(ii) Add all the products for all the specialties. [56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42493, Sept. 15, 1992; 58 FR 63687, Dec. 2, 1993] 8414.24 Review, revision, and addition of RVUS for physicians' services. (a) Interim values for new and revised HCPCS level 1 and level 2 codes. (1) HCFA establishes interim RVUS for new services and for codes for which definitions have changed. (2) HCFA publishes a notice in the FEDERAL REGISTER to announce interim RVUS and seek public comment on them. The RVUS are effective prospectively for services furnished beginning on the effective date specified in the notice. (3) After considering public comments, HCFA revises, if necessary, the interim RVUS and announces those revisions in a final notice published in the FEDERAL REGISTER. Any revisions in the RVUs are effective prospectively for services furnished beginning on the effective date specified in the final notice. (b) Revision of RVUS for established HCPCS level 1 and level 2 codes. (1) HCFA publishes a proposed notice in the FEDERAL REGISTER to announce changes in RVUS for established codes and provides an opportunity for public comment no less often than every 5 years. (2) After considering public comments, HCFA publishes a final notice in the FEDERAL REGISTER to announce revisions to RVUS. (3) The RVU revisions are effective prospectively for services furnished beginning on the effective date specified in the final notice. (c) Values for local codes (HCPCS Level 3). (1) Carriers establish relative values for local codes for services not included in HCPCS levels 1 or 2. (2) Carriers must obtain prior approval from HCFA to establish local codes for services that meet the definition of "physician services" in § 414.2. [56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992] §414.26 Determining the GAF. HCFA establishes a GAF for each service in each fee schedule area. (a) Geographic indices. HCFA uses the following indices to establish the GAF: (1) An index that reflects one-fourth of the difference between the relative value of physicians' work effort in each of the different fee schedule areas as determined under §414.22(a) and the national average of that work effort. (2) An index that reflects the relative costs of the mix of goods and services comprising practice expenses (other than malpractice expenses) in each of the different fee schedule areas as determined under §414.22(b) compared to the national average of those costs. (3) An index that reflects the relative costs of malpractice expenses in each of the different fee schedule areas as determined under §414.22(c) compared to the national average of those costs. (b) Class-specific practice cost indices. If the application of a single index to different classes of services would be substantially inequitable because of differences in the mix of goods and services comprising practice expenses for the different classes of services, more than one index may be established under paragraph (a)(2) of this section. (c) Computation of GAF. The GAF for each fee schedule area is the sum of the physicians' work adjustment factor, the practice expense adjustment factor, and the malpractice cost adjustment factor, as defined in this section: (1) The geographic physicians' work adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUS for the work component and the geographic physicians' work index value established under paragraph (a)(1) of this section. (2) The geographic practice expense adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUS for the practice expense component, multiplied by the geographic practice cost index (GPCI) value established under paragraph (a)(2) of this section. (3) The geographic malpractice adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUS for the malpractice component, multiplied by the GPCI §414.28 Conversion factors. HCFA establishes CFS in accordance with section 1848(d) of the Act. (a) Base-year CFs. HCFA established the CF for 1992 so that had section 1848 of the Act applied during 1991, it would have resulted in the same aggregate amount of payments for physicians' services as the estimated aggregate amount of these payments in 1991, adjusted by the update for 1992 computed as specified in § 414.30. (b) Subsequent CFs. Beginning January 1, 1993, the CF for each year is equal to the CF for the previous year, adjusted in accordance with § 414.30. [56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992] 8414.30 Conversion factor update. Unless Congress acts in accordance with section 1848(d)(3) of the Act (a) General rule. The CF update for a CY equals the Medicare Economic Index increased or decreased by the number of percentage points by which the percentage increase in expenditures for physicians' services (or for a particular category of physicians' services, such as surgical services) in the second preceding FY over the third preceding FY exceeds the performance standard rate of increase established for the second preceding FY. (b) Downward adjustment. The downward adjustment may not exceed the following: (1) For CYS 1992 and 1993, 2 percentage points. (2) For CYS 1994 and 1995, 2.5 percentage points. (3) For CY 1996 and thereafter, 3 percentage points. § 414.32 Determining payments for certain physicians' services furnished in facility settings. (a) Definition. As used in this section, facility settings include the following facilities: (1) Hospital outpatient departments, including clinics and emergency rooms. (2) Hospital inpatient departments. (3) Comprehensive outpatient rehabilitation facilities. (4) Comprehensive inpatient rehabilitation facilities. (5) Inpatient psychiatric facilities. (b) General rule. If physicians' services of the type routinely furnished in physicians' offices are furnished in facility settings, the fee schedule amount for those services is determined by reducing the practice expense RVUS for the service by 50 percent. (c) Services covered by the reduction. HCFA establishes a list of services routinely furnished in physicians' offices nationally. Services furnished at least 50 percent of the time in physicians' offices are subject to this reduction. (d) Services excluded from the reduction. The reduction established under this section does not apply to the following: (1) Rural health clinic services. (2) Surgical services included on the ambulatory surgical center covered list of procedures published under §416.65(c) of this chapter. (3) Anesthesiology services and diagnostic and therapeutic radiology services. [58 FR 63687, Dec. 2, 1993] 8414.34 Payment for services and supplies incident to a physician's service. (a) Medical supplies. (1) Except as otherwise specified in this paragraph, office medical supplies are considered to be part of a physician's practice expense, and payment for them is included in the practice expense portion of the payment to the physician for the medical or surgical service to which they are incidental. (2) If physician services of the type routinely furnished in provider settings are furnished in a physician's office, separate payment may be made for certain supplies furnished incident to that physician service if the following requirements are met: (i) It is a procedure that can safely be furnished in the office setting in appropriate circumstances. (ii) It requires specialized supplies that are not routinely available in physicians' offices and that are generally disposable. (3) For the purpose of paragraph (a)(2) of this section, provider settings include only the following settings: (i) Hospital inpatient and outpatient departments. (ii) Ambulatory surgical centers. (4) For the purpose of paragraph (a)(2) of this section, "routinely furnished in provider settings" means furnished in inpatient or outpatient hospital settings or ambulatory surgical centers more than 50 percent of the time. (5) HCFA establishes a list of services for which a separate supply payment may be made under this section. (6) The fee schedule amount for supplies billed separately is not subject to a GPCI adjustment. (b) Services of nonphysicians that are incident to a physician's service. Services of nonphysicians that are covered as incident to a physician's service are paid as if the physician had personally furnished the service. $414.36 Payment for drugs incident to a physician's service. Payment for drugs incident to a physician's service is made in accordance with §405.517 of this chapter. §414.38 Special rules for payment of low osmolar contrast media. (a) General. Payment for low osmolar contrast media is included in the technical component payment for diagnostic procedures except as specified in paragraph (b) of this section. (b) Conditions for separate payment. For diagnostic procedures furnished to beneficiaries who are neither inpatients nor outpatients of any hospital, separate payment is made for low osmolar contrast media used in all intrathecal injections and in intravenous, and intra-arterial injections, if it is used for patients with one or more of the following characteristics: (1) A history of a previous adverse reaction to contrast material, with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting. (2) A history of asthma or allergy. (3) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmias, unstable angina pectoris, recent myo cardial infarction, and pulmonary hypertension. (4) Generalized severe debilitation. (5) Sickle cell disease. (c) Method of payment. If one of the conditions of paragraph (b) of this section is met, payment is made for low osmolar contrast media as set forth in §414.36 as a drug furnished incident to a physician's service, subject to paragraph (d) of this section. (d) Drug payment reduction. If separate payment is made for low osmolar contrast media, the payment amount calculated in accordance with §414.36 is reduced by 8 percent to account for the allowance for contrast media already included in the technical component of the diagnostic procedure code. [56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, 42493, Sept. 15, 1992] §414.40 Coding and ancillary policies. (a) General rule. HCFA establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. (b) Specific types of policies. HCFA establishes uniform national ancillary policies necessary to implement the fee schedule for physicians' services. These include, but are not limited to, the following policies: (1) Global surgery policy (for example, post- and pre-operative periods and services, and intra-operative services). (2) Professional and technical components (for example, payment for services, such as an EEG, which typically comprise a technical component (the taking of the test) and a professional component (the interpretation)). (3) Payment modifiers (for example, assistant-at-surgery, multiple surgery, bilateral surgery, split surgical global services, team surgery, and unusual services). 8414.42 Adjustment for first 4 years of practice. (a) General rule. For services furnished during CYS 1992 and 1993, except as specified in paragraph (b) of this section, the fee schedule payment amount or prevailing charge must be phased in as specified in paragraph (d) of this section for physicians, physical therapists (PTs), occupational therapists (OTs), and all other health care practitioners who are in their first through fourth years of practice. (b) Exception. The reduction required in paragraph (d) of this section does not apply to primary care services or to services furnished in a rural area as defined in section 1886(d)(2)(D) of the Act that is designated under section 332(a)(1)(A) of the Public Health Service Act as a Health Professional Shortage Area. (c) Definition of years of practice. (1) The "first year of practice" is the first full CY during the first 6 months of which the physician, PT, OT, or other health care practitioner furnishes professional services for which payment may be made under Medicare Part B, plus any portion of the prior CY if that prior year does not meet the first 6 months test. (2) The "second, third, and fourth years of practice“ are the first, second, and third CYS following the first year of practice, respectively. (d) Amounts of adjustment. The fee schedule payment for the service of a new physician, PT, OT, or other health care practitioner is limited to the following percentages for each of the indicated years: (1) First year-80 percent [57 FR 42493, Sept. 15, 1992, as amended at 58 FR 63687, Dec. 2, 1993] 8414.44 Transition rules. (a) Adjusted historical payment basis— (1) All services other than radiology and nuclear medicine services. For all physicians' services other than radiology services, furnished in a fee schedule area, the adjusted historical payment basis (AHPB) is the estimated weighted average prevailing charge applied in the fee schedule area for the service in CY 1991, as determined by HCFA without regard to physician specialty and as adjusted to reflect payments for services below the prevailing charge, adjusted by the update established for CY 1992. (2) Radiology services. For radiology services, the AHPB is the amount paid for the service in the fee schedule area in CY 1991 under the fee schedule estab lished under section 1834(b), adjusted by the update established for CY 1992. (3) Nuclear medicine services. For nuclear medicine services, the AHPB is the amount paid for the service in the fee schedule area in CY 1991 under the fee schedule established under section 6105(b) of Public Law 101-239 and section 4102(g) of Public Law 101-508, adjusted by the update established for CY 1992. (4) Transition adjustment. HCFA adjusts the AHPB for all services by 5.5 percent to produce budget-neutral payments for 1992. (b) Adjustment of 1992 payments for physicians' services other than radiology services. For physicians' services furnished during CY 1992 the following rules apply: (1) If the AHPB determined under paragraph (a) of this section is from 85 percent to 115 percent of the fee schedule amount for the area for services furnished in 1992, payment is at the fee schedule amount. (2) If the AHPB determined under paragraph (a) of this section is less than 85 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB plus 15 percent of the fee schedule amount is substituted for the fee schedule amount. (3) If the AHPB determined under paragraph (a) of this section is greater than 115 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB minus 15 percent of the fee schedule amount is substituted for the fee schedule amount. (c) Adjustment of 1992 payments for radiology services. For radiology services furnished during CY 1992 the following rules apply: (1) If the AHPB determined under paragraph (a) of this section is from 85 percent to 109 percent of the fee schedule amount for the area for services furnished in 1992, payment is at the fee schedule amount. (2) If the AHPB determined under paragraph (a) of this section is less than 85 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB plus 15 percent of the fee sched ule amount is substituted for the fee schedule amount. (3) If the AHPB determined under paragraph (a) of this section is greater than 109 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB minus 9 percent of the fee schedule amount is substituted for the fee schedule amount. (d) Computation of payments for CY 1993. For physicians' services subject to the transition rules in CY 1992 and furnished during CY 1993, the fee schedule is equal to 75 percent of the amount that would have been paid in the fee schedule area under the 1992 transition rules, adjusted by the amount of the 1993 update, plus 25 percent of the 1993 fee schedule amount. (e) Computation of payments for CY 1994. For physicians' services subject to the transition rules in CY 1993, and furnished during CY 1994, the fee schedule is equal to 67 percent of the amount that would have been paid in the fee schedule area under the 1993 transition rules, adjusted by the amount of the 1994 update, plus 33 percent of the 1994 fee schedule amount. (f) Computation of payments for CY 1995. For physicians' services subject to the transition rules in CY 1994 and furnished during CY 1995, the fee schedule is equal to 50 percent of the amount that would have been paid in the fee schedule area under the 1994 transition rules, adjusted by the amount of the 1995 update, plus 50 percent of the 1995 fee schedule amount. 8414.46 Additional rules for payment of anesthesia services. (a) Definitions. For purposes of this section, the following definitions apply: (1) Base unit means the value for each anesthesia code that reflects all activities other than anesthesia time. These activities include usual pre-operative and post-operative visits, the administration of fluids and/or blood incident to anesthesia care, and monitoring procedures. (2) Time units involve the continuous actual presence of the physician (or of the medically directed qualified anesthetist or resident) and start when he or she begins to prepare the patient for anesthesia care and ends when the anesthesiologist (or medically directed CRNA) is no longer in personal attendance, that is, when the patient may be safely placed under post-operative care. (b) General rules. (1) For physician anesthesia services furnished beginning January 1, 1992, HCFA bases payment on the lesser of the actual charge or the physician fee schedule amount in accordance with §414.20. (2) The physician fee schedule amount is based on the product of allowable base and time units and an anesthesia-specific CF. (3) The allowable base units are determined by the uniform relative value guide based on the 1988 American Society of Anesthesiologists' Relative Value Guide except that the number of base units recognized for anesthesia services furnished during cataract or iridectomy surgery is four units. The uniform base units are identified in program operating instructions. (c) Physician personally performs the anesthesia procedure. (1) HCFA determines the fee schedule amount for anesthesia procedures personally performed by a physician on the basis of an anesthesia-specific fee schedule CF and unreduced base units and anesthesia time units. For purposes of this paragraph, one anesthesia time unit is equivalent to 15 minutes of anesthesia time, and fractions of a 15-minute period are recognized as fractions of an anesthesia time unit. (2) HCFA considers an anesthesia procedure to be personally performed by a physician if it meets one of the following circumstances: (i) The physician personally performs the entire anesthesia procedure. (ii) The physician is continuously involved in a single case involving a certified registered nurse anesthetist (CRNA), anesthesiologist assistant (AA), or student nurse anesthetist. (iii) For services furnished before January 1, 1994, the physician establishes an attending physician relationship in one or two concurrent cases involving an intern or resident as described in §405.521 of this chapter. HCFA pays the full fee in each of these two concurrent cases. If the physician is involved in two concurrent cases |