Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule, 32410-32813 [2011-13052]

Agencies

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

[Federal Register Volume 76, Number 108 (Monday, June 6, 2011)]
[Proposed Rules]
[Pages 32410-32813]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-13052]



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Vol. 76

Monday,

No. 108

June 6, 2011

Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Part 414



Medicare Program; Five-Year Review of Work Relative Value Units Under 
the Physician Fee Schedule; Proposed Rule

Federal Register / Vol. 76 , No. 108 / Monday, June 6, 2011 / 
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 414

[CMS-1582-PN]
RIN 0938-AQ87


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

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) and corresponding changes to the practice 
expense and malpractice RVUs affecting payment for physicians' 
services. The statute requires that we review RVUs no less often than 
every 5 years. This is our Fourth Five-Year 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, 2012. These revisions reflect changes in 
medical practice and coding that affect the relative amount of 
physician work required to perform each service as required by the 
statute. The Fourth Five-Year Review of Work includes services that 
were submitted through public comment and by the Medicare contractor 
medical directors (CMDs), as well as a number of potentially misvalued 
codes identified by CMS (that is, Harvard valued codes and codes with 
Site-of-Service anomalies).

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on July 25, 2011.

ADDRESSES: In commenting, please refer to file code CMS-1582-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed).
    1. Electronically. You may submit electronic comments on this 
regulation to https://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address only: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-1582-PN, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    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 to 
the following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1582-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 before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey 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.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    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: Erin Smith, (410) 786-4497, for issues 
related to physician payment and for all other issues not identified 
below.
    Elizabeth Truong, (410) 786-6005, or Sara Vitolo, (410) 786-5714, 
for issues related to work RVUs.
    Ryan Howe, (410) 786-3355, for issues related to PE RVUs.

SUPPLEMENTARY INFORMATION: 
    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 have been received: https://regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will be also 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.

Table of Contents

I. Background
    A. History
    B. Physician Fee Schedule Rulemaking
    C. The Five-Year Review Process
    1. Identification of CPT Codes for Review
    2. Background on American Medical Association/Specialty Society 
Relative Value Update Committee (AMA RUC) Recommendations AMA RUC
    3. Five-Year Review of Work Process
II. CMS Review of Five-Year Review Codes
    A. CMS Analytical Approach
    B. Summary of Proposed Work RVUs for Five-Year Review Codes
    C. Code-Specific Discussions of Proposed Alternative Work RVUs
    1. Drainage of Hematoma
    2. Wound Repair
    3. Skin Grafts
    4. Destruction of Skin Lesions
    5. Partial Mastectomy
    6. Percutaneous Vertebroplasty/Kyphoplasty
    7. Closed Treatment of Distal Radial Fracture
    8. Orthopaedic Surgery--Thigh/Knee
    9. Treatment of Ankle Fracture
    10. Orthopaedic Surgery/Podiatry
    11. Application of Cast and Strapping
    12. Cardiothoracic Surgery
    13. Vascular Surgery
    14. Excise Parotid Gland/Lesion
    15. Endoscopic Cholangiopancreatography
    16. Sigmoidoscopy
    17. Laparoscopic Cholecystectomy
    18. Hernia Repair
    19. Laparoscopic Hernia Repair
    20. Urologic Procedures
    21. Removal of Thyroid/Parathyroid
    22. Implant Neuroelectrodes
    23. Injection of Anesthetic Agent
    24. Gastric Emptying Study
    25. Nasopharyngoscopy
    26. Cardiopulmonary Resuscitation
    27. Osteopathic Manipulative Treatment
    28. Observation Care
    D. HCPAC-Recommended Work RVUs--Excision of Nail
    E. CPT Codes Identified Through the Five-Year Review Process, 
But Not Reviewed by CMS
    1. CPT Codes Referred to CPT Editorial Board
    2. CPT Codes Withdrawn From the Five-Year Review

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    3. CPT Codes That Are Interim Final for CY 2011
    4. CPT Codes for Preventive Medicine Services
    F. Resource-Based Practice Expense RVUs
    1. Overview
    2. Practice Expense Methodology
    a. Direct Practice Expense
    b. Indirect Practice Expense per Hour Data
    c. Allocation of Practice Expense to Services
    d. Facility and Nonfacility Costs
    e. Services With Technical Components and Professional 
Components
    f. Practice Expense RVU Methodology
    3. Practice Expense RVUs for Codes Included in the Five-Year 
Review
    a. Changes to Direct Practice Expense Inputs
    (1) Changes in Intra-Service Physician Time in the Nonfacility 
Setting
    (2) Changes in Hospital Discharge Management Services in the 
Facility Setting
    (3) Changes in the Number or Level of Postoperative Office 
Visits in the Global Period
    b. Changes in Components of the Indirect Practice Expense 
Methodology
    (1) Work RVUs, Direct PE RVUs, and Clinical Labor PE RVUs
    (2) Physician Time
    G. Malpractice RVUs
III. Budget Neutrality
IV. Collection of Information Requirements
V. Regulatory Impact Analysis
    A. Overall Impact
    B. Anticipated Effects: Impact on Beneficiaries
    C. Alternatives Considered
    D. Accounting Statement and Table
    E. Conclusion
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] Veteran Affairs

CPT (Current Procedural Terminology) Copyright Notice

    Throughout this proposed rule, we use CPT codes and descriptions to 
refer to a variety of services. We note that CPT codes and descriptions 
are copyright 2010 American Medical Association. All Rights Reserved. 
CPT is a registered trademark of the American Medical Association 
(AMA). Applicable FARS/DFARS apply.

I. Background

A. 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. In order to establish physician work, PE, and 
malpractice expense RVUs, section 1848(c)(2)(K)(iii) of the Act (as 
added by section 3134 of the Patient Protection and Affordable Care Act 
(Pub. L. 111-148) (hereinafter the ``Affordable Care Act'') also 
specifies that the Secretary may use existing processes to receive 
recommendations on the review and appropriate adjustment of potentially 
misvalued services. Section 1848(c)(2)(B)(i) of the Act requires that 
we review RVUs no less often than every 5 years.
    The statute also specifies a budget neutrality requirement. 
Specifically,

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section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or 
decreases in RVUs may not cause the amount of expenditures under Part B 
for the year to differ more than $20 million from what it would have 
been in the absence of these changes. If this threshold is exceeded, we 
are required to make adjustments to preserve budget neutrality.

B. Physician Fee Schedule Rulemaking

    On an annual basis, we publish regulations relating to updates to 
the RVUs and revisions to the payment policies under the PFS. Most 
recently, in the calendar year (CY) 2011 PFS final rule with comment 
period that was published in the Federal Register on November 29, 2010 
(75 FR 73170) (hereinafter referred to as the CY 2011 PFS final rule 
with comment period), we finalized most of the CY 2010 interim 
physician work, PE, and malpractice RVUs; issued new interim work, PE, 
and malpractice RVUs for new and revised codes for CY 2011; and 
finalized several other payment policies related to the PFS. In the 
January 11, 2011 Federal Register (76 FR 1670), we published a 
correction notice that identified and corrected a number of technical 
and typographical errors in the CY 2011 PFS final rule with comment 
period. The provisions of the correction notice were effective January 
1, 2010.
    As noted previously, 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 Five-Year Review of Work was initiated in December 1994, and was 
effective for services furnished beginning January 1, 1997. The Second 
Five-Year Review of Work was initiated in November 1999, and was 
effective for services furnished beginning January 1, 2002. The Third 
Five-Year Review of Work was initiated in November 2004, and was 
effective for services furnished beginning January 1, 2007. The Fourth 
Five-Year Review of Work, the subject of this proposed notice, was 
initiated in November 2009 and will be effective for services furnished 
beginning January 1, 2012.
    This proposed notice describes the Fourth Five-Year Review of Work 
and sets forth proposed revisions to work RVUs resulting from the 
latest Review. This proposed notice also sets forth corresponding 
proposed changes to PE and malpractice RVUs affecting payment for 
physicians' services. Proposed revisions of physician work RVUs in this 
proposed notice and corresponding proposed changes to the PE and 
malpractice RVUs 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 final values in the CY 2012 
PFS final rule with comment period, effective for services furnished 
beginning January 1, 2012.
    We note that with each PFS rule, we provide a summary table 
(``Addendum B'') of physician work, PE, and malpractice RVUs by HCPCS 
code for all services under the PFS. For this proposed notice, to 
create Addendum B, we retained the current CY 2011 RVUs for most codes 
and displayed new RVUs for only those codes involved in the Fourth 
Five-Year Review of Work. PE RVUs for these Five-Year Review codes were 
calculated using CY 2009 Medicare PFS utilization data in order to 
maintain consistency with the current CY 2011 RVUs displayed for all 
other services.
    We note that the Addendum B that will appear in the upcoming CY 
2012 PFS proposed rule, where the annual updates to the RVUs and 
revisions to the payment policies under the PFS are customarily 
proposed, will include PE RVUs recalculated using the most recently 
available Medicare PFS utilization data and reflect other changes that 
would result from proposed revisions to PFS payment policies for CY 
2012 that also would be effective beginning January 1, 2012.

C. The Five-Year Review Process

1. Identification of CPT Codes for Review
    We initiated the Fourth Five-Year Review of Work by soliciting 
public comments in the CY 2010 PFS final rule with comment period that 
was published in the Federal Register on November 25, 2009 (74 FR 61738 
and 61941) on potentially misvalued codes for all services. In response 
to our solicitation of potentially misvalued codes, we received 
comments from approximately 16 specialty groups, organizations, and 
individuals involving 113 Current Procedural Terminology (CPT) codes. 
Ten additional codes were submitted by the Medicare contractor medical 
directors (CMDs). Furthermore, CMS identified 96 services that we 
believed should be reviewed as part of the Fourth Five-Year Review of 
Work. These services fall within the two categories described in the CY 
2010 PFS final rule with comment period: (1) Codes that were not 
previously reviewed by the AMA RUC, specifically, Harvard-valued codes 
with an annual utilization of > 30,000 services, and (2) codes that are 
valued as being performed in the inpatient setting, but that are now 
performed predominantly on an outpatient basis (codes with Site-of-
Service anomalies). For Site-of-Service anomaly codes, we also applied 
additional selection criteria. Specifically, the codes we selected for 
the Fourth Five-Year Review of Work contained at least one inpatient 
hospital visit in their value and the most recently available Medicare 
PFS claims data at that time showed annual allowed charges of greater 
than $1 million.
    The following tables list the codes identified for the Fourth Five-
Year Review of Work.
BILLING CODE P

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BILLING CODE P
2. Background on American Medical Association Specialty Society 
Relative Value Update Committee (AMA RUC) Recommendations
    Section 1848(c)(2)(K)(iii) of the Act (as added by section 3134 of 
the Affordable Care Act) specifies that the Secretary may use existing 
processes to receive recommendations on the review and appropriate 
adjustment of potentially misvalued services. In accordance with 
section 1848(c)(2)(K)(iii) of the Act, we develop and propose 
appropriate adjustments to the RVUs, taking into account the 
recommendations provided by the AMA RUC, the Medicare Payment Advisory 
Commission (MedPAC), and others. To respond to concerns expressed by 
MedPAC, the Congress, and other stakeholders regarding the accuracy of 
values for services under the PFS, the AMA RUC has used an annual 
process to systematically identify, review, and provide CMS with 
recommendations for revised work values for many existing potentially 
misvalued services. In addition to providing recommendations to CMS for 
work RVUs, the AMA RUC also reviews direct PE (clinical labor, medical 
supplies, and medical equipment) for individual services and examines 
the many broad methodological issues relating to the development of PE 
RVUs.
    For many years, the AMA RUC has provided CMS with recommendations 
on the appropriate relative values for PFS services. The AMA RUC's 
recommendations on physician work RVUs have resulted in significant 
refinements in physician work RVUs over the years. In recent years CMS 
and the AMA RUC have taken increasingly significant steps to address 
potentially misvalued codes. As MedPAC noted in its March 2009 Report 
to Congress, in the intervening years since MedPAC made the initial 
recommendations, ``CMS and the AMA RUC have taken several steps to 
improve the review process.'' In addition to the Five-Year Reviews of 
Work, over the past several years CMS and the AMA RUC have identified 
and reviewed a number of potentially misvalued codes on an annual basis 
based on various identification screens for codes at risk for being 
misvalued, such as codes with high growth rates, codes that are 
frequently billed together in one encounter, and codes that are valued 
as inpatient services but that are now predominantly performed as 
outpatient services. This annual review of work RVUs and direct PE 
inputs for potentially misvalued codes was further bolstered by the 
Affordable Care Act mandate to examine potentially misvalued codes, 
with an emphasis on the following categories specified in section 
1848(c)(2)(K)(ii) (as added by section 3134 of the Affordable Care 
Act):
     Codes and families of codes for which there has been the 
fastest growth.
     Codes or families of codes that have experienced 
substantial changes in practice expenses.
     Codes that are recently established for new technologies 
or services.
     Multiple codes that are frequently billed in conjunction 
with furnishing a single service.
     Codes with low relative values, particularly those that 
are often billed multiple times for a single treatment.
     Codes which have not been subject to review since the 
implementation of the RBRVS (the `Harvard valued codes').
     Other codes determined to be appropriate by the Secretary. 
(For example, codes for which there have been shifts in the Site-of-
Service (Site-of-Service anomalies), as well as codes that qualify as 
``23-hour stay'' outpatient services.)
    As a result of the annual potentially misvalued code review, CMS 
has reviewed over 700 codes for work and PE RVU changes outside of the 
comprehensive Five-Year Review process over the past several years and 
adopted appropriate work RVUs and direct PE inputs for these services 
in the context of contemporary medical practice.
    This Fourth Five-Year Review of Work advances the progress of our 
initiative to examine potentially misvalued codes by identifying and 
reviewing additional codes for CY 2012 in several of the categories 
specified in the Affordable Care Act, including a number of Harvard-
valued codes. As

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noted previously, we typically discuss the potentially misvalued codes 
initiative in the annual PFS proposed and final rules (for CY 2011, at 
75 FR 40065 through 40082 and 75 FR 73215 through 73216, respectively). 
For example, we provided a detailed discussion of the prior reviews of 
potentially misvalued codes in the CY 2011 PFS final rule with comment 
period (75 FR 73215 through 73216). Furthermore, in addition to the 
proposals in this Five-Year Review of Work proposed notice, we plan to 
continue our work examining potentially misvalued codes for CY 2012 in 
the areas specified by the Affordable Care Act and others identified by 
the Secretary, consistent with the new legislative mandate on this 
issue. We will provide a comprehensive update regarding our progress to 
date in evaluating and revising the values for potentially misvalued 
codes, and discuss our priorities and future plans to ensure the 
accuracy of the relative values for all services paid under the PFS in 
the forthcoming CY 2012 PFS proposed rule.
    We greatly appreciate the considerable sustained efforts made by 
all members and staff of the AMA RUC to date, and we look forward to 
continuing our collaborative work with the AMA RUC toward our mutual 
goal of ensuring that CPT codes are appropriately valued under the PFS.
    For codes used primarily by nonphysician practitioners, the Health 
Care Professionals Advisory Committee (HCPAC), a deliberative body of 
nonphysician practitioners that also convenes during the AMA RUC 
meeting, submits recommendations directly to CMS. The HCPAC represents 
physician assistants, chiropractors, nurses, occupational therapists, 
optometrists, physical therapists, podiatrists, psychologists, 
audiologists, speech pathologists, social workers, and registered 
dieticians. We greatly appreciate the efforts of the HCPAC as well.
3. AMA RUC Five-Year Review of Work Process
    After compiling the list of potentially misvalued codes to be 
reviewed in the Fourth Five-Year Review of Work (Tables 1 through 4), 
we submitted the list to the AMA RUC.
    According to the AMA RUC's Five-Year Review timetable, upon receipt 
of the list of codes from CMS, the AMA RUC sent Level of Interest (LOI) 
forms to all specialty societies and the HCPAC so that the Five-Year 
Review codes could be reviewed initially by the appropriate specialty 
societies. To prepare for presentations of the codes to the AMA RUC, 
most specialty societies compiled data using a standard survey 
instrument whereby respondents compared the surveyed service with 
similar ``reference'' services for which there generally are well-
established work values. Respondents were asked to estimate: the work 
RVU 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 respondents for 
the typical service. Each specialty society was responsible for 
selecting the physician sample size to be surveyed. In general, a 
minimum of 30 responses was required by the AMA RUC for the survey to 
be considered adequate. It is our understanding that the AMA RUC is 
currently reviewing its survey methodologies in order to improve the 
survey instrument's ability to provide valid and reliable data.
    As part of the AMA RUC's process, the specialty societies also 
provided the AMA RUC with a work RVU recommendation for each code under 
review. The AMA RUC met to hear the presentations from the specialty 
societies for each code, deliberate as a group, and vote on the work 
RVU, physician times, PE direct inputs (if applicable), and other 
aspects pertaining to the valuation of a code. The AMA RUC then sent 
its recommendations to CMS. As we have stated previously in conducting 
Five-Year Reviews, we retain the responsibility for analyzing any 
comments and recommendations received from the AMA RUC, developing the 
proposed notice, evaluating the comments on the proposed notice, and 
deciding whether and how to revise the work RVUs for any given service.

II. CMS Review of Five-Year Review Codes

A. CMS Analytical Approach

    We conducted a clinical review of each code and reviewed the AMA 
RUC recommendations for work RVU, time to perform the ``pre-'', 
``intra-'', and ``post-'' service activities, as well as other 
components of the service which contribute to the value. Our clinical 
review generally includes, but is not limited to, a review of 
information provided by the AMA RUC, medical literature, public 
comments, and comparative databases, as well as a comparison with other 
codes within the Medicare PFS, consultation with other physicians and 
healthcare care professionals within CMS and the Federal Government, 
and the clinical experience of the physicians on the clinical team. We 
also assessed the methodology and data used to develop the 
recommendations and the rationale for the recommendations. As we noted 
in the CY 2011 PFS final rule with comment period (75 FR 73328 through 
73329), the AMA RUC uses a variety of methodologies and approaches to 
assign work RVUs, including building block, survey data, crosswalk to 
key reference or similar codes, and magnitude estimation. The resource-
based relative value system (RBRVS) has incorporated into it cross-
specialty and cross-organ system relativity. This RBRVS requires 
assessment of relative value and takes into account the clinical 
intensity and time required to perform a service. In selecting which 
methodological approach will best determine the appropriate value for a 
service we consider the current physician work and time values, AMA RUC 
recommended physician work and time values, and specialty society 
physician work and time values, as well as the intensity of the 
service, all relative to other services. In general, if we had concerns 
regarding the AMA RUC's application of a particular methodology for a 
code, we assessed whether the recommended work RVUs were appropriate by 
using alternative methodologies. For a full discussion of our views and 
concerns regarding the various methodologies, we refer readers to the 
CY 2011 PFS final rule with comment period (75 FR 73328 through 73329). 
During our clinical review to assess the appropriate values for the 
codes included in the Fourth Five-Year Review, several recurring 
scenarios emerged. We developed systematic approaches to address two 
particular areas of concern.
    The first area of concern pertains to codes with Site-of-Service 
anomalies. These are codes that were originally valued as inpatient 
services but current Medicare PFS claims data show they are furnished 
predominantly as outpatient services. We noted that for nearly all of 
the codes with Site-of-Service anomalies, the accompanying survey data 
suggest they are ``23 hour stay'' outpatient services. We discussed in 
the CY 2011 PFS final rule with comment period (75 FR 73226 through 
73227) the ``23 hour stay service,'' which is a term of art describing 
services that typically have lengthy hospital outpatient recovery 
periods. For these 23 hour stay services, the typical patient is 
commonly at the hospital for less than

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24 hours, but often stays overnight at the hospital. For example, if 
the patient arrives at the hospital at 6 a.m. for a scheduled surgical 
procedure that typically has a lengthy hospital outpatient recovery 
period, the patient may recover during the day and be ready to be 
discharged late in the evening without having to stay overnight at the 
hospital. More commonly, however, if the patient arrives at the 
hospital at noon for a surgical procedure that typically has a lengthy 
hospital outpatient recovery period, the patient may stay at the 
hospital overnight to recover and be discharged the following morning. 
On occasion, the patient may recover at the hospital for longer than a 
single night, either because the patient requires an even longer 
recovery period or the surgery was performed outside of usual business 
hours. For example, if the patient arrives at the hospital at 11 p.m. 
and requires an unscheduled surgical procedure that typically has a 
lengthy hospital outpatient recovery period, the patient may stay at 
the hospital overnight in preparation for surgery, have the surgical 
procedure performed, and then stay through another night recovering at 
the hospital before being discharged. In all these cases, unless a 
treating physician has written an order to admit the patient as an 
inpatient, the patient is considered for Medicare purposes to be a 
hospital outpatient, not an inpatient, and our claims data support that 
the typical 23 hour stay service is billed as an outpatient service.
    We believe that the values of the codes that fall into the 23 hour 
stay category, that is, services that typically have lengthy hospital 
outpatient recovery periods, should not reflect work that is typically 
associated with an inpatient service. For example, inpatient E/M visit 
codes such as CPT codes 99231 (Level 1 subsequent hospital care, per 
day); 99232 (Level 2 subsequent hospital care, per day); and 99233 
(Level 3 subsequent hospital care, per day), should not be included at 
their full RVU value in the valuation of these services that typically 
have lengthy hospital outpatient recovery periods. However, as we 
stated in the CY 2011 PFS final rule with comment period (75 FR 73226 
through 73227), we find it is plausible that while the patient 
receiving the outpatient 23 hour stay service remains a hospital 
outpatient, the patient would typically be cared for by a physician 
during that lengthy recovery period at the hospital. While we do not 
believe that post-procedure hospital visits would be at the inpatient 
level since the typical case is an outpatient who would be ready to be 
discharged from the hospital in 23 hours or less, we believe it is 
generally appropriate to include the intra-service time of the 
inpatient hospital visit in the immediate post-service time of the 23 
hour stay code under review. In addition, we indicated that we believe 
it is appropriate to include a half day, rather than a full day, of a 
discharge day management service. While some commenters advocated for a 
deferral on the issue of valuing 23 hour stay services, we note that a 
number of commenters supported CMS' approach. Consequently, we 
finalized this policy in the CY 2011 PFS final rule with comment period 
(75 FR 73226 through 73227) and encouraged the AMA RUC to apply this 
methodology in developing the recommendations it provides to us for 
valuing 23 hour stay codes, in order to ensure the consistent and 
appropriate valuation of the physician work for these services.
    The AMA RUC reviewed a number of Site-of-Service anomaly codes 
during its February 2011 meeting, many of which are Site-of-Service 
anomaly codes that have been valued on an interim basis since CY 2009. 
These Site-of-Service anomaly codes typically have a lengthy hospital 
outpatient recovery period and thus would be subject to the policy 
previously described for valuing the post-procedure physician care. CMS 
had requested that the AMA RUC re-review them due to concerns over the 
methodology the AMA RUC used originally in valuing these codes (74 FR 
61777 and 75 FR 73221). Contrary to the 23 hour stay policy we 
finalized in the CY 2011 PFS final rule with comment period (75 FR 
73226 through 73227), as described above, in the AMA RUC's review of 
Site-of-Service anomaly codes for CY 2012 as part of this Five-Year 
Review, the AMA RUC often recommended replacing the hospital inpatient 
post-operative visit blocks in the current work values with blocks for 
subsequent observation care services, specifically CPT codes 99224 
(Level 1 subsequent observation care, per day) and 99225 (Level 2 
subsequent observation care, per day), which recently became effective 
under the PFS beginning in CY 2011. The AMA RUC stated in its summary 
recommendations to CMS, ``Adjustments to the allocation of post-
operative visits are used as proxies and do not constitute changes to 
the physician work relative value of the service which was determined 
by magnitude estimation and physician specialty survey data during the 
last RUC review.'' However, we note that the AMA RUC generally 
recommended maintaining the current interim value of the CY 2009 Site-
of-Service anomaly codes while replacing the inpatient hospital visit 
code blocks with subsequent observation care code blocks.
    We continue to be concerned over the AMA RUC's approach to valuing 
the physician work for these Site-of-Service anomaly codes. We believe 
the appropriate methodology entails accounting for the removal of the 
inpatient visit blocks in the work value for the Site-of-Service 
anomaly code since these services are no longer typically furnished in 
the inpatient setting. We do not believe it is appropriate to simply 
exchange the inpatient post-operative visits in the original value with 
subsequent observation care visits (which are appropriately reported in 
cases of nonsurgical hospital outpatient stays spanning 3 calendar days 
or longer), and maintain the current work RVUs. Furthermore, instead of 
the half discharge day management service included in past 
recommendations (CPT code 99238 (Hospital discharge day management; 30 
minutes or less)), the AMA RUC generally recommended including a full 
observation care discharge day management service (CPT code 99217 
(Observation care discharge day management (this code is to be utilized 
by the physician to report all services provided to a patient on 
discharge from ``observation status'' if the discharge is on other than 
the initial date of ``observation status.''))) However, the AMA RUC 
indicated it is currently assessing this code to revise the physician 
times. We do not believe it is appropriate to substitute a full day of 
CPT code 99217 for the half day of CPT code 99238 that would be 
included in the work value for a Site-of-Service anomaly code according 
to CMS' established policy, especially given the AMA RUC's ongoing 
review of CPT code 99217.
    Accordingly, where the data suggested a Site-of-Service anomaly 
code (more than 50 percent of the most recent Medicare utilization is 
outpatient--based on PFS data from the fourth quarter of CY 2009 and 
the first three quarters of CY 2010 to represent the most recent full 
12 months of claims data available) resembles a 23 hour stay outpatient 
service and the AMA RUC's recommended value from the Five-Year Review 
continued to include inpatient visits (or subsequent observation care 
codes) in the post-operative period, we applied the policy described 
above. That is, we consistently removed any post-procedure inpatient 
visits or subsequent observation care services

[[Page 32422]]

included in the AMA RUC-recommended values for these codes and adjusted 
physician times accordingly. We also consistently included the value of 
a half day of a discharge management service.
    An additional concern that arose in our clinical review of the 
codes relates to codes that are typically billed with an E/M service on 
the same day. The AMA RUC noted for a number of codes that the service 
was typically billed with an additional E/M service on the same day; 
however, it appears the AMA RUC did not consistently account for this 
overlap in formulating its time recommendations, an issue discussed on 
a CPT code-specific basis below. In cases where a service is typically 
furnished with an E/M service on the same day, we believe it is 
understood that there may be overlap between the two services in some 
of the activities conducted during the pre- and post-service times of 
the procedure code, and that these overlapping activities should not be 
counted twice. Accordingly, in cases where the most recently available 
Medicare PFS claims data show the code is typically (greater than 50 
percent of the time--based on PFS data from CY 2009) billed with an E/M 
visit on the same day, and where we believe that the AMA RUC did not 
adequately account for overlapping activities in the recommended value 
for the code, we systematically adjusted the physician times for the 
code to account for the overlap. After clinical review of the pre- and 
post-service work, we believe that at least \1/3\ of the physician time 
in both the pre-service evaluation and post-service period is 
duplicative of the E/M visit in this circumstance. Therefore, we 
adjusted the pre-service evaluation portion of the pre-service time to 
\2/3\ of the AMA RUC-recommended time. Similarly, we also adjusted the 
post-service time to \2/3\ of the AMA RUC-recommended time.
    As noted in the CY 2011 proposed rule (75 FR 73328), in reviewing 
the AMA RUC recommendations for valuing the work of new, revised, and 
potentially misvalued services, we expend significant effort in 
evaluating whether the recommended values reflect the work elements, 
such as time, mental effort, and professional judgment, technical skill 
and physical effort, and stress due to risk, involved with furnishing 
the service. Subjecting each of the codes to a clinical review, we 
examined the pre-, post-, and intra-service components of the work. In 
cases where we disagreed with the AMA RUC's recommended work RVU, we 
proposed alternative values based on comparisons with other established 
reference codes with clinical similarity or analogous physician times, 
or the 25th percentile or low value as indicated in the physician 
survey, or, where applicable, employed the building block approach.
    Over the last several years our rate of acceptance of the AMA RUC 
recommendations has been higher. However, in response to concerns 
expressed by MedPAC, and other stakeholders regarding the accurate 
valuation of services under the PFS, we have intensified our scrutiny 
of the work valuations of new, revised, and potentially misvalued 
codes. We note that most recently, section 3134 of the Affordable Care 
Act added a new requirement, which specifies that the Secretary shall 
establish a formal process to validate RVUs under the PFS. The 
validation process may include validation of work elements (such as 
time, mental effort and professional judgment, technical skill and 
physical effort, and stress due to risk) involved with furnishing a 
service and may include validation of the pre-, post-, and intra-
service components of work. Furthermore, the Secretary is directed to 
validate a sampling of the work RVUs of codes identified through any of 
the seven categories of potentially misvalued codes specified by 
section 1848(c)(2)(K)(ii) of the Act (as added by section 3134 of the 
Affordable Care Act). While we are currently in the planning stage of 
developing a formal validation process, we have incorporated, where 
appropriate, the validation principles specified in the law in this 
Five-Year Review process.

B. Summary of Proposed Work RVUs for Five-Year Review Codes

    As stated previously, we sent the AMA RUC an initial list of 219 
codes for review. We have encouraged the AMA RUC to review codes on a 
``family'' basis rather than in isolation in order to ensure that 
appropriate relativity in the system is retained. Consequently, the AMA 
RUC included additional codes for review, resulting in a total of 290 
codes for the Fourth Five-Year Review of Work. Of those 290 codes, 53 
were subsequently sent to the CPT Editorial Panel to consider coding 
changes, 14 were not reviewed by the AMA RUC (and subsequently not 
reviewed by CMS) because the specialty society that had originally 
requested the review in its public comments on the CY 2010 PFS final 
rule with comment period elected to withdraw the codes, 36 were not 
reviewed by the AMA RUC because their values were set as interim final 
in the CY 2011 PFS final rule with comment period, and 14 were not 
reviewed by CMS because they were noncovered services under Medicare. 
Therefore, the AMA RUC reviewed 173 of the 290 codes initially 
identified for this Fourth Five-Year Review of Work, and provided the 
recommendations to CMS that are addressed below in this proposed 
notice. A list of the remaining codes that were identified for possible 
review through the Five-Year Review process but not reviewed can be 
found in section II.E. of this proposed notice. Upon clinical review, 
we are proposing to accept 89 out of 173 (51 percent) of the AMA RUC 
recommendations for work RVUs. In some cases, we also refined physician 
times for codes as deemed appropriate to correspond with the proposed 
work RVUs. CMS' decisions are summarized in Table 6.
    In addition, the HCPAC submitted for CMS review its recommendations 
to modify work RVUs for five CPT codes under the Fourth Five-Year 
Review of Work. Of those five CPT codes, three were not reviewed by CMS 
because the codes were withdrawn by the relevant specialty society due 
to a low survey response rate. We did not accept the HCPAC 
recommendations for the two remaining CPT codes, as detailed in section 
II.D.1 of this proposed notice.
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BILLING CODE C

C. Code-Specific Discussion of Proposed Alternative Work RVUs

1. Drainage of Hematoma
[GRAPHIC] [TIFF OMITTED] TP06JN11.020

    In the Fourth Five-Year Review, we identified CPT codes 10140 and 
10160 as potentially misvalued through the Harvard-Valued--Utilization 
> 30,000 screen.
    For CPT code 10140 (Incision and drainage of hematoma, seroma or 
fluid collection), the AMA RUC reviewed the survey results and 
determined that these data support maintaining the current work RVU of 
1.58 for this service. The AMA RUC believed that the current work RVU 
for CPT code 10140 is appropriate and recommended a work RVU of 1.58.

[[Page 32432]]

    We agree with the AMA RUC-recommended work RVU for CPT code 10140 
and are proposing a work RVU of 1.58 for CY 2012, with a refinement to 
the time. We believe the current pre-service evaluation time of 7 
minutes is more appropriate than the AMA RUC-recommended pre-service 
evaluation time of 17 minutes. CPT code 10160 (Puncture aspiration of 
abscess, hematoma, bulla, or cyst) has the same description of typical 
pre-service evaluation work and an AMA RUC-recommended pre-service 
evaluation time of 7 minutes. After clinical review, we believe that 7 
minutes accurately reflects the time required to conduct the pre-
service evaluation work associated with this service. A complete list 
of CMS time refinements can be found in Table 6.
2. Wound Repair
[GRAPHIC] [TIFF OMITTED] TP06JN11.021

    In the Fourth Five-Year Review, we identified CPT codes 12031, 
12051, and 13101 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. CPT codes 12032-12047, 12052-12057, and 
13100 were added as part of the family of services for review. In its 
review of this set of CPT codes, the AMA RUC determined that the 
original Harvard values led to compression within these code families, 
which the AMA RUC recommended correcting by reducing the relative 
values for the smallest wound size repair codes and increasing the 
relative values for the larger wound size repair codes.
    In general, the specialty society surveys of physicians furnishing 
these intermediate wound repair codes confirmed that the work of 
performing these services had not changed in the past 5 years and that 
the complexity of patients requiring the services had also remained 
constant. Despite the survey findings, however, the survey median work 
RVUs were usually somewhat higher than the current work RVUs for the 
larger wound size repair codes. For many of these codes, the AMA RUC 
recommended the survey median values as the work RVUs for these wound 
repair services, despite its common recommendation of the survey 25th 
percentile values for codes in other families. In those cases discussed 
below where we disagreed with the AMA RUC recommendations, we based our 
proposed work RVU on the survey 25th percentile value, which was also 
usually higher than the current work RVU for the larger wound size 
repair codes. For the smaller wound size repair codes the AMA RUC 
recommended a lower work RVU than the current work RVU, and we agreed. 
In this way, our proposals for the revised work RVUs for the wound 
repair codes address concerns about compression in the original 
Harvard-valued work RVUs within the family. Our proposed range of work 
RVUs for intermediate wound repair codes in various body areas, while 
not as large as the range that would have resulted from our adoption of 
the AMA RUC's recommendations, nevertheless is greater than the current 
range of work RVUs for the variety of wound sizes described by the 
repair codes.
    For CPT code 12035 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 
cm), the AMA RUC reviewed the survey data from physicians who 
frequently perform this service and determined that the survey median 
work RVU appropriately accounts for the work required for this service. 
The AMA RUC recommended a work RVU of 3.60 for CPT code 12035.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12035 and believe that the survey 25th percentile value of a work RVU 
of 3.50 is more appropriate for this service. The majority of survey 
respondents

[[Page 32433]]

indicated that the work of performing this service has not changed in 
the past 5 years (79 percent), and that there has been no change in 
complexity among the patients requiring this service (82 percent). We 
believe that the survey 25th percentile value accurately reflects the 
work associated with this service and is consistent with the relativity 
adjustments recommended by the AMA RUC. Therefore, we are proposing an 
alternative work RVU of 3.50 for CPT code 12035 for CY 2012.
    For CPT code 12036 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 
cm), the AMA RUC reviewed the survey data from physicians who 
frequently perform this service and determined that the survey median 
work RVU appropriately accounts for the work required for this service. 
The AMA RUC recommended a work RVU of 4.50 for CPT code 12036.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12036 and believe that the survey 25th percentile value of a work RVU 
of 4.23 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (81 percent), and that there has been no 
change in complexity among the patients requiring this service (84 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. We are proposing 
an alternative work RVU of 4.23 for CPT code 12036 for CY 2012.
    In addition to the work RVU adjustment for CPT code 12036, we are 
refining the time associated with this code. We find an intra-service 
time of 70 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 75 minutes. Per the survey, 
this time correctly captures the intra-service time differential 
between this CPT code and the key reference code. After clinical 
review, we believe that 70 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 12037 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); over 30.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required for this service. The AMA 
RUC recommended a work RVU of 5.25 for CPT code 12037.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12037 and believe that the survey 25th percentile value of a work RVU 
of 5.00 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (81 percent), and that there has been no 
change in complexity among the patients requiring this service (83 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. Therefore, we 
are proposing an alternative work RVU of 5.00 for CPT code 12037 for CY 
2012.
    For CPT code 12045 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 12.6 cm to 20.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the physician work required for this service. The AMA RUC 
recommended a work RVU of 3.90 for CPT code 12045.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12045 and believe that the survey 25th percentile value of a work RVU 
of 3.75 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (80 percent), and that there has been no 
change in complexity among the patients requiring this service (80 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. Therefore, we 
are proposing an alternative work RVU of 3.75 for CPT code 12045 for CY 
2012.
    For CPT code 12046 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 20.1 cm to 30.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the work required for this service. The AMA RUC 
recommended a work RVU of 4.60 for CPT code 12046.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12046 and believe that the survey 25th percentile value of a work RVU 
of 4.30 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.30 for CPT code 12046 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12046, we are 
refining the time associated with this code. This service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described in 
section II.A. of this proposed notice, to account for this overlap, we 
reduced the pre-service evaluation and post-service time by one-third. 
We believe that 9 minutes pre-service evaluation time and 9 minutes 
post-service time accurately reflect the time required to conduct the 
work associated with this service. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 12047 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; over 30.0 cm) the AMA RUC reviewed the 
survey data from physicians who frequently perform this service and 
determined the survey median work RVU appropriately accounts for the 
work required for this service. The AMA RUC recommended a work RVU of 
5.50 for CPT code 12046.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12047 and believe that the survey 25th percentile value of a work RVU 
of 4.95 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.95 for CPT code 12047 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12047, we are 
refining the time associated with this code. Recent Medicare PFS claims 
data show that this service typically is performed on the same day as 
an E/M visit. We believe some of the activities conducted during the 
pre- and post-service times of the procedure code and the E/M visit 
overlap and, therefore,

[[Page 32434]]

should not be counted twice in developing the procedure's work value. 
As described in section II.A. of this proposed notice, to account for 
this overlap, we reduced the pre-service evaluation and post service 
time by one-third. We believe that 9 minutes pre-service evaluation 
time and 10 minutes post-service time accurately reflect the time 
required to conduct the work associated with this service. A complete 
list of CMS time refinements can be found in Table 6.
    For CPT code 12055 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 4.65 for CPT code 12055.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12055 and believe that the survey 25th percentile value of a work RVU 
of 4.50 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.50 for CPT code 12055 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12055, we are 
refining the time associated with this code. We find an intra-service 
time of 60 minutes, the survey median and intra-service time of the key 
reference code, to be more appropriate than the AMA RUC-recommended 
intra-service time of 70 minutes. After clinical review, we believe 
that 60 minutes accurately reflects the time required to conduct the 
intra-service work associated with this service. A complete list of CMS 
time refinements can be found in Table 6.
    For CPT code 12056 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 5.50 for CPT code 12056.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12056 and believe that the survey 25th percentile value of a work RVU 
of 5.30 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (80 percent), and that there has been no 
change in complexity among the patients requiring this service (81 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 5.30 for CPT code 12056 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12056, we are 
refining the time associated with this code. We find an intra-service 
time of 70 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 85 minutes. After clinical 
review, we believe that 70 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 12057 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; over 30.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the work required to perform this service. The AMA RUC 
recommended a work RVU of 6.28 for CPT code 12057.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12057 and believe that the survey 25th percentile value of a work RVU 
of 6.00 (the current value) is more appropriate for this service. The 
majority of survey respondents indicated that the work of performing 
this service has not changed in the past 5 years (80 percent), and that 
there has been no change in complexity among the patients requiring 
this service (81 percent). We believe that the survey 25th percentile 
value accurately reflects the work associated with this service. 
Therefore, we are proposing an alternative work RVU of 6.00 for CPT 
code 12057 for CY 2012.
    In addition to the work RVU adjustment for CPT code 12057, we are 
refining the time associated with this code. We find an intra-service 
time of 90 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 100 minutes. After clinical 
review, we believe that 90 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and agreed that the current work RVU of 3.17 maintains the 
appropriate relativity for this service. The AMA RUC recommended a work 
RVU of 3.17 for CPT code 13100.
    We note that the AMA RUC reviewed only two CPT codes in the complex 
wound repair family. While at this time we agree with the AMA RUC-
recommended work RVU for CPT code 13100 and are proposing a work RVU of 
3.17 for CY 2012, with a refinement to time, we request that, in order 
to ensure consistency, the AMA RUC review the entire set of codes in 
this family and assess the appropriate gradation of the work RVUs in 
this family. The majority of survey respondents indicated that the work 
of performing this service has not changed in the past 5 years (89 
percent), and that there has been no change in complexity among the 
patients requiring this service (79 percent). We believe at this time 
that the current work RVU (3.17) and current times accurately reflect 
the service.
    For CPT code 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the current work RVU of 3.96 maintains 
the appropriate relativity for this service. The AMA RUC recommended a 
work RVU of 3.