $52.92 $22.05 Radiologic Procedures. 0297............. Level II S 7.80 $405.67 $172.51 $81.13 Therapeutic Radiologic Procedures. 0299............. Miscellaneous S 6.20 $322.46 ............ $64.49 Radiation Treatment. 0300............. Level I Radiation S 1.53 $79.57 ............ $15.91 Therapy. 0301............. Level II Radiation S 2.22 $115.46 ............ $23.09 Therapy. 0302............. Level III Radiation S 10.17 $528.93 $200.99 $105.79 Therapy. 0303............. Treatment Device X 2.93 $152.39 $68.58 $30.48 Construction. 0304............. Level I Therapeutic X 1.69 $87.90 $41.52 $17.58 Radiation Treatment Preparation. 0305............. Level II X 3.87 $201.27 $91.38 $40.25 Therapeutic Radiation Treatment Preparation. 0310............. Level III X 14.38 $747.89 $339.05 $149.58 Therapeutic Radiation Treatment Preparation. 0312............. Radioelement S 4.23 $220.00 ............ $44.00 Applications. 0313............. Brachytherapy...... S 13.80 $717.72 ............ $143.54 0314............. Hyperthermic S 4.24 $220.52 $101.77 $44.10 Therapies. 0320............. Electroconvulsive S 4.46 $231.96 $80.06 $46.39 Therapy. 0321............. Biofeedback and S 1.27 $66.05 $21.78 $13.21 Other Training. 0322............. Brief Individual S 1.44 $74.89 $12.40 $14.98 Psychotherapy. 0323............. Extended Individual S 1.95 $101.42 $21.26 $20.28 Psychotherapy. 0324............. Family S 2.71 $140.94 ............ $28.19 Psychotherapy. 0325............. Group Psychotherapy S 1.55 $80.61 $18.27 $16.12 0330............. Dental Procedures.. S 0.64 $33.29 ............ $6.66 0332............. Computerized Axial S 3.62 $188.27 $91.27 $37.65 Tomography and Computerized Angiography without Contrast Material. 0333............. Computerized Axial S 5.69 $295.93 $146.98 $59.19 Tomography and Computerized Angio w/o Contrast Material followed by Contrast. 0335............. Magnetic Resonance S 6.46 $335.98 $151.46 $67.20 Imaging, Miscellaneous. 0336............. Magnetic Resonance S 7.01 $364.58 $176.94 $72.92 Imaging and Magnetic Resonance Angiography without Contrast. 0337............. MRI and Magnetic S 9.86 $512.81 $240.77 $102.56 Resonance Angiography without Contrast Material followed by Contrast Material. 0339............. Observation........ S 7.60 $395.27 ............ $79.05 0340............. Minor Ancillary X 0.66 $34.33 ............ $6.87 Procedures. 0341............. Skin Tests and X 0.16 $8.32 $3.08 $1.66 Miscellaneous Red Blood Cell Tests. 0342............. Level I Pathology.. X 0.23 $11.96 $5.88 $2.39 0343............. Level II Pathology. X 0.47 $24.44 $13.20 $4.89 0344............. Level III Pathology X 0.66 $34.33 $18.54 $6.87 0345............. Level I Transfusion X 0.19 $9.88 $3.06 $1.98 Laboratory Procedures. 0346............. Level II X 0.42 $21.84 $5.46 $4.37 Transfusion Laboratory Procedures. 0347............. Level III X 0.98 $50.97 $12.74 $10.19 Transfusion Laboratory Procedures. 0348............. Fertility X 0.83 $43.17 ............ $8.63 Laboratory Procedures. 0352............. Level I Injections. X 0.14 $7.28 ............ $1.46 0353............. Level II Allergy X 0.43 $22.36 ............ $4.47 Injections. 0354............. Administration of K 0.09 $4.68 ............ ............ Influenza/ Pneumonia Vaccine. 0355............. Level I K 0.24 $12.48 ............ $2.50 Immunizations. 0356............. Level II K 0.69 $35.89 ............ $7.18 Immunizations. 0359............. Level II Injections X 0.83 $43.17 ............ $8.63 0360............. Level I Alimentary X 1.65 $85.81 $42.91 $17.16 Tests. 0361............. Level II Alimentary X 3.55 $184.63 $83.23 $36.93 Tests. 0362............. Level III X 2.83 $147.19 ............ $29.44 Otorhinolaryngolog ic Function Tests. 0363............. Level I X 0.76 $39.53 $14.63 $7.91 Otorhinolaryngolog ic Function Tests. 0364............. Level I Audiometry. X 0.45 $23.40 $9.13 $4.68 0365............. Level II Audiometry X 1.31 $68.13 $20.16 $13.63 0367............. Level I Pulmonary X 0.60 $31.21 $15.61 $6.24 Test. 0368............. Level II Pulmonary X 0.96 $49.93 $24.97 $9.99 Tests. 0369............. Level III Pulmonary X 2.39 $124.30 $41.02 $24.86 Tests. 0370............. Allergy Tests...... X 0.74 $38.49 $11.16 $7.70 0371............. Level I Allergy X 0.50 $26.00 ............ $5.20 Injections. 0372............. Therapeutic X 0.56 $29.13 $10.09 $5.83 Phlebotomy. 0373............. Neuropsychological X 2.37 $123.26 ............ $24.65 Testing. 0374............. Monitoring X 1.20 $62.41 ............ $12.48 Psychiatric Drugs. [[Page 52156]] 0600............. Low Level Clinic V 0.91 $47.33 ............ $9.47 Visits. 0601............. Mid Level Clinic V 1.04 $54.09 ............ $10.82 Visits. 0602............. High Level Clinic V 1.57 $81.65 ............ $16.33 Visits. 0610............. Low Level Emergency V 1.49 $77.49 $19.57 $15.50 Visits. 0611............. Mid Level Emergency V 2.66 $138.34 $36.47 $27.67 Visits. 0612............. High Level V 4.53 $235.60 $54.14 $47.12 Emergency Visits. 0620............. Critical Care...... S 10.25 $533.09 $150.55 $106.62 0656............. Transcatheter T 90.90 $4,927.70 ............ $985.54 Placement of Drug- Eluting Coronary Stents. 0657............. Placement of Tissue S 1.38 $71.77 ............ $14.35 Clips. 0658............. Percutaneous Breast T 5.57 $289.69 ............ $57.94 Biopsies. 0659............. Hyperbaric Oxygen.. S 3.12 $162.27 ............ $32.45 0660............. Level II X 1.65 $85.81 $31.75 $17.16 Otorhinolaryngolog ic Function Tests. 0661............. Level IV Pathology. X 3.46 $179.95 $98.97 $35.99 0662....
