Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology, 37170-37430 [06-5665]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 71, Number 125 (Thursday, June 29, 2006)]
[Notices]
[Pages 37170-37430]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 06-5665]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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

Federal Register / Vol. 71, No. 125 / Thursday, June 29, 2006 / 
Notices

[[Page 37170]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1512-PN]
RIN 0938-AO22


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

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

ACTION: Proposed notice.

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

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

ADDRESSES: In commenting, please refer to file code CMS-1512-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to https://www.cms.hhs.gov/eRulemaking. Click 
on the link ``Submit electronic comments on CMS regulations with an 
open comment period.'' (Attachments should be in Microsoft Word, 
WordPerfect, or Excel; however, we prefer Microsoft Word.)
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-1512-PN, P.O. Box 8014, Baltimore, MD 
21244-8014.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-1512-PN, Mail Stop C4-26-05, 7500 
Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses. If you 
intend to deliver your comments to the Baltimore address, please call 
telephone number (410) 786-7195 in advance to schedule your arrival 
with one of our staff members.
    Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, 
SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 
21244-1850.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Diane Milstead, (410) 786-3355, or 
Gaysha Brooks, (410) 786-9649

SUPPLEMENTARY INFORMATION: Submitting Comments: We welcome comments 
from the public on the proposed work RVUs set forth in Addendum C, the 
proposed practice expense methodology, and other issues set forth in 
this proposed notice to assist us in fully considering issues and 
developing policies. You can assist us by referencing the file code 
CMS-1512-PN and the specific ``issue identifier'' that precedes the 
section on which you choose to comment.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they are received: https://
www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on 
CMS Regulations'' on that Web site to view public comments.
    Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, at the headquarters of the Centers for 
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, 
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 
p.m. To schedule an appointment to view public comments, phone 1-800-
743-3951.
    Information on the PFS can be found on the CMS homepage. You can 
access this data by using the following directions:
    1. Go to the following Web site https://www.cms.hhs.gov/
PhysicianFeeSched/.
    2. Select ``Physician Fee Schedule Federal Regulation Notices.''
    To assist readers in referencing sections contained in this 
preamble, we are providing the following table of contents.

Table of Contents

I. Background
    A. Legislative History
    B. Published Changes to the Physician Fee Schedule
    C. Current Proposed Notice
    D. The 5-Year Review Process
II. Discussion of Comments and Decisions
    A. Review of Comments
    B. Discussion of Comments by Clinical Area
    1. Dermatology and Plastic Surgery
    2. Orthopedic Surgery
    3. Gynecology, Urology, Pain Medicine, and Neurosurgery
    4. Radiology, Pathology, and Other Miscellaneous Services
    5. Evaluation and Management Services
    6. Cardiothoracic Surgery
    7. General, Colorectal and Vascular Surgery
    8. Otolaryngology and Ophthalmology
    9. HCPAC Codes
    C. Other Issues Under the 5-Year Review
    1. Anesthesia Services
    2. Discussion of Post-Operative Visits Included in the Global 
Surgical Packages
    3. Codes Referred to CPT Editorial Panel from Five-Year Review 
of Work Relative Value Units
    4. Budget Neutrality

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    5. Effect on Practice Expense Inputs Stemming From the 5-Year 
Review
    6. Nature and Format of Comments on Work RVUs
    D. Resource-Based Practice Expense (PE) RVUs
    1. Current Methodology
    2. PE Proposed Methodology for CY 2006
    3. Modifications to PE Proposals
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
Addendum A: Explanation and Use of Addendum B
Addendum B: Relative Value Units and Related Information
Addendum C: Codes With Work RVUs Subject to Comment

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

AAD American Academy of Dermatology
AAN American Academy of Neurology
AANEM American Association of Neuromuscular and Electrodiagnostic 
Medicine
AAFP American Academy of Family Physicians
AAGP American Association for Geriatric Psychiatry
AAHCP American Academy of Home Care Physicians
AANS American Association of Neurological Surgeons
AAO American Academy of Ophthalmology
AAO-HNS American Academy of Otolaryngology-Head and Neck Surgery
AAOA American Academy of Otolaryngic Allergy
AAOS American Academy of Orthopaedic Surgeons
AAP American Academy of Pediatrics
AAPM American Academy of Pain Medicine
AAPMR American Academy of Physical Medicine and Rehabilitation
AATS American Association for Thoracic Surgery
ACC American College of Cardiology
ACG American College of Gastroenterology
ACNS American Clinical Neurophysiology Society
ACOG American College of Obstetricians and Gynecologists
ACR American College of Radiology
ACS American College of Surgeons
AFROC Association of Freestanding Radiation Oncology Centers
AGA American Gastroenterological Association
AGS American Geriatric Society
AK Actinic keratoses
AMA American Medical Association
AMDA American Medical Directors Association
AOA American Optometric Association
ASA American Society of Anesthesiologists
ASC Ambulatory surgical center
ASCRS American Society of Colon and Rectal Surgeons
ASGE American Society of Gastrointestinal Endoscopy
ASHA American Speech-Language-Hearing Association
ASPS American Society of Plastic Surgeons
ASSH American Society for Surgery of the Hand
ASTRO American Society for Therapeutic Radiology and Oncology
AUA American Urological Association
BBA 97 Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program] 
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
BNF Budget neutrality factor
CAPU Coalition for the Advancement of Prosthetic Urology
CF Conversion factor
CNS Congress of Neurological Surgeons
CPEP Clinical Practice Expert Panels
CPT Current Procedural Terminology
CY Calendar year
DRG Diagnosis-Related Group
E/M Evaluation and management
FR Federal Register
HCPAC Health Care Professionals Advisory Committee
HCPCS Healthcare Common Procedure Coding System
HHS Health and Human Services
ICU Intensive care unit
IDTF Independent diagnostic testing facility
IWPUT Intra-service work per unit of time
JCAAI Joint Council of Allergy, Asthma, and Immunology
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (Pub. L. 108-173)
MMSV Minimum multi-specialty visit
MPC [the RUC's] Multi-Specialty Points of Comparison
NCQDIS National Coalition of Quality Diagnostic Imaging Services
NPWP Non-physician work pool
NSQIP National Surgical Quality Improvement Program
PC Professional component
PE Practice Expense
PE/HR Practice expense per hour
PEAC Practice Expense Advisory Committee
PERC Practice Expense Review Committee
PFS Physician fee schedule
RFA Regulatory Flexibility Act
RIA Regulatory impact analysis
RN Registered nurse
RUC [AMA's Specialty Society] Relative [Value] Update Committee
RVU Relative value unit
SMS [AMA's] Socioeconomic Monitoring System
SNF Skilled nursing facility
STS Society of Thoracic Surgeons
SVS Society for Vascular Surgery
TC Technical component
VA [Department of] Veterans Affairs

I. Background

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

A. Legislative History

    Since January 1, 1992, Medicare has paid for physicians' services 
under section 1848 of the Social Security Act (the Act), ``Payment for 
Physicians' Services.'' Section 1848 of the Act contains three major 
elements: (1) A fee schedule for the payment of physicians' services; 
(2) a sustainable growth rate for the rates of increase in Medicare 
expenditures for physicians' services; and (3) limits on the amounts 
that nonparticipating physicians can charge beneficiaries. The Act 
requires that payments under the fee schedule be based on national 
uniform relative value units (RVUs) based on the resources used in 
furnishing a service. Section 1848(c) of the Act requires that national 
RVUs be established for physician work, practice expense (PE), and 
malpractice expense.
    Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments 
in RVUs may not cause total physician fee schedule (PFS) payments for 
the year to differ by more than $20 million from the amount that would 
have been paid had the adjustments not been made. If this tolerance is 
exceeded, we must make adjustments to the conversion factors (CFs) to 
preserve budget neutrality.

B. Published Changes to the Physician Fee Schedule

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

C. Current Proposed Notice

    This proposed notice sets forth proposed revisions to work RVUs 
affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of 
the Act requires that we review RVUs no less often than every 5 years. 
We implemented the PFS effective for services furnished beginning 
January 1, 1992. The first 5-Year Review of work was initiated in 
December 1994 and was effective for services furnished beginning 
January 1, 1997. The second 5-Year Review of work was initiated in 
November 1999 and was effective for services furnished beginning 
January 1 2002. The third 5-Year Review of work was initiated in 
November 2004.

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Revisions of physician work RVUs proposed in this proposed notice are 
subject to a 60-day public comment period. We will review public 
comments, make adjustments to our proposals in response to comments, as 
appropriate, and include revised values in our CY 2007 Physician Fee 
Schedule final rule with comment period, effective for services 
furnished beginning January 1, 2007.

D. The 5-Year Review Process

    We initiated the third 5-Year Review by soliciting public comments 
on potentially misvalued work RVUs for all services in the CY 2005 
Physician Fee Schedule final rule with comment period that appeared in 
the Federal Register on November 15, 2004 (69 FR 66370) and provided a 
60-day comment period.
    We received comments from approximately 35 specialty groups, 
organizations, and individuals involving over 500 Current Procedural 
Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) 
codes. As explained in the CY 2006 PFS final rule with comment period 
(70 FR 70283), we shared these comments with the American Medical 
Association (AMA) Specialty Society Relative Value Update Committee 
(RUC). The RUC was formed in November 1991 and grew out of a series of 
discussions between the AMA and major national medical specialty 
societies. The work of the RUC is supported by the RUC Advisory 
Committee, which is made up of representatives of 100 specialty 
societies in the AMA's House of Delegates.
    The RUC currently makes annual recommendations to us on RVUs for 
new and revised CPT codes. The RUC also provided recommendations on 
changes to the work RVUs for existing codes during the previous 5-Year 
Reviews. We believe that the RUC's participation was beneficial because 
the RUC is experienced in recommending RVUs for the codes that have 
been added to or revised by the CPT Editorial Panel since we 
implemented the PFS in 1992. By virtue of its multispecialty membership 
and consultation with specialty societies, the RUC involves the medical 
community in formulating its recommendations. For codes used primarily 
by nonphysician practitioners, the Health Care Professionals Advisory 
Committee (HCPAC), a companion to the RUC, has made recommendations to 
us.
    As we stated in the previous 5-Year Reviews, we retain the 
responsibility for analyzing any comments and recommendations received, 
developing the proposed rule, evaluating the comments on the proposed 
rule, and deciding whether and how to revise the work RVUs for any 
given service.
    After we sent the RUC the comments we received on potentially 
misvalued services, as well as a list of approximately 160 services 
that we had identified as being potentially misvalued, the RUC 
identified the specialty societies that expressed interest in making 
presentations concerning those services. To prepare for presentations 
to the RUC, most specialty societies compiled data using a standard 
survey instrument whereby respondents compared the surveyed service 
with similar ``reference'' services that have established, agreed upon 
work values. Respondents were asked to estimate: the work for the 
survey code; the time to perform the ``pre-'', ``intra-'', and ``post-
'' service activities; and the technical skill, risk, and judgment 
involved with performing the service. Post-service activities were 
broken down into hospital and office visits and were assigned an 
appropriate evaluation and management (E/M) code by the respondent. 
Each specialty society selected the physician sample that was surveyed. 
A minimum of 30 responses was required by the RUC for the survey to be 
considered adequate.
    For this 5-Year Review, the RUC permitted a specialty society to 
use a ``minisurvey'' for some codes if the number of codes a specialty 
society was reviewing was extremely high. These minisurveys required 
less information from the respondent, but were similar in design. In 
addition, the RUC approved the use of information from the National 
Surgical Quality Improvement Program (NSQIP) database and the Society 
of Thoracic Surgeons (STS) national database in the valuation of some 
services.
    The NSQIP was started by the Department of Veterans Affairs (VA) 
for quality improvement purposes in 1991 with 128 VA medical centers, 
but now includes a large volume of surgical procedures from non-VA 
medical centers as well. The total number of cases for VA and non-VA 
medical centers is greater than one million. The NSQIP database 
contains pre-, intra-, and post-operative data, including intra-service 
times and length of stay data.
    The STS National database is a voluntary reporting system for the 
collection of outcomes data related to thoracic surgical services. This 
database currently contains over two million patient records collected 
from more than 450 practices (from 1995 through 2004). Over 70 percent 
of the hospitals currently performing heart surgeries in the U.S. 
reportedly participate in this database.
    Some specialty societies used a ``building-block'' approach to 
validate the survey results for surgical services. In constructing the 
building blocks, a service is divided into pre-, intra-, and post-
service components. The pre-service component consists of all services 
furnished before the physician makes the skin incision (for example, 
pre-operative evaluation and scrubbing); the intra-service component 
consists of the ``skin-to-skin'' time; and the post-service component 
includes immediate post-surgery services and subsequent hospital and 
office visits. Each component (or building block) is then assigned work 
RVUs. Pre-service and intra-service work RVUs are based on time and the 
intensity of the activities, and post-service work is based on the 
specified E/M service for each post-operative visit. These three values 
are then summed to compute ``building-block'' work RVUs.
    The results of the surveys were reviewed and organized by the 
specialty societies and then presented to the RUC. The RUC used eight 
workgroups, comprised of RUC members, to evaluate a series of 
clinically related codes based on the survey results and additional 
discussion. The workgroups also evaluated the relative work (time and 
intensity) for each service compared to other services on the fee 
schedule. The workgroups submitted their recommendations to the full 
RUC, which then considered the workgroup reports and then sent the 
final RUC recommendations to us.

II. Discussion of Comments and Decisions

A. Review of Comments

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

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When appropriate and feasible, if we had concerns about the application 
of a particular methodology, we assessed whether the recommended work 
RVUs were appropriate by using alternative methodologies.
    In conducting our review of the RUC recommendations we considered 
whether: (1) The code was part of a completed survey process; (2) the 
methodology used by the specialty society followed the standard RUC 
process; (3) the survey respondents stated the work had or had not 
changed in the past 5 years; (4) databases (for example, STS, NSQIP, 
and Medicare diagnosis-related group (DRG)) were used in lieu of the 
standard RUC methodology or as a supplement to the standard 
methodology; and (5) the intra-service work per unit of time (IWPUT) 
calculation was used to determine work RVUs in lieu of the standard RUC 
process. (The IWPUT is derived from components of the ``building-
block'' approach, described above, and is used as a measure of service 
intensity.) Although CMS recognizes that the work values of codes may 
change over time, it is the responsibility of the specialty society to 
present compelling evidence that a code is misvalued.
    We have some concerns that many of the codes that were reviewed in 
the second 5-Year Review have been brought back again for further 
consideration. The main purpose of the 5-Year Review is to identify 
those services that need to be revalued because the work involved in 
performing the service has changed. Since there have been three 
opportunities for specialties to have services that are believed to be 
undervalued reviewed, we expect that, for the most part, only those 
services where there is compelling evidence of a change in the work 
will be considered for further review. However, because there has been 
little incentive for specialties to bring codes that may be overvalued 
for review, such services will still need to be identified for the next 
5-Year Review.
    Table 1, Five-Year Review of Work Relative Value Units, lists the 
codes reviewed during the 5-Year Review. This table includes the 
following information:
     CPT/HCPCS Code. This is the CPT or alphanumeric HCPCS code 
for a service.
     Modifier. A modifier -26 is shown if the work RVUs 
represent the professional component of the service.
     Description. This is an abbreviated version of the 
narrative description of the code.
     2005 Work RVU. The work RVUs that appeared in the CY 2005 
Physician Fee Schedule final rule with comment period are shown for 
each reviewed code.
     Requested Work RVU. This column identifies the work RVUs 
requested by the commenting specialty society or individual commenter. 
If we received more than one comment on a code, the code is listed more 
than once with the recommended RVUs. If the commenters did not 
recommend specific RVUs, we indicate this by ``N/A''. A ``WD'' 
(withdrawal) indicates that the commenter withdrew the request for 
review of a code and chose not to pursue review of the code under the 
5-Year Review and that no RUC recommendation was received.
     RUC Recommendation. This column identifies the work RVUs 
recommended by the RUC. ``CPT'' indicates that the RUC referred this 
code to the AMA CPT Editorial Panel for review and clarification and 
recommended maintaining the current work RVUs. An ``(a)'' indicates the 
commenting specialty society withdrew the proposal, and therefore, the 
RUC recommends maintaining the current work RVUs. A ``(b)'' in this 
column indicates there was no RUC recommendation.
    HCPAC Recommendation. This column identifies the work RVUs 
recommended by the HCPAC. An ``(a)'' indicates that the commenting 
specialty society withdrew the proposal; therefore, the HCPAC 
recommends maintaining the current work RVUs. A ``(b)'' in this column 
indicates there was no HCPAC recommendation.
     CMS Proposal. This column indicates whether we agreed with 
the RUC recommendation (``Agree''); we are instead proposing to 
maintain the present work RVUs (``Disagree''); we are proposing work 
RVUs higher than the RUC recommendation (``Disagree/+''); or we are 
proposing work RVUs that are less than the RUC recommendation 
(``Disagree/-''). Codes for which we did not accept the RUC 
recommendation are discussed in greater detail following Table 1. A 
``(c)'' in this column indicates that in the absence of a RUC/HCPAC 
recommendation we are proposing to maintain the present work RVUs.
     Proposed base work RVU. This column contains the 2007 
proposed work RVUs. The proposed work RVUs for surgical services with a 
10- or 90-day global period do not include the application of the RUC-
recommended work values for E/M services. However, the additional work 
value attributed to the increase for E/M services included as part of 
the global period is reflected in the work RVUs contained in Addenda B 
and C of this proposed rule. (Note: ** denotes codes that were deleted 
for 2006.)
    The following is a summary of our response to the RUC-recommended 
work RVUs for the 5-Year Review of work. We sent the RUC approximately 
709 codes to review. The RUC referred 136 codes to the CPT Editorial 
Panel for review and 151 codes were withdrawn by the specialty 
societies. We accepted the RUC's recommended work RVUs for 299 of the 
services reviewed and disagreed with the RUC's recommended work RVUs 
for 123 of the services reviewed. Of the 123 services for which we did 
not accept the RUC's recommended work RVUs, we increased the work RVUs 
for 3 services, recommended maintaining the current work RVUs for 48 
services, and decreased the work RVUs for 72 services. (Note: 12 CPT 
codes for nursing facility and rest home services that were referred to 
the AMA CPT Editorial Panel were deleted for 2007.)
    Additionally, the HCPAC reviewed a total of 7 services as part of 
the 5-Year Review. Of the 7 services reviewed by the HCPAC, we accepted 
the HCPAC recommendations for 1 service, recommended maintaining the 
current work RVU for 1 service, decreased the work RVUs for 4 services, 
and 1 code was withdrawn by the specialty society.
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B. Discussion of Comments by Clinical Area

1. Dermatology and Plastic Surgery
    [If you choose to comment on issues in this section, please include 
the caption ``DISCUSSION OF COMMENTS-DERMATOLOGY AND PLASTIC SURGERY'' 
at the beginning of your comments.]
a. Hidradenitis
    The American Society of Plastic Surgeons (ASPS) submitted the 
hidradenitis services (CPT codes 11450, 11451, 11462, 11463, 11470 and 
11471) as undervalued but, based on the very low response rate to the 
survey they conducted the ASPS withdrew these codes from the 5-Year 
Review.
b. Craniofacial Surgery
    The ASPS originally requested that 10 craniofacial reconstruction 
and fracture codes be reviewed. ASPS conducted a standard RUC survey 
for these services and, based on the low survey response rate, withdrew 
the following six CPT codes from the 5-Year Review: 21365, 21366, 
21432, 21435, 21436, and 21470. ASPS presented survey data for the 
remaining four CPT codes listed in Table 2 to the RUC indicating there 
is compelling evidence that these codes had been valued based on an 
incorrect assumption regarding the value of the bone graft portion of 
each service.

                                 Table 2
------------------------------------------------------------------------
              CPT code                            Descriptor
------------------------------------------------------------------------
21145..............................  Reconstruction midface, LeFort I;
                                      single piece, segment movement in
                                      any direction, requiring bone
                                      grafts (includes obtaining
                                      autografts).
21146..............................  Reconstruction midface, LeFort I;
                                      two pieces, segment movement in
                                      any direction, requiring bone
                                      grafts (includes obtaining
                                      autografts) (e.g., ungrafted
                                      unilateral alveolar cleft).
21147..............................  Reconstruction midface, LeFort I;
                                      three or more pieces, segment
                                      movement in any direction,
                                      requiring bone grafts (includes
                                      obtaining autografts) (e.g.,
                                      ungrafted bilateral alveolar cleft
                                      or multiple osteotomies).
21395..............................  Open treatment of orbital floor
                                      blowout fracture; periorbital
                                      approach with bone graft (includes
                                      obtaining graft).
------------------------------------------------------------------------

RUC Recommendations
    The RUC agreed that the appropriate increment of work for the bone 
graft should be 50 percent of CPT code 20902, Bone graft, any donor 
area; major or large (7.54 work RVUs x 50 percent = 3.77 work RVUs). 
The RUC recommended that this increment of 3.77 be used and added to 
the base code for each of these services.
    The RUC-recommended work RVUs for these CPT codes are as follows: 
21145 = 21.84 work RVUs; 21146 = 22.55 work RVUs, 21147 = 23.32 work 
RVUs; and 21395 = 13.88 work RVUs.
CMS Proposed Valuation
    We agree with the RUC recommendations for craniofacial surgery 
services.
c. Other Plastic Surgery Services
    ASPS initially submitted five additional services for review (see 
Table 3). However, the specialty society was unable to obtain an 
adequate survey response rate for these codes and withdrew them from 
the RUC review. In addition, the RUC recommended that CPT code 15831 
should be referred to the CPT Editorial Panel for review to capture the 
new population of patients using this service.

                                 Table 3
------------------------------------------------------------------------
              CPT code                            Descriptor
------------------------------------------------------------------------
11960..............................  Insertion of tissue expander(s) for
                                      other than breast, including
                                      subsequent expansion.
15831..............................  Excision, excessive skin and
                                      subcutaneous tissue (including
                                      lipectomy); abdomen
                                      (abdominoplasty).
19361..............................  Breast reconstruction with
                                      latissimus dorsi flap, with or
                                      without prosthetic implant.
43496..............................  Free jejunum transfer with
                                      microvascular anastomosis.
49906..............................  Free omental flap with
                                      microvascular anastomosis.
------------------------------------------------------------------------

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

                                 Table 4
------------------------------------------------------------------------
              CPT code                            Descriptor
------------------------------------------------------------------------
15100..............................  Split-thickness autograft, trunk,
                                      arms, legs; first 100 sq cm or
                                      less, or one percent of body area
                                      of infants and children (except
                                      15050).
15240..............................  Full thickness graft, free,
                                      including direct closure of donor
                                      site, forehead, cheeks, chin,
                                      mouth, neck, axillae, genitalia,
                                      hands, and/or feet; 20 sq cm or
                                      less.
15732..............................  Muscle, myocutaneous, or
                                      fasciocutaneous flap; head and
                                      neck (e.g., temporalis, masseter
                                      muscle, sternocleidomastoid,
                                      levator scapulae).
15734..............................  Muscle, myocutaneous, or
                                      fasciocutaneous flap; trunk.
------------------------------------------------------------------------


[[Page 37190]]

RUC Recommendations
    The RUC was convinced that the survey data validated the current 
valuation of CPT codes 15100, 15240, and 15734. The RUC recommended 
that the current work RVUs be maintained for these CPT codes as 
follows: 15100 = 9.04 work RVUs; 15240 = 9.03 work RVUs; and 15734 = 
17.76 work RVUs. The RUC reviewed and discussed the issue concerning 
the change in setting from inpatient to outpatient for CPT code 15732 
and determined that this code describes two disparate procedures; 
therefore, the RUC recommended that this CPT code be forwarded to the 
CPT Editorial Panel for review.
CMS Proposed Valuation
    We agree with the RUC recommendations for these plastic surgery 
services.
d. Other Dermatology Services
    The American Academy of Dermatology (AAD) and a pharmaceutical 
company submitted CPT code 96567, Photodynamic therapy by external 
application of light to destroy premalignant and/or malignant lesions 
of the skin and adjacent mucosa (e.g., lip) by activation of 
photosensitive drug(s), each phototherapy exposure session, for the 5-
Year Review but, subsequent to discussions with the RUC regarding the 
need for potential CPT revisions, withdrew the code from the 5-Year 
Review.
    We submitted the CPT codes for integumentary services in Table 5 
for review because they had never been previously reviewed by the RUC.

                                 Table 5
------------------------------------------------------------------------
              CPT code                            Descriptor
------------------------------------------------------------------------
11100..............................  Biopsy of skin, subcutaneous tissue
                                      and/or mucous membrane (including
                                      simple closure), unless otherwise
                                      listed; single lesion.
12052..............................  Layer closure of wounds of face,
                                      ears, eyelids, nose, lips and/or
                                      mucous membranes; 2.6 cm to 5.0
                                      cm.
13121..............................  Repair, complex, scalp, arms, and/
                                      or legs; 2.6 cm to 7.5 cm.
14040..............................  Adjacent tissue transfer or
                                      rearrangement, forehead, cheeks,
                                      chin, mouth, neck, axillae,
                                      genitalia, hands and/or feet;
                                      defect 10 sq cm or less.
14060..............................  Adjacent tissue transfer or
                                      rearrangement, eyelids, nose, ears
                                      and/or lips; defect 10 sq cm or
                                      less.
17003..............................  Destruction (e.g., laser surgery,
                                      electrosurgery, cryosurgery,
                                      chemosurgery, surgical
                                      curettement), all benign or
                                      premalignant lesions (e.g.,
                                      actinic keratoses) other than skin
                                      tags or cutaneous vascular
                                      proliferative lesions; second
                                      through 14 lesions, each (List
                                      separately in addition to code for
                                      first lesion).
17262..............................  Destruction, malignant lesion
                                      (e.g., laser surgery,
                                      electrosurgery, cryosurgery,
                                      chemosurgery, surgical
                                      curettement), trunk, arms or legs;
                                      lesion diameter 1.1 to 2.0 cm.
17281..............................  Destruction, malignant lesion
                                      (e.g., laser surgery,
                                      electrosurgery, cryosurgery,
                                      chemosurgery, surgical
                                      curettement), face, ears, eyelids,
                                      nose, lips, mucous membrane;
                                      lesion diameter 0.6 to 1.0 cm.
------------------------------------------------------------------------

    We requested that CPT code 17003 be reviewed because we believe 
that advances in technology have likely resulted in a modification to 
the physician work required to accomplish the procedure. In discussions 
at the RUC meeting, we noted that new Medicare coverage policies 
related to actinic keratoses (AK) have increased the reporting of this 
service to describe cryosurgical destruction of AK. Standard RUC 
surveys were conducted for all of these services.
RUC Recommendations
    Based on a review of the survey data, the RUC was convinced that 
the survey data validated the current valuation of the following 
services and recommended the work RVUs for these CPT codes be 
maintained as follows: 11100 = 0.81 work RVUs; 12052 = 2.77 work RVUs; 
13121 = 4.32 work RVUs; 14040 = 7.86 work RVUs; 14060 = 8.49 work RVUs; 
17262 = 1.58 work RVUs; and 17281 = 1.72 work RVUs.
    For CPT code 17003, the RUC reviewed previous and current survey 
data and agreed that the application of cryosurgery to each lesion 
requires no more than two minutes of physician time. Therefore, the RUC 
recommended a work RVU of 0.07 for CPT code 17003. The RUC determined 
that the revision to the work RVUs for CPT code 17003 created a rank 
order anomaly in this family of codes. In addition to referring codes 
in this family to the CPT Editorial Panel to clarify the code 
descriptors, the RUC in February 2006 also recommended a change to the 
work RVUs for CPT code 17004, Destruction (e.g., laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), all 
benign or premalignant lesions (e.g., actinic keratoses) other than 
skin tags or cutaneous vascular proliferative lesions; 15 or more 
lesions. This was based on the understanding that when rank order 
anomalies were identified, the specialty could bring these additional 
codes forward for consideration for re-evaluation under the 5-Year 
Review at the next RUC meeting (that is, February 2006).
    A standard RUC survey was conducted for this code and based on the 
survey responses, the specialty society recommended a change in the 
intra-service work descriptions to reflect a greater time based on 
their belief that the destruction of premalignant lesions requires more 
time than benign lesions. Thus, the intra-service period for CPT code 
17004 was changed to 20 minutes which is twice as much as the time 
associated with the destruction of benign lesion in CPT code 17111, 
Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 
chemosurgery, surgical curettement), of flat warts, molluscum 
contagiosum, or milia; 15 or more lesions, of 10 minutes. The RUC 
agreed to this time change and recommended work RVUs of 1.80 for CPT 
code 17004.
CMS Proposed Valuation
    We are in agreement with the RUC-recommended work RVUs for these 
services with the exception of CPT code 17004. For CPT code 17004, we 
believe that the work associated with benign and premalignant lesions 
is comparable and, therefore, the work RVUs for CPT code 17004 should 
be more similar to that of CPT code 17111, which is 0.92. Based on our 
proposed valuation of 17003 (the code used for 2-14 lesions), of 0.07 
work RVUs, the 14th lesion would equal 0.91 work RVUs (0.07 x 13 
lesions) plus 0.6 work RVUs for the initial lesion, that is, base code 
CPT code 17000, which is billed once in conjunction with 17003. We are 
proposing to value CPT code 17004, for 15 or more lesions, at 1.58 work 
RVUs by adding the 0.07 work RVU increment of 17003 and the 0.6 work 
RVUs for the base code, CPT code 17000, which is not billed in 
conjunction with CPT code 17004.

[[Page 37191]]

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

                                 Table 6
------------------------------------------------------------------------
              CPT code                            Descriptor
------------------------------------------------------------------------
17304..............................  Chemosurgery (Mohs micrographic
                                      technique), including removal of
                                      all gross tumor, surgical excision
                                      of tissue specimens, mapping,
                                      color coding of specimens,
                                      microscopic examination of
                                      specimens by the surgeon, and
                                      complete histopathologic
                                      preparation including the first
                                      routine stain (e.g., hematoxylin
                                      and eosin, toluidine blue); first
                                      stage, fresh tissue technique, up
                                      to 5 specimens.
17305..............................  Chemosurgery (Mohs micrographic
                                      technique), including removal of
                                      all gross tumor, surgical excision
                                      of tissue specimens, mapping,
                                      color coding of specimens,
                                      microscopic examination of
                                      specimens by the surgeon, and
                                      complete histopathologic
                                      preparation including the first
                                      routine stain (e.g., hematoxylin
                                      and eosin, toluidine blue); second
                                      stage, fixed or fresh tissue, up
                                      to 5 specimens).
------------------------------------------------------------------------

    The specialty society conducted surveys to collect data for these 
two codes. The workgroup then reviewed the history of these services, 
including the fact that the nomenclature for these services is not 
consistent with other integumentary coding conventions in CPT and that 
the RUC had previously indicated that the specialty society should work 
with the CPT Editorial Panel to redefine these services.
RUC Recommendations
    The RUC recommended that these CPT codes be referred to the CPT 
Editorial Panel.
CMS Proposed Valuation
    We will maintain the current valuation for these services pending 
the results of the review of the CPT Editorial Panel.
f. Excision of Lesions
    We submitted all of the excision of lesion codes for review, noting 
that these services should be surveyed and reviewed by the RUC (see 
Table 7--benign: CPT codes 11400 through 11446, and malignant: CPT 
codes 11600 through 11646).
    The work RVUs for the codes predominantly performed by the surgical 
specialties (CPT codes representing services to excise larger lesions) 
were all valued, with the exception of two CPT codes, by acceptable RUC 
surveys. However, there were no acceptable RUC surveys for the 18 
services predominantly performed by the dermatologists (CPT codes 
representing services to excise smaller lesions) due to incomplete 
surveys and low response rates.
RUC Recommendations
    The RUC agreed that the primary difference in the work between the 
family of codes for excision of benign lesions versus those codes for 
excision of malignant lesions (see Table 7) is in the pre-evaluation 
time (that is, additional planning, and discussions with the patient), 
the intensity of the intra-service time, and the level of post-
operative visit.
    The workgroup used the RUC surveys to determine the work RVUs for 
those services performed by the surgeons and then applied the building-
block approach using the IWPUT values of the codes primarily performed 
by the surgical specialties to derive IWPUT values and corresponding 
work RVUs for the CPT codes primarily performed by dermatology. (The 
IWPUT is derived by dividing the intra-service work by the intra-
service time, and is used to measure the relative intensity of the work 
between services.)
    As a result of the application of the building-block methodology to 
the codes without RUC acceptable surveys, the RUC recommended that 24 
codes retain their current work RVUs, 5 codes have decreased work RVUs, 
and 7 codes have increased work RVUs. The specific RUC recommendations 
for these CPT codes are presented in Table 7.

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[GRAPHIC] [TIFF OMITTED] TN29JN06.038

BILLING CODE 4120-01-C
CMS Proposed Valuation
    We are in agreement with the RUC recommendations for the excision 
of lesions services.
2. Orthopedic Surgery
    [If you choose to comment on issues in this section, please include 
the caption ``DISCUSSION OF COMMENTS--ORTHOPEDIC SURGERY'' at the 
beginning of your comments.]
a. Tumor Procedures
    The American Academy of Orthopaedic Surgeons (AAOS) submitted CPT 
codes in the following three families of tumor procedures for review. 
(See Table 8, Table 9, and Table 10.)

          Table 8.--Family 1--Excision of Deep Soft Tissue Mass
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
21556..............................  Excision tumor, soft tissue of neck
                                      or thorax; deep, subfascial,
                                      intramuscular
23076..............................  Excision, soft tissue tumor,
                                      shoulder area; deep, subfascial,
                                      or intramuscular.
24076..............................  Excision, tumor, soft tissue of
                                      upper arm or elbow area; deep
                                      (subfascial or intramuscular).
25076..............................  Excision, tumor, soft tissue of
                                      forearm and/or wrist area; deep
                                      (subfascial or intramuscular).
27048..............................  Excision, tumor, pelvis and hip
                                      area; deep, subfascial,
                                      intramuscular.
27328..............................  Excision, tumor, thigh or knee
                                      area, deep, subfascial, or
                                      intramuscular.
27619..............................  Excision, tumor, leg or ankle area;
                                      deep (subfascial or
                                      intramuscular).
28045..............................  Excision, tumor, foot; deep,
                                      subfascial, intramuscular.
------------------------------------------------------------------------


      Table 9.--Family 2--Radical Resection of Soft Tissue Sarcoma
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
24077..............................  Radical resection of tumor (e.g.,
                                      malignant neoplasm), soft tissue
                                      of upper arm or elbow area.
25077..............................  Radical resection of tumor (e.g.,
                                      malignant neoplasm), soft tissue
                                      of forearm and/or wrist area.
27049..............................  Radical resection of tumor, soft
                                      tissue of pelvis and hip area
                                      (e.g., malignant neoplasm).
27329..............................  Radical resection of tumor (e.g.,
                                      malignant neoplasm), soft tissue
                                      of thigh or knee area.
27615..............................  Radical resection of tumor (e.g.,
                                      malignant neoplasm), soft tissue
                                      of leg or ankle area).
------------------------------------------------------------------------


         Table 10.--Family 3--Radical Resection of Bone Sarcoma
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
21935..............................  Radical resection of tumor (e.g.,
                                      malignant neoplasm), soft tissue
                                      of back or flank.
23200..............................  Radical resection for tumor;
                                      clavicle.
23210..............................  Radical resection for tumor;
                                      scapula.
23220..............................  Radical resection of bone tumor,
                                      proximal humerus.
24150..............................  Radical resection for tumor, shaft
                                      or distal humerus.
24151..............................  Radical resection for tumor, shaft
                                      or distal humerus; with autograft
                                      (includes obtaining graft).

[[Page 37196]]

 
24152..............................  Radical resection for tumor, radial
                                      head or neck.
24153..............................  Radical resection for tumor, radial
                                      head or neck; with autograft
                                      (includes obtaining graft).
25170..............................  Radical resection for tumor, radius
                                      or ulna.
27076..............................  Radical resection of tumor or
                                      infection; ilium, including
                                      acetabulum, both pubic rami, or
                                      ischium and acetabulum.
27078..............................  Radical resection of tumor or
                                      infection; ischial tuberosity and
                                      greater trochanter of femur.
27365..............................  Radical resection of tumor, bone,
                                      femur or knee.
27645..............................  Radical resection of tumor, bone;
                                      tibia.
27646..............................  Radical resection of tumor, bone;
                                      fibula.
27647..............................  Radical resection of tumor; talus
                                      or calcaneus.
------------------------------------------------------------------------

    The specialty subsequently withdrew CPT codes 21935, 24151, and 
24153 from the 5-Year Review. A minisurvey methodology was used for all 
three families of codes.
RUC Recommendations
    Based on a review of the survey results for the codes in Families 1 
and 2, the RUC recommended referring these codes to the CPT Editorial 
Panel for clarification. The RUC indicated that the survey data from 
the specialty society described a hospitalized patient as the typical 
patient. However, our data indicates that the typical patient is not 
hospitalized and that this inconsistency could be the result of 
ambiguous CPT descriptors.
    For the services in Family 3, the RUC discussion focused on the 
issue of whether there may also be different patient populations 
covered by each of these codes.
    The RUC also recommended referring the codes in Family 3 to the CPT 
Editorial Panel for clarification.
CMS Proposed Valuation
    We will maintain the current valuation for these services pending 
the results of the review by the CPT Editorial Panel.
b. Trauma Procedures
    The AAOS submitted the following trauma procedure codes for review 
(see Table 11). Standard RUC surveys of these services were conducted.

                                Table 11
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
20680..............................  Removal of implant; deep (e.g.,
                                      buried wire, pin, screw, metal
                                      band, nail, rod or plate).
20692..............................  Application of a multiplane (pins
                                      or wires in more than one plane),
                                      unilateral, external fixation
                                      system (e.g., Ilizarov, Monticelli
                                      type).
24430..............................  Repair of nonunion or malunion,
                                      humerus; without graft (e.g.,
                                      compression technique).
27465..............................  Osteoplasty, femur; shortening
                                      (excluding 64876).
27470..............................  Repair, nonunion or malunion,
                                      femur, distal to head and neck;
                                      without graft (e.g., compression
                                      technique).
27472..............................  Repair, nonunion or malunion,
                                      femur, distal to head and neck;
                                      with iliac or other autogeneous
                                      bone graft (includes obtaining
                                      graft).
27709..............................  Osteotomy; tibia and fibula.
27720..............................  Repair of nonunion or malunion,
                                      tibia; without graft, (e.g.,
                                      compression technique).
------------------------------------------------------------------------

RUC Recommendations
    Based on a review of the compelling evidence, the RUC made the 
following recommendations.
    For CPT code 20680, the RUC agreed that the intra-operative time 
for this code is misvalued based on the significant changes in 
physician work for the removal of deep implants due to changes in 
technology. Using the survey's 25th percentile value for the work RVUs 
along with the 25th percentile value for intra-service time, and 
adjusting for the fact that this procedure is typically performed in an 
outpatient setting, the RUC recommended a work RVU of 5.86 for this 
service.
    For CPT code 24430, the workgroup did not believe that the current 
work value for CPT code 24430 accounts for all the work typically 
involved with this service. This is based on the survey's physician 
time and visit data and a comparison to CPT code 24515, Open treatment 
of humeral shaft fracture with plate/screws, with or without cerclage, 
which is a less complex procedure than CPT code 24430. The RUC 
recommended a work RVU of 14.00 and an intra-service time of 102 
minutes for this service, which was the 25th percentile for work of the 
survey data.
    Based on a comparison to CPT code 27506, Open treatment of femoral 
shaft fracture, with or without external fixation, with insertion of 
intramedullary implant, with or without and/or locking screws, the 
workgroup determined that the current work RVUs for CPT code 27465, do 
not fully account for the work typically involved in shortening the 
femur because it typically includes the insertion of an intermedullary 
nail. However, the workgroup believed that CPT code 27465 should be 
valued lower than the reference service code, CPT code 27454, 
Osteotomy, multiple, with realignment on intramedullary rod, femoral 
shaft (e.g., Sofield type procedure), which has a work RVU of 17.53, 
and is a greater intensity procedure. The RUC-recommended work RVU for 
CPT code 27645 was 17.50, based on the median of the survey data.
    Based on a review of the survey data, the workgroup did not believe 
that there was compelling evidence to change the work RVU for CPT code 
27470. Therefore, the RUC recommended that the current work RVU of 
16.05 be maintained for this service. However, the workgroup also 
recommended using the new survey times as they believed the Harvard 
times from the original Harvard relative value study, which was used to 
establish RVUs at the outset of the Medicare PFS, are inflated.
    For CPT code 27709, Osteotomy; tibia and fibula, the RUC reviewed 
the survey time and compared this service to CPT

[[Page 37197]]

code 27705, Osteomy, tibia, which has a work RVU of 10.36. The RUC 
recommended a work RVU of 16.50 for CPT code 27709 which would place 
the code in proper rank order with CPT code 27705.
    The RUC recommended the referral of CPT codes 20692, 27472, and 
27720 to the CPT Editorial Panel to clarify whether these 90-day global 
period codes should be exempt from modifier 51. (Modifier 51 denotes 
that a multiple procedure was performed.) The RUC was concerned that 
attempting to value these codes would lead to double counting some of 
the work.
    The RUC-recommended valuation for these CPT codes was as follows: 
20680 = 5.86 work RVUs; 24430 = 14.00 work RVUs; 27465 = 17.50 work 
RVUs; 27470 = 16.05 work RVUs; and 27709 = 16.50 work RVUs.
CMS Proposed Valuation
    We are in agreement with the RUC-recommended work values for these 
trauma services.
c. Total Elbow and General Procedures
    AAOS submitted the following elbow athroplasty service for review 
(see Table 12).

                                Table 12
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
24363..............................  Arthroplasty, elbow; with distal
                                      humerus and proximal ulnar
                                      prosthetic replacement (e.g.,
                                      total elbow).
------------------------------------------------------------------------

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

                                Table 13
------------------------------------------------------------------------
              CPT code                           Description
------------------------------------------------------------------------
20600..............................  Arthrocentesis, aspiration and/or
                                      injection; small joint or bursa
                                      (e.g., fingers, toes).
20610..............................  Arthrocentesis, aspiration and/or
                                      injection; major joint or bursa
                                      (e.g., shoulder, hip, knee joint,
                                      subacromial bursa).
29075..............................  Application, cast; elbow to finger
                                      (short arm).
------------------------------------------------------------------------

    Standard RUC surveys of these services were conducted.
RUC Recommendations
    The RUC recommended maintaining the current work RVUs for CPT codes 
20600, 20610, and 29075 because of the low response rate for the 
surveys and the lack of compelling evidence for changing the work 
value.
    Based on a review of the survey data and information provided by 
the presenting specialty societies, AAOS and the American Society of 
Shoulder and Elbow Surgeons, the RUC concluded that the CPT code 24363 
should be valued the same as CPT code 23472, Arthroplasty, glenohumeral 
joint; total shoulder (glenoid and proximal humeral replacement (e.g., 
total shoulder), and recommended a work RVU of 21.07 to maintain 
appropriate rank-order alignment with this family of codes. The RUC-
recommended valuation for these CPT codes was as follows: 20600 = 0.66 
work RVUs; 20610 = 0.79 work RVUs; 24363 = 21.07 work RVUs; and 29075 = 
0.77 work RVUs.
CMS Proposed Valuation
    We agree with the RUC-recommended work RVUs for these elbow and 
general procedure services.
d. Wrist,