Summation of the Final Rules for Payment Policies and Rates. Paid Under the Medicare Physician Fee Schedule

Transcription

1 regulatory and reimbursement Summation of the Final Rules for Payment Policies and Rates Paid Under the Medicare Physician Fee Schedule by Ron DiGiaimo, CEO, Revenue Cycle, Inc. for Calendar Year 2010 On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued the final rule applicable to the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) The final rule went into effect on January 1, 2010, and implements changes to the physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that the payment system is updated to reflect changes in medical practices and the relative value of services furnished to Medicare patients. The final rule discusses several provisions of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, finalizes CY 2009 interim relative value units (s), and issues interim s for new and revised codes for CY In response to the CY 2010 PFS proposed rules released on July 1, 2009, CMS received approximately 16,500 timely public comments. These comments were from concerned citizens, physicians, healthcare workers, professional associations and societies, manufacturers, and members of Congress. The majority of the comments addressed proposals related to the MIPPA provisions concerning teaching anesthesiology and cardiac and pulmonary rehabilitation, the Physician Practice Information Survey, and the impact of the proposed rule on specific specialties. Update to the Conversion Factor Medicare law requires CMS to adjust the MPFS payment rates annually based on an update formula, which includes application of the sustainable growth rate (SGR) that was adopted in the Balanced Budget Act of This formula has yielded negative updates every year beginning in CY 2002, although CMS was able to take administrative steps to avert a reduction in CY 2003, and Congress has taken a series of legislative actions to prevent reductions in CYs 2004 to For CY 2010, the update to the PFS conversion factor would have been $28.406, which is a 21.2% decrease from the CY 2009 conversion factor. Per Correction Notice (CN) 6973, published to the Federal Register on May 10, 2010, the CY 2010 conversion factor was changed to $ The table below reflects updates published in CN Legislative action has maintained the CY at a rate of $ through May 31, However, also included in CN 6973 is an additional update to the setting it at $ ; this change will be implemented on June 1, 2010 and is retroactive back to January 1, Calculation of the CY 2010 PFS Conversion Factor CY 2006 conversion factor $37.90 CY 2007 prelegislation conversion factor update -5.0%, (.94953) CY 2007 prelegislation conversion factor $35.98 CY 2008 prelegislation conversion factor update -5.3%, (.94674) CY 2008 prelegislation conversion factor $34.07 CY 2009 prelegislation total, including budget neutrality adjustments totaling -6.3% -11.5%, (.88502) CY 2009 prelegislation conversion factor $30.15 CY 2010 Medicare economic index 1.2%, CY 2010 update adjustment factor -7.0%, -.93 CY budget neutrality adjustment %, CY 2010 conversion factor $

2 Relative Value Units, Equipment Utilization, and Geographic Practice Cost Index The Social Security Act requires that payments under the physician fee schedule be based on national uniform s based on the relative resources used in furnishing services. The act requires that national s be established for physician work, practice expense, and malpractice expense. Under the MPFS, a relative value is assigned to each of more than 7,000 types of services to capture the amount of work, the direct and indirect (overhead) practice expenses, and the malpractice premiums typically involved in furnishing the service. The higher the number of s assigned to a service, the higher the payment. The s for a particular service are multiplied by a fixed-dollar conversion factor to determine the payment amount for each service. Practice Expense (PE) s PE s are based upon the portion of the resources utilized when furnishing procedures or services that reflect physician and practitioner expenses, such as rent and personnel salaries. Separate PE s are established for procedures that can be performed in both a nonfacility, such as a physician s office, and a facility setting, such as a hospital outpatient department. The difference between the facility and nonfacility s reflects the fact that a facility typically receives separate payment from Medicare for its costs of providing the service, apart from payment under the PFS. The nonfacility s reflect all the direct and indirect PEs of providing a particular service. In CY 2007, the PE methodology was changed to a bottom-up approach and was implemented over a fouryear period. In CY 2010, the transition period is concluded, and PE s will be calculated based entirely on the bottom-up approach. The American Medical Association (AMA) conducted a new survey, the Physician Practice Information Survey (PPIS), which expanded to include nonphysician practitioners (NPPs) paid under the PFS. The PPIS was administered in CY 2007 and CY 2008 and was designed to update the specialtyspecific PE/HR (practice expense per hour) date used to develop PE s. This survey increased the PE/HR ratio for radiation oncology and resulted in a proposed 12% decrease for the radiation oncology specialty. CMS proposed to utilize the PE/HR developed using PPIS data for all Medicare-recognized specialties that participated in the PPIS for payments effective January 1, In response to comments received on the proposed rule, CMS performed additional analyses of summary data supplied by the AMA, the supplement survey, and cardiology, urology, and radiology groups. This analysis indicated that while the PE/HR for these specialties differs between the data sources reviewed, these differences do not validate commenter conclusions that the PPIS data is invalid. CMS continues to believe that the PPIS is the most appropriate data source available for the development of resource-based PE s. CMS did, however, recognize that some specialties would experience significant payment reductions with the use of the PPIS data. Given the magnitude of these payment reductions, CMS agreed with suggestions to transition to the new PE s developed using the PPIS data and has provided a four-year transition period. Equipment Utilization Rate As part of the PE methodology associated with the allocation of equipment costs for calculating PE s, CMS currently performs these calculations with an equipment usage assumption of 50% utilization, which translates into approximately 25 hours per week 46 managedcareoncology Quarter

3 out of a 50-hour workweek. In a study cited by Med PAC, the utilization rate for magnetic resonance imaging and computed tomography equipment was closer to 90% than 50%. Therefore, for CY 2010, CMS proposed to increase the equipment usage rate to 90% for all services containing equipment that cost in excess of $1 million due to Med PAC s suggestion that providers would not typically make significant capital investments in equipment that would be utilized only 50% of the time. Due to comments received on the proposed rule, CMS has made the decision to finalize the increased utilization rate for expensive diagnostic equipment priced at $1 million or more, but this will not include therapeutic equipment. Miscellaneous Practice Expense Issues In the proposed rules for CY 2010, CMS stated that comments had been received regarding the PE direct cost inputs (supply cost and useful life of the renewable sources) related to the high-dose radiation (HDR) brachytherapy current procedural terminology (CPT) codes (77785, remote afterloading high-dose-rate radionuclide brachytherapy, one channel; 77786, remote afterloading high-dose-rate radionuclide brachytherapy, two to 12 channels; 77787, remote afterloading high-dose-rate radionuclide brachytherapy, over 12 channels). Based on CMS review of these codes and comments received, it has been requested that the AMA s Relative Value System Update Committee (RUC) consider these CPT codes for additional review. The AMA RUC reviewed these CPT codes based on the request and recommended revisions to the clinical labor staff type, supplies, and equipment. The AMA RUC also recommended further discussion between the specialty and CMS regarding a resolution for the useful life of Iridium-192 source. The AMA RUC and other comments stated that the useful life of the Iridium-192 source is 70 to 90 days. However, many comments stated that physician offices enter into one-year contracts for its replacement. Several comments supported the AMA RUC s recommended changes to the practice expense inputs for these codes. Based on the comments received and further analysis, CMS is changing the useful life of the Iridium-192 source from five years to one year and it will be considered as equipment. CMS will also revise the direct PE inputs for clinical labor staff type, supplies, and equipment. Geographic Practice Cost Indices (GPCIs) CMS is required to establish separate GPCIs to measure resource cost differences among localities compared to the national average for each of the three fee schedule components (work, PE, and malpractice). While requiring that the PE and malpractice GPCIs reflect the full relative cost differences, the physician work GPCIs reflect only one-quarter of the relative cost differences compared to the national average. A 1.0 work GPCI floor was enacted and implemented for CY 47

4 2006 and was set to expire on June 30, 2008, but it was extended through December 31, 2009, by the MIPPA. MIPPA also set a 1.5 work GPCI floor in Alaska for services beginning January 1, Therefore, as required by MIPPA, beginning January 1, 2010, the 1.0 work GPCI floor will be removed; the 1.5 floor for Alaska will remain in effect. Comments requested that the 1.0 floor be extended through CY 2010, but CMS stated that it does not have the authority to extend this provision beyond the MIPPA period. Malpractice (MP) Relative Value Units In the proposed rules, CMS planned to implement a second review and update of malpractice s. CMS proposed to revise the s using specialty-specific malpractice premium data because they represent the actual malpractice expense to the physician. The new malpractice expense s would be based upon three data sources: actual CY 2006 and CY 2007 malpractice premium data, CY 2008 Medicare payment data on allowed services and charges, and CY 2008 geographic adjustment data for malpractice premiums. Using the three data sources, CMS would calculate the risk factors to express the relative differences in national average premiums throughout the specialties. Due to comments received, CMS did not finalize the proposal to establish specialty-specific risk factors but instead will continue to utilize the current approach for assigning risk factors to services while the issue receives further study. As such, CPT codes will continue to be assigned to either a nonsurgical or a surgical risk factor: surgery (CPT code range through 69999; through 92998; through 93536; through 92974; through 93533; through 93581; through 93613; through 93652; 92975; through 92998; and through 93641) and nonsurgery (all other CPT codes). Impacts It is required that increases or decreases in s may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, CMS makes adjustments to preserve budget neutrality. The table below displays the average impact for some specialties based on Medicare utilization. The payment impact for an individual physician would be different from the average, based on the mix of services the physician provides. The average change in total revenues would be less than the impact displayed in the table because physicians furnish services to both Medicare and non-medicare patients. Specialty 2010 Final Allowed Charges ($ millions) 2010 Final Impact of Work Changes 2010 Final Impact of PE Changes* 2010 Final Impact of MP Changes 2010 Final Combined Impact 2010 Proposed Combined Impact Full 2010 Trans Full 2010 Trans Total 77,796 0% 0% 0% 0% 0% 0% 0% Family practice 5,094 2% 5% 2% 1% 7% 4% 8% General practice 727 1% 4% 1% 0% 6% 3% 6% General surgery 2,227-1% 3% 1% 1% 4% 1% 4% Hematology/oncology 1,897 0% -5% -1% 0% -6% -1% -6% Interventional radiology 225-1% -9% -2% 0% -10% -3% -10% Neurosurgery 591-1% 2% 0% 0% 1% -1% 2% Nuclear medicine 74-5% -15% -10% -2% -23% -18% -13% Radiation oncology 1,809 0% 3% 0% 2% 5% 1% 19% Urology 1,993-1% -8% -3% 0% -10% -4% -7% Diagnostic testing facility 923-1% -29% -7% -4% -34% -12% -24% Does not include the impact of the current statute CY 2010 negative update except as applied in the outpatient prospective payment system (OPPS) imaging cap comparison (see next footnote). Rows may not sum to total due to rounding. * Note: The statute caps the PFS imaging payment amount at the comparable payment amount in the hospital OPPS cap. In the absence of the negative current statute CY 2010 PFS update, the proposed fully implemented PE change to the equipment utilization rate for expensive diagnostic equipment from 50% to 90% would increase expenditures by less than 1% due to a loss of savings from the OPPS cap. 48 managedcareoncology Quarter

5 CPT Code Descriptor RUC Rec CMS Decision 2010 W2 CMS Fastest Growing CMS Request PE Review Radiotherapy dose plan, IMRT CPT Agree 7.99 X SRS, multisource New PE inputs Agree (a) X Radiation therapy delivery, IMRT CPT Agree 0 X HDR brachytherapy, one channel New PE Inputs Agree (a) X HDR brachytherapy, two to 12 channels New PE Inputs Agree (a) X HDR brachytherapy, over 12 channels New PE Inputs Agree (a) X (a) = work unchanged; code was reviewed for PE only! Work impacts are primarily attributable to the changes for consultation services. CMS will no longer recognize the billing codes for consultation services. CMS is budget neutrally eliminating the use of all consultation codes (except telehealth), and it has allocated the work s that were allotted to these services to the work s for new and established office visit services, initial hospital visits, and initial nursing facility visits to reflect this change. PE impacts are primarily attributable to the incorporation of PE data from PPIS. Malpractice impacts are attributable to the changes adopted for the five-year review of the MP s. These impacts are primarily driven by the expansion of the MP premium data collection and the changes to the methodology for TC services. Consultation Services The AMA developed current physician visit and consultation codes in A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient s problem(s). In 2006, a report by the Office of Inspector General found that approximately 75% of services paid as consultations did not meet all applicable program requirements, resulting in improper payments. In January 2008, CMS stopped recognizing office/outpatient consultation CPT codes for payment of hospital outpatient visits. Instead, CMS instructed hospitals to bill a new or established patient visit CPT code, as appropriate to the particular patient, for all hospital outpatient visits. Beginning January 1, 2010, CMS has eliminated the use of all consultation codes (inpatient and office/ outpatient codes for various places of service except for telehealth consultation G-codes) on a budget-neutral basis by increasing the work s for new and established office visits, increasing the work s for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into the PE and malpractice calculations. Work s for new and established office visits will increase approximately 6% and initial hospital and facility visits by approximately 0.3%. Potentially Misvalued Services Under the MPFS To address concerns expressed by stakeholders with regard to the process CMS uses to price services paid under the PFS, the AMA RUC created the Five- Year Review Identification Workgroup. In CY 2008, there were 204 services identified as misvalued, and CMS plans to continue working with the AMA RUC to identify additional codes that are potentially misvalued. CMS continues to believe there are additional steps that can be taken to help address the issue of potentially misvalued services and will continue to work with the AMA RUC and specialty groups to address issues. See the table on this page for a list of radiation oncology codes under review. Physician Quality Reporting Initiative (PQRI) The PQRI is a voluntary reporting program that provides an incentive payment to eligible professionals who satisfactorily report data on quality measures for covered professional services during a specified reporting period. For 2010, the Secretary is authorized to provide an incentive payment equal to 2.0% of the estimated total allowed charges (based on claims submitted no later than two months after the end of the reporting period) for all covered professional services furnished during the reporting period for The PQRI incentive payment amount is calculated using estimated allowed charges for all covered professional services furnished under the PFS, not just those charges associated with the reported quality measures. Allowed charges refers to total charges, including the beneficiary deductible and coinsurance, and is not limited to the 80% paid by Medicare or the portion covered by Medicare where Medicare is a secondary payor. Beginning in 2010, group practices who satisfactorily submit data on quality measures also are eligible to earn an incentive payment equal to 2.0% of the estimated total allowed charges for all covered professional services furnished by the group practice during the applicable reporting period. Incentive payments will be made either to the group itself or to the physician reporting individually, not both. CMS 49

6 is targeting finalization and publication of the detailed specifications for all 2010 PQRI measures on the CMS website by November 15, 2009, but no later than December 31, CMS is also finalizing a six-month reporting period beginning July 1, 2010, for claims-based reporting of individual measures. Physician Self-Referral The physician self-referral law prohibits the following: (1) A physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a direct or indirect financial relationship (an ownership/investment or a compensation arrangement), unless an exception applies; and (2) the entity from presenting or causing a claim to be presented to Medicare (or billing another individual, entity, or third-party payor) for those referred services. In this final rule, CMS has clarified the application of certain exceptions to arrangements in which a physician stands in the shoes of his or her physician organization. Determining whether an entity furnishing DHS and a physician has a direct or indirect compensation arrangement is a key step in applying the statute because it affects which compensation exceptions may apply to the arrangement. CMS is revising the second sentence of (c) (3) (i) to provide that [w]hen applying the exceptions in and of this part to arrangements in which a physician stands in the shoes of his or her physician organization, the relevant referrals and other business generated between the parties are referrals and other business generated between the entity furnishing DHS and the physician organization (including all members, employees, and independent contractor physicians). We believe the finalized language clarifies the regulation text and is consistent with our intent to minimize the potential for abuse without imposing undue burden on the provider community. Work Refinements for Interim s Although the s in the CY 2009 PFS final rule with comment period were used to calculate 2009 payment amounts, CMS considered the s for the new or revised codes to be interim. To evaluate these comments, CMS used a process similar to the processes used since CMS convened a multispecialty panel of physicians to assist in the review of the comments. CMS invited representatives from the organizations from which it received substantive comments to attend a panel for discussion of the code on which they had commented. Ratings of work were analyzed for consistency among the groups represented on each panel. For CPT codes (stereotactic radiosurgery particle beam, gamma ray, or linear accelerator one simple cranial lesion), (stereotactic radiosurgery particle beam, gamma ray, or linear accelerator each additional cranial lesion, simple), and (stereotactic radiosurgery particle beam, gamma ray, or linear accelerator one spinal lesion), the AMA RUC recommended work s for CPT code 61796, work s for CPT code 61798, and work s for CPT code CMS disagreed with the AMA RUC recommendations and assigned work s to all three of these codes in the CY 2009 PFS final rule with comment. CMS believed the specialty societies and the AMA RUC, in general, used open surgical codes as comparators during the AMA RUC process instead of a more equivalent stereotactic radiation treatment code. Based on these concerns, CMS referred these codes to the Multi-Specialty Validation Panel for review. As a result of the statistical analysis of these codes by the Multi-Specialty Validation Panel ratings, we have assigned work s to CPT code 61796, work s to CPT code 61798, and work s to CPT code See tables below. Interim Work Relative Value Units for SRS Codes Reviewed Under the Refinement Panel Process CPT Code Descriptor 2009 Work Requested Work 2010 Work SRS, cranial lesion simple SRS, cranial lesion complex SRS, spinal lesion AMA RUC Recommendations and CMS Decisions for New and Revised 2010 CPT Codes New and Revised 2010 CPT Codes New Tech Descriptor AMA RUC W Rec CMS Decision CMS 2010 Interim W x Bronchoscopy w/markers 4.16 Agree x Navigational bronchoscopy 2 Agree x Ins mark thor for RT perq 3.8 Agree x Ins mark abd/pel for RT perq 3.82 Agree Design MLC device for IMRT 4.29 Agree managedcareoncology Quarter

7 Global Periods Status Codes Final 2010 Codes and Rates Global Periods Descriptors Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount: evaluation and management services on the day of the procedure generally not payable. Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period included in the fee schedule amount: evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable. 090 Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule amount. MMM XXX YYY ZZZ Maternity codes: usual global period does not apply. The global concept does not apply. The carrier is to determine whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing. The code is related to another service and is always included in the global period of the other service. SC Short Descriptor Descriptor A B C D E F G H I J Active Bundled code Carriers price the code Deleted/discontinued code Excluded from the PFS by regulation Deleted/discontinued code Not valid for Medicare purposes Deleted modifier Not valid for Medicare purposes Anesthesia services These codes are separately payable under the PFS if covered. There will be s for codes with this status. The presence of an A indicator does not mean that Medicare has made a national coverage determination regarding the service. Carriers remain determination regarding the service. Carriers remain responsible for coverage decisions in the absence of a national Medicare policy. Payments for covered services are always bundled into payment for other services not specified. If s are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient). Carriers will establish s and payment amounts for these services, generally on an individual case basis following review of documentation, such as an operative report. These codes are deleted effective with the beginning of the applicable year. These codes will not appear on the 2006 file, as the grace period for deleted codes is no longer applicable. These codes are for items and services that CMS chose to exclude from the fee schedule payment by regulation. No s are shown, and no payment may be made under the PFS for these codes. Payment for them, when covered, continues under reasonable charge procedures. (Code not subject to a 90-day grace period.) These codes will not appear on the 2006 file, as the grace period for deleted codes is no longer applicable. Medicare uses another code for reporting of, and payment for, these services. (Codes subject to a 90-day grace period.) These codes will not appear on the 2006 file, as the grace period for deleted codes is no longer applicable. This code had an associated TC and/or 26 modifier in the previous year. For the current year, the TC or 26 component shown for the code has been deleted, and the deleted component is shown with a status code of H. These codes will not appear on the 2006 file, as the grace period for deleted codes is no longer applicable. Medicare uses another code for the reporting of and the payment for these services. (Codes not subject to a 90-day grace period.) There are no s and no payment amounts for these codes. The intent of this value is to facilitate the identification of anesthesia services. M Measurement codes Used for reporting purposes only. N Noncovered service Medicare does not cover these services. P R T X Bundled/excluded codes Restricted coverage Injections Statutory exclusion There are no s and no payment amounts for these services. No separate payment should be made for them under the fee schedule. If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the Act. Special coverage instructions apply. If covered, the service is carrier priced. (Note: The majority of codes to which this indicator will be assigned are the alphanumeric dental codes, which begin with D. We are assigning the indicator to a limited number of CPT codes, which represent services that are covered only in unusual circumstances.) There are s for these services, but they are only paid if there are no other services payable under the PFS billed on the same date by the same provider. If any other services payable under the PFS are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made. These codes represent an item or service that is not within the statutory definition of physicians' services for PFS payment purposes. No s are shown for these codes, and no payment may be made under the PFS. (Examples are ambulance services and clinical diagnostic laboratory services.) 51

8 PE MP Total Total Payment 0073T Delivery, comp imrt $ $ T Hdr elect brachytherapy $0.00 $ T TC Hdr elect brachytherapy $0.00 $ T 26 Hdr elect brachytherapy $0.00 $ T Place intraoc radiation src $0.00 $ T Intrafraction tracking motion $0.00 $ Drainage of breast lesion $ $ Place po breast cath for rad $3, $ Place breast cath for rad $71.44 $ Place breast rad tube/caths $1, $ Breast surgery procedure $0.00 $ Place ndl musc/tis for rt $ $ Apply, rem fixation device $ $ Removal of fixation device $ $ Musculoskeletal surgery $0.00 $ Spine surgery procedure $0.00 $ Diagnostic laryngoscopy $ $ Diagnostic laryngoscopy $ $ Bronchoscopy w/markers $ $ Navigational bronchoscopy $1, $ Diag bronchoscope/catheter $ $ Ins mark thor for rt perq $ $ Non-routine bl draw > 3 yrs $18.76 $ Place needles h&n for rt $ $ Ins mark abd/pel for rt perq $ $ Removal of prostate $ $1, Extensive prostate surgery $ $1, Extensive prostate surgery $1, $1, Extensive prostate surgery $1, $1, Removal of prostate $ $ Removal of prostate $ $ Extensive prostate surgery $ $1, Extensive prostate surgery $1, $1, Extensive prostate surgery $1, $1, Surgical exposure, prostate $ $ Extensive prostate surgery $ $1, Extensive prostate surgery $ $1, Cryoablate prostate $5, $ Transperi needle place, pros $ $ Place rt device/marker, pros $ $ Genital surgery procedure $0.00 $ Place needles pelvic for rt $ $ Insert uteri tandems/ovoids $ $ Insert heyman uteri capsule $ $ Genital surgery procedure $0.00 $ Incise skull for treatment $1, $1, Srs, cranial lesion simple $ $ Srs, cran les simple, addl $ $ managedcareoncology Quarter

9 PE MP Total Total Payment Srs, cranial lesion complex $ $1, Srs, cran les complex, addl $ $ Apply srs headframe add-on $ $ Srs, spinal lesion $ $ Srs, spinal lesion, addl $ $ Fluoroscope examination $96.69 $ TC Fluoroscope examination $88.03 $ Fluoroscope examination $8.66 $ Fluoroscope exam, extensive $0.00 $ TC Fluoroscope exam, extensive $0.00 $ Fluoroscope exam, extensive $35.36 $ CAT scan follow-up study $ $ TC CAT scan follow-up study $ $ CAT scan follow-up study $49.07 $ Us exam, breast(s) $89.48 $ TC Us exam, breast(s) $62.06 $ Us exam, breast(s) $27.42 $ Us, transrectal $ $ TC Us, transrectal $99.58 $ Us, transrectal $35.72 $ Echograp trans r, pros study $ $ TC Echograp trans r, pros study $93.81 $ Echograp trans r, pros study $79.01 $ Echo guide for biopsy $ $ TC Echo guide for biopsy $ $ Echo guide for biopsy $33.91 $ Echo guidance radiotherapy $67.83 $ TC Echo guidance radiotherapy $38.60 $ Echo guidance radiotherapy $29.22 $ Echo guidance radiotherapy $ $ TC Echo guidance radiotherapy $58.09 $ Echo guidance radiotherapy $68.91 $ Needle localization by xray $69.63 $ TC Needle localization by xray $42.57 $ Needle localization by xray $27.06 $ Ct scan for needle biopsy $ $ TC Ct scan for needle biopsy $ $ Ct scan for needle biopsy $58.09 $ Ct scan for therapy guide $ $ TC Ct scan for therapy guide $ $ Ct scan for therapy guide $42.93 $ Mr guidance for needle place $ $ TC Mr guidance for needle place $ $ Mr guidance for needle place $76.85 $ Radiation therapy planning $72.16 $ Radiation therapy planning $ $ Radiation therapy planning $ $ Set radiation therapy field $ $

10 PE MP Total Total Payment TC Set radiation therapy field $ $ Set radiation therapy field $35.36 $ Set radiation therapy field $ $ TC Set radiation therapy field $ $ Set radiation therapy field $53.40 $ Set radiation therapy field $ $ TC Set radiation therapy field $ $ Set radiation therapy field $78.65 $ Set radiation therapy field $ $ TC Set radiation therapy field $ $ Set radiation therapy field $ $ Radiation therapy planning $0.00 $ TC Radiation therapy planning $0.00 $ Radiation therapy planning $0.00 $ Radiation therapy dose plan $68.55 $ TC Radiation therapy dose plan $37.16 $ Radiation therapy dose plan $31.39 $ Radiotherapy dose plan, imrt $2, $ TC Radiotherapy dose plan, imrt $1, $ Radiotherapy dose plan, imrt $ $ Teletx isodose plan simple $67.47 $ TC Teletx isodose plan simple $32.11 $ Teletx isodose plan simple $35.36 $ Teletx isodose plan intermed $95.61 $ TC Teletx isodose plan intermed $42.21 $ Teletx isodose plan intermed $53.40 $ Teletx isodose plan complex $ $ TC Teletx isodose plan complex $63.50 $ Teletx isodose plan complex $78.65 $ Special teletx port plan $ $ TC Special teletx port plan $62.06 $ Special teletx port plan $47.99 $ Brachytx isodose calc simp $ $ TC Brachytx isodose calc simp $92.72 $ Brachytx isodose calc simp $46.90 $ Brachytx isodose calc interm $ $ TC Brachytx isodose calc interm $ $ Brachytx isodose calc interm $70.35 $ Brachytx isodose plan compl $ $ TC Brachytx isodose plan compl $ $ Brachytx isodose plan compl $ $ Special radiation dosimetry $62.42 $ TC Special radiation dosimetry $18.40 $ Special radiation dosimetry $44.02 $ Radiation treatment aid(s) $75.77 $ TC Radiation treatment aid(s) $48.35 $ Radiation treatment aid(s) $27.42 $ Radiation treatment aid(s) $62.78 $ managedcareoncology Quarter

11 PE MP Total Total Payment TC Radiation treatment aid(s) $20.20 $ Radiation treatment aid(s) $42.57 $ Radiation treatment aid(s) $ $ TC Radiation treatment aid(s) $88.39 $ Radiation treatment aid(s) $62.42 $ Radiation physics consult $53.40 $ Design mlc device for imrt $ $ TC Design mlc device for imrt $ $ Design mlc device for imrt $ $ Radiation physics consult $ $ Srs, multisource $0.00 $ Srs, linear based $ $ Sbrt delivery $1, $ External radiation dosimetry $0.00 $ TC External radiation dosimetry $0.00 $ External radiation dosimetry $0.00 $ Radiation treatment delivery $25.98 $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiation treatment delivery $ $ Radiology port film(s) $14.79 $ Radiation tx delivery, imrt $ $ Stereoscopic x-ray guidance $ $ TC Stereoscopic x-ray guidance $87.67 $ Stereoscopic x-ray guidance $19.48 $ Neutron beam tx, simple $ $ Neutron beam tx, complex $ $ Radiation tx management, x $ $ Radiation therapy management $98.50 $ Stereotactic radiation trmt $ $ Sbrt management $ $ Special radiation treatment $ $ TC Special radiation treatment $ $ Special radiation treatment $ $ Radiation therapy management $0.00 $ TC Radiation therapy management $0.00 $ Radiation therapy management $0.00 $ Proton trmt, simple w/o comp $0.00 $ Proton trmt, simple w/comp $0.00 $

12 PE MP Total Total Payment Proton trmt, intermediate $0.00 $ Proton treatment, complex $0.00 $ Hyperthermia treatment $ $ TC Hyperthermia treatment $ $ Hyperthermia treatment $78.65 $ Hyperthermia treatment $ $ TC Hyperthermia treatment $ $ Hyperthermia treatment $ $ Hyperthermia treatment $ $ TC Hyperthermia treatment $ $ Hyperthermia treatment $77.21 $ Hyperthermia treatment $ $ TC Hyperthermia treatment $ $ Hyperthermia treatment $ $ Hyperthermia treatment $ $ TC Hyperthermia treatment $ $ Hyperthermia treatment $75.41 $ Infuse radioactive materials $ $ TC Infuse radioactive materials $92.36 $ Infuse radioactive materials $ $ Apply intrcav radiat simple $ $ TC Apply intrcav radiat simple $ $ Apply intrcav radiat simple $ $ Apply intrcav radiat interm $ $ TC Apply intrcav radiat interm $ $ Apply intrcav radiat interm $ $ Apply intrcav radiat compl $ $ TC Apply intrcav radiat compl $ $ Apply intrcav radiat compl $ $ Apply interstit radiat simpl $ $ TC Apply interstit radiat simpl $ $ Apply interstit radiat simpl $ $ Apply interstit radiat inter $ $ TC Apply interstit radiat inter $ $ Apply interstit radiat inter $ $ Apply interstit radiat compl $ $ TC Apply interstit radiat compl $ $ Apply interstit radiat compl $ $ Hdr brachytx, 1 channel $ $ TC Hdr brachytx, 1 channel $ $ Hdr brachytx, 1 channel $72.16 $ Hdr brachytx, 2-12 channel $ $ TC Hdr brachytx, 2-12 channel $ $ Hdr brachytx, 2-12 channel $ $ Hdr brachytx over 12 chan $ $ TC Hdr brachytx over 12 chan $ $ Hdr brachytx over 12 chan $ $ Apply surface radiation $ $ managedcareoncology Quarter

13 PE MP Total Total Payment TC Apply surface radiation $48.71 $ Apply surface radiation $58.09 $ Radiation handling $88.39 $ TC Radiation handling $35.36 $ Radiation handling $53.04 $ Radium/radioisotope therapy $0.00 $ TC Radium/radioisotope therapy $0.00 $ Radium/radioisotope therapy $0.00 $ Pet image, ltd area $0.00 $ TC Pet image, ltd area $0.00 $ Pet image, ltd area $80.10 $ Pet image, skull-thigh $0.00 $ TC Pet image, skull-thigh $0.00 $ Pet image, skull-thigh $98.86 $ Pet image, full body $0.00 $ TC Pet image, full body $0.00 $ Pet image, full body $ $ Pet image w/ct, lmtd $0.00 $ TC Pet image w/ct, lmtd $0.00 $ Pet image w/ct, lmtd $ $ Pet image w/ct, skull-thigh $0.00 $ TC Pet image w/ct, skull-thigh $0.00 $ Pet image w/ct, skull-thigh $ $ Pet image w/ct, full body $0.00 $ TC Pet image w/ct, full body $0.00 $ Pet image w/ct, full body $ $ Nuclear rx, oral admin $ $ TC Nuclear rx, oral admin $54.12 $ Nuclear rx, oral admin $89.12 $ Nuclear rx, iv admin $ $ TC Nuclear rx, iv admin $58.81 $ Nuclear rx, iv admin $ $ Blood product/irradiation $0.00 $ Hydration iv infusion, init $53.76 $ Hydrate iv infusion, add-on $15.15 $ Ther/proph/diag iv inf, init $66.02 $ Ther/proph/diag iv inf addon $20.57 $ Tx/proph/dg addl seq iv inf $32.11 $ Ther/diag concurrent inf $19.12 $ Sc ther infusion, up to 1 hr $ $ Sc ther infusion, addl hr $14.79 $ Sc ther infusion, reset pump $75.04 $ Ther/proph/diag inj, sc/im $21.29 $ Ther/proph/diag inj, ia $18.04 $ Ther/proph/diag inj, iv push $52.68 $ Tx/pro/dx inj new drug addon $22.01 $ Tx/pro/dx inj new drug adon $0.00 $ Ther/prop/diag inj/inf proc $0.00 $