RUC Recommendations May 2021

Home , Laminotomy

AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS RUC RECOMMENDATIONS FOR CPT 2022 May 2021 Meeting

TABLE OF CONTENTS

Table of Contents _ TAB

Table of Contents ...... 01

New/Revised CPT Codes CPT 2022 Codes______TAB

Arthrodesis Decompression (22630, 22632, 22633, 22634, 63052, 63053) ...... 04

Drug Induced Sleep Endoscopy (DISE) (42975) ...... 05

Transcutaneous Passive Implant-Temporal Bone (69714, 69716, 69717, 69719, 69726, 69727) ...... 06

Cardiac Ablation (93613, 93621, 93653, 93654, 93655, 93656, 93657, 93662) ...... 07

AMA/Specialty Society RVS Update Committee Summary of Recommendations

April 2021

Arthrodesis Decompression – Tab 4

In October 2020, the CPT Editorial Panel approved the revision of four codes describing arthrodesis, addition of two codes to report laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar to more appropriately identify the decompression that may be separately reported. A CPT coding change application (CCA) was created to assist with coding confusion for reporting additional decompression performed at the same interspace as a lumbar interbody fusion procedure. The coding confusion stemmed from language ("other than for decompression") included in the descriptors for CPT codes 22630-22634. To clarify correct coding, the CCA created two new add-on codes (63052 and 63053) to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace, and revised definitions, guidelines, and parenthetical instructions. The terms corpectomy, facetectomy, foraminotomy, hemilaminectomy, lamina, laminectomy, and laminotomy were defined and editorial changes were made to several codes to consistently use the term "interspace" instead of "level" or "segment." In January 2021, the specialty societies surveyed the two new add-on codes and indicated that the revisions to existing codes were editorial precluding survey. The RUC disagreed and recommended that the entire family (CPT codes 22630, 22632, 22633, 22634, 63052 and 63053) be surveyed together for review at the April 2021 RUC meeting and interim values were established for CPT codes 63052 and 63053 until these two new codes could be reviewed again with the entire family in April.

22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic surgeons and spine surgeons and determined that maintaining the current work RVU of 22.09, which falls well below the survey 25th percentile, appropriately accounts for the physician work involved in this service. The RUC recommends the following physician time components as supported by the survey: 40 minutes pre-service evaluation, 20 minutes pre-service positioning, 15 minutes pre-service scrub/dress/wait time, 150 minutes intra-service time, and 30 minutes immediate post- service time, 1-99238 discharge visit, 1-99231 and 2-99232 post-operative visits and 2-99213 and 1-99214 office visits, 479 minutes total time. The scrub/dress/wait time was reduced from Pre-time Package 4 so as not to exceed survey median data. The positioning time was increased from the pre-time package to account for the additional work related to prone positioning.

The RUC noted that the total recommended time of 479 minutes is nearly identical to the total time of both the survey and the current code (487 minutes) which was initially valued in 1995. The post-operative visits have decreased by one, but the level of the visits has changed, practically resulting in a net change of zero in overall physician time despite the decrease of one visit. The RUC discussed the significant decrease in intra- service time of 30 minutes and considered crosswalk code alternatives; however, none of the crosswalk code options were deemed clinically comparable or sufficiently matched to the difficulty of the procedure. The change in time for the survey code, since it was valued in 1995, is attributed intra-operatively to the use of more effective drills, better X-rays, and several steps that streamline the procedure and make it more efficient. However, the RUC noted that while the procedure may be more efficient, it is not safer or less difficult. The elements that remain are

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

intense, such that the risk of the procedure, remains the same as it was originally; therefore, the RUC agreed that the current value should be maintained.

To justify the current work RVU of 22.09, the RUC compared the survey code to the top key reference service codes 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (work RVU = 24.79, 180 minutes intra-service time and 549 minutes total time) and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (work RVU = 23.53, 150 minutes intra-service time and 482 minutes total time) and noted that the majority of respondents who chose 22533 as a key reference service indicated that the intensity/complexity of 22630 is similar to or somewhat more than 22533. Also, the respondents who chose 22612 as a key reference service indicated the intensity/complexity of 22630 is more than 22612.

The RUC also compared CPT code 22630 to MPC codes 35301 Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision (work RVU = 21.16, 120 minutes intra-service time and 404 minutes total time) and 32669 Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) (work RVU = 23.53, 150 minutes intra-service time and 502 minutes total time) and noted that the multi-specialty points of comparison code values appropriately bracket the survey code recommendation. For additional support, the RUC noted that the survey code is further bracketed by comparator codes 38720 Cervical lymphadenectomy (complete) (work RVU = 21.95, 150 minutes intra-service time and 482 minutes total time) and 44140 Colectomy, partial; with anastomosis (work RVU = 22.59, 150 minutes intra- service time and 480 minutes total time). The RUC concluded that the value of CPT code 22630 should be maintained at 22.09 work RVUs, which is below the 25th percentile of the survey. The RUC recommends a work RVU of 22.09 for CPT code 22630.

22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic surgeons and spine surgeons and determined that maintaining the current work RVU of 5.22, which falls well below the survey 25th percentile, appropriately accounts for the physician work involved in this add-on service. The RUC recommends 60 minutes of intra-service time and noted that the intraoperative time has not changed since the code was initially valued in 1995. At that time, the value of this code was calculated based on 25% of the base code.

The specialties noted that a comparison to the key reference service codes 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (work RVU = 6.43, 40 minutes intra-service and total time) and 22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure) (work RVU = 6.50, 45 minutes intra-service time and 50 minutes total time) might support a higher work RVU, however, there was no compelling evidence that the work had changed. The RUC agreed that work had not changed.

The RUC also compared CPT code 22632 to MPC code 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) (work RVU = 4.13, 40 minutes intra-service and total time) and

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

noted that the comparator code has less intra-service and total time and is appropriately valued lower than the survey code. The specialties noted that the MPC code involves open femoral artery exposure by groin incision and closure of the wound, typically for separately reported percutaneous delivery of an endovascular prosthesis for an asymptomatic infrarenal abdominal aortic aneurysm (AAA) while, in comparison, the lower intensity exposure and closure for the survey code are performed as part of the primary arthrodesis code.

For additional support, the RUC noted that the survey code is appropriately bracketed by comparator codes with the same time and similar intensity: 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) (work RVU = 5.00, 60 minutes intra-service and total time) and 22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) (work RVU = 5.50, 60 minutes intra- service and total time). The RUC concluded that the value of CPT code 22632 should be maintained at 5.22 work RVUs which is below the 25th percentile of the survey. The RUC recommends a work RVU of 5.22 for CPT code 22632.

22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic surgeons and spine surgeons and concurred that the survey respondents overvalued the physician work involved in performing this service. The RUC determined that changes in intra-service and total time for the procedure warranted a direct work RVU crosswalk to MPC code 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed (work RVU= 26.80, 180 minutes intra-service and 442 minutes total time) which falls below the survey 25th percentile and has identical intra-service time that appropriately accounts for the total physician work involved in this service.

The RUC recommends the following physician time components as supported by the survey: 40 minutes pre-service evaluation, 20 minutes pre- service positioning, 15 minutes pre-service scrub/dress/wait time, 180 minutes intra-service time, and 30 minutes immediate post-service time, 1- 99238 discharge visit, 1-99231 and 2-99232 post-operative visits and 2-99213 and 1-99214 office visits, 509 minutes total time. The scrub/dress/wait time was reduced from Pre-time Package 4 so as not to exceed survey median data. The positioning time was increased from the pre-time package to account for the additional work related to prone positioning. The RUC used a crosswalk due to the changes in visits that caused a decrease in total time, primarily due to a change in inpatient care. Previously, there were two level-3 hospital visits and one level-2 hospital visit, this has been decreased to two level-2 and one level-1 inpatient visit along with a discharge day visit causing a substantial decrease in total time for the procedure, greater than the decrease in intra-service time; thus, a crosswalk was selected rather than recommending maintaining current value. The RUC discussed the recommended crosswalk code 55866 and noted that it is recently reviewed and performed 20,000/year and places the intraoperative intensity appropriately within this family of codes.

To justify the crosswalk value of 26.80 work RVUs, the RUC compared the survey code to the top key reference service code 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (work RVU = 23.53, 150 minutes

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

intra-service time and 482 minutes total time) and 2nd key reference code 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (work RVU = 27.13, 180 minutes intra- service time and 550 minutes total time) and noted that the physician work and total time of the survey code is appropriately bracketed between the two reference services using magnitude estimation.

For additional support, the RUC noted that the survey code is appropriately bracketed by comparator codes with the same intraoperative time and similar intensity: 43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh (complete) (work RVU = 26.60, 180 minutes intra-service time and 424 minutes total time). The RUC concluded that, given changes in intra- service and total time for the procedure, CPT code 22633 should be valued based on a direct work RVU crosswalk to CPT code 55866 which falls below the survey 25th percentile and preserves rank order within the family. The RUC recommends a work RVU of 26.80 for CPT code 22633.

22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; each additional interspace and segment (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic surgeons and spine surgeons and determined that the survey 25th percentile work RVU of 7.96 appropriately accounts for the physician work involved in this add-on service and is less than the current value. The RUC noted that the current value for 22634 is based on a calculation in 2011 that estimated the new add-on code was 70% of the survey 25th percentile work RVU. Although the current survey median work RVU would suggest an increase is warranted, the specialty did not present compelling evidence for an increase and the RUC recommends a decrease in the work RVU to account for the five minute decrease in median intra-service time. The RUC recommends 65 minutes of intra-service time as supported by the survey. The RUC noted that this service is more difficult and complex than CPT code 22632 due to the more complex patient undergoing this procedure and considerable additional steps that are not included in 22630 and 22632.

To justify a work RVU of 7.96, the RUC compared the survey code to the top key reference service code 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (work RVU = 6.43, 40 minutes intra-service and total time) and noted that the survey code has greater intra-service and total time and involves more physician work than the reference service. It was also rated as more intense/complex overall than the key reference service by 88% of survey respondents who selected the KRS. The RUC also compared CPT code 22634 to MPC code 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) (work RVU = 4.13, 40 minutes intra-service and total time) and noted that the MPC code has much less intra-service and total time and is appropriately valued lower than the survey code.

For additional support, the RUC noted that the survey code is bracketed by comparator codes 34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) (work RVU = 7.00, 60 minutes intra-service and total time) and 33746 Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac catherization for congenital cardiac anomalies, and target zone

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

angioplasty, when performed (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); each additional intracardiac shunt location (List separately in addition to code for primary procedure) (work RVU = 8.00, 60 minutes intra-service and total time). The RUC concluded that CPT code 22634 should be valued at the 25th percentile work RVU as supported by the survey and comparator codes. The RUC recommends a work RVU of 7.96 for CPT code 22634.

63052 Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic surgeons and spine surgeons and determined that the survey 25th percentile work RVU of 5.70 appropriately accounts for the physician work involved in this add-on service. The RUC recommends 45 minutes intra-service time and noted that the time has increased by five minutes compared to the previous survey and that the recommendation is slightly higher than the interim recommendation. This code was initially surveyed in January of 2021. At that time, the RUC concluded that the survey was flawed because the add-on codes were not surveyed in conjunction with the base codes. The RUC was concerned that without the base codes and add-on codes being surveyed together, that the survey for the add-on codes may have included work from the primary codes. For this reason, an interim value was assigned with guidance to the specialties to perform a new survey to include the add-on codes and the base codes. The current survey included all six codes on one survey instrument. Additionally, the overall experience of the survey respondents is greater for the new survey of six codes when compared to the prior survey of only the new add-on codes. The RUC determined that the value of 5.70 is more accurate as it is based on the survey of the entire code family and further noted that compelling evidence is not necessary for increases over interim values since interim values are, by definition, temporary. The RUC also noted that the time included in this add-on service is essentially all high-risk. The lower intensity surgical exposure activities have already been completed with the base code, so the physician work of 63052 involves is the actual higher intensity decompression as clarified by CPT.

To justify a work RVU of 5.70, the RUC compared the survey code to the top key reference service code 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) (work RVU = 12.52, 60 minutes intra-service and total time) and noted that the reference code has both more physician work and intra-service time and is therefore valued higher.

The RUC also compared the survey code to MPC code 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) (work RVU = 4.13, 40 minutes intra-service and total time) and noted that the MPC code involves open femoral artery exposure by groin incision and closure of the wound, typically for separately reported delivery of an endovascular prosthesis for an asymptomatic infrarenal abdominal aortic aneurysm (AAA). In comparison, exposure and closure for the survey code are performed as part of the primary arthrodesis code and the intra-service time includes bony and soft tissue resection (typically pathologic and not normal in nature) and decompression of neural elements in immediate high-risk proximity of the pathologic anatomy. Therefore, the physician work, time, and intensity of 63052 is greater than 34812.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

For additional support, the RUC noted that the survey code is appropriately bracketed by comparator codes with the same intraoperative time and similar intensity: 22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure) (work RVU = 6.50, 45 minutes intra-service time and 50 minutes total time) and code 22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) (work RVU = 5.52, 45 minutes intra-service and total time). The RUC concluded that CPT code 63052 should be valued at the 25th percentile work RVU as supported by the survey and comparator codes using magnitude estimation. The RUC recommends a work RVU of 5.70 for CPT code 63052.

63053 Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 111 neurosurgeons, orthopaedic and spine surgeons and determined that the survey 25th percentile work RVU of 5.00 appropriately accounts for the physician work involved in this add-on service. The RUC recommends 40 minutes intra-service time and noted that the time has increased by ten minutes compared to the previous survey. This code was initially surveyed in January of 2021. At that time, the RUC concluded that the survey was flawed because the add-on codes were not surveyed in conjunction with the base codes. For this reason, an interim value was assigned with guidance to the specialties to perform a new survey to include the add-on codes and the base codes. The new survey, which included all six codes, elicited a time that is only five minutes less than the work related to 63052 and is believed to be a more accurate reflection of the difference in work between laminectomy/facetectomy/foraminotomy with decompression of the first segment and of an additional segment. The RUC determined that the new value is more accurate as it is based on the survey of the entire code family and further noted that compelling evidence is not necessary for increases over interim values since interim values are, by definition, temporary.

To justify a work RVU of 5.00, the RUC compared the survey code to the top key reference service code 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (work RVU = 6.43, 40 minutes intra-service and total time) and noted that the codes have the same intra-service time, but the reference code is more intense and is appropriately valued higher than the survey code using magnitude estimate. The RUC also compared the survey code to the second key reference service code 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) (work RVU = 12.52, 60 minutes intra-service and total time) and noted that this reference code has more physician work and intra- service time and is therefore valued higher than the survey code.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

(typically pathologic and not normal in nature) and decompression of neural elements in immediate high-risk proximity of the pathologic anatomy. Therefore, the physician work and intensity of 63053 is appropriately greater than 34812.

For additional support, the RUC noted that the survey code is appropriately bracketed by comparator codes with the similar intraoperative time and similar intensity: 44128 Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure) (work RVU = 4.44, 40 minutes intra-service and total time) and 22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) (work RVU = 5.52, 45 minutes intra- service and total time). The RUC concluded that CPT code 63053 should be valued at the 25th percentile work RVU as supported by the survey and comparator codes using magnitude estimation. The RUC recommends a work RVU of 5.00 for CPT code 63053.

Practice Expense The Practice Expense Subcommittee removed the EQ168 light, exam for CPT codes 22630 and 22633. No direct practice expense inputs were recommended for the facility-only add-on codes 22632, 22634, 63052 and 63053. The RUC recommends the direct practice expense inputs as modified by the Practice Expense Subcommittee.

CPT Tracking Global Work RVU Code Number CPT Descriptor Period Recommendation Arthrodesis Posterior, Posterolateral or Lateral Transverse Process Technique

To report instrumentation procedures, see 22840-22855, 22859. (Report in addition to code[s] for the definitive procedure[s].) Do not append modifier 62 to spinal instrumentation codes 22840-22848, 22850, 22852, 22853, 22854, 22859.

To report bone graft procedures, see 20930-20938. (Report in addition to code[s] for the definitive procedure[s].) Do not append modifier 62 to bone graft codes 20900-20938. Corpectomy identifies removal of a vertebral body during spinal surgery. Facetectomy is the excision of the facet joint between two vertebral bodies. There are two facet joints at each vertebral segment (see below) Foraminotomy is the excision of bone to widen the intervertebral foramen. The intervertebral foramen is bordered by the superior notch of the adjacent vertebra, the inferior notch of the vertebra, the facet joint and the intervertebral disc.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Hemilaminectomy is removal of a portion of a vertebral lamina, usually performed for exploration of, access to, or decompression of the intraspinal contents. Lamina pertains to the vertebral arch, the flattened posterior portion of the vertebral arch extending between the pedicles and the midline, forming the dorsal wall of the vertebral foramen, and from the midline junction of which the spinous process extends. Laminectomy is excision of a vertebral lamina; commonly used to denote removal of the posterior arch. Laminotomy is excision of a portion of the vertebral lamina, resulting in enlargement of the intervertebral foramen for the purpose of relieving pressure in on a spinal nerve root. A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the nonbony compartment between two adjacent vertebral bodies which contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates. Decompression performed on the same vertebral segment(s) and/or interspace[s] as posterior lumbar interbody fusion that includes laminectomy, facetectomy, and/or foraminotomy may be separately reported using 63052, 63053. Decompression solely to prepare the interspace for fusion is not separately reported. (e)22600 - 090 17.40 Arthrodesis, posterior or posterolateral technique, single level (No change) interspace; cervical below C2 segment

(e)22610 - 090 17.28 thoracic (with lateral transverse technique, when (No change) performed)

(e)22612 - 090 23.53 lumbar (with lateral transverse technique, when (No change) performed)

(Do not report 22612 in conjunction with 22630 for the same interspace and segment, use 22633) (e)22614 - ZZZ 6.43 each additional vertebral segment interspace (List (No change) separately in addition to code for primary procedure)

(Use 22614 in conjunction with 22600, 22610, 22612, 22630 or 22633 when performed for arthrodesis at a different level interspace. When performing a posterior or posterolateral technique for fusion/arthrodesis at an additional level interspace, use 22614. When performing a posterior interbody fusion arthrodesis at an additional level interspace,

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

use 22632. When performing a combined posterior or posterolateral technique with posterior interbody arthrodesis at an additional level interspace, use 22634) (For facet joint fusion, see 0219T-0222T) (For placement of a posterior intrafacet implant, see 0219T-0222T) (f)22630 J1 090 22.09 Arthrodesis, posterior interbody technique, including laminectomy (No change) and/or discectomy to prepare interspace (other than for

decompression), single interspace; lumbar

(Do not report 22630 in conjunction with 22612 for the same interspace and segment, use 22633) (f)22632 J2 ZZZ 5.22 each additional interspace (List separately in addition to (No change) code for primary procedure)

(Use 22632 in conjunction with 22612, 22630, or 22633 when performed at a different level interspace. When performing a posterior interbody fusion arthrodesis at an additional level interspace, use 22632. When performing a posterior or posterolateral technique for fusion/arthrodesis at an additional level interspace, use 22614. When performing a combined posterior or posterolateral technique with posterior interbody arthrodesis at an additional level interspace, use 22634) 22633 J3 090 26.80 Arthrodesis, combined posterior or posterolateral technique with

posterior interbody technique including laminectomy and/or

discectomy sufficient to prepare interspace (other than for

decompression), single interspace and segment; lumbar (Do not report with 22612 or 22630 at the for the same level interspace) 22634 J4 ZZZ 7.96 each additional interspace and segment (List separately

in addition to code for primary procedure)

(Use 22634 in conjunction with 22633)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

(Do not report 22630, 22632, 22633, 22634 in conjunction with 63030, 63040, 63042, 63047, 63056, 63052, 63053, for laminectomy performed to prepare the interspace on the same spinal interspace[s]) (To report decompression performed on the same interspace as posterior interbody fusion that includes laminectomy, removal of facets, and/or opening/widening of the foramen for decompression of nerves or spinal components such as spinal cord, cauda equina, or nerve roots, see 63052, 63053) Nervous System Posterior Extradural Laminotomy or Laminectomy for Exploration/Decompression of Neural Elements or Excision of Herniated Intervertebral Discs Definitions For purposes of CPT coding . . . 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical (For bilateral procedure, report 63020 with modifier 50) 63030 1 interspace, lumbar (For bilateral procedure, report 63030 with modifier 50) +63035 each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) (Use 63035 in conjunction with 63020-63030) (Do not report 63030, 63035 in conjunction with 22630, 22632, 22633, 22634 for laminotomy performed to prepare the interspace for fusion on the same spinal interspace) (To report decompression performed on the same interspace and vertebral segment[s] as posterior interbody fusion that includes laminectomy, removal of facets, and/or opening/widening of the foramen for decompression of nerves or spinal components such as spinal cord, cauda equina, or nerve roots, see 63052, 63053) (For bilateral procedure, report 63035 twice. Do not report modifier 50 in conjunction with 63035) (For percutaneous endoscopic approach, see 0274T, 0275T) 63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

63042 lumbar (For bilateral procedure, report 63042 with modifier 50) +63043 each additional cervical interspace (List separately in addition to code for primary procedure) (Use 63043 in conjunction with 63040) (For bilateral procedure, report 63043 twice. Do not report modifier 50 in conjunction with 63043) 63044 each additional lumbar interspace (List separately in addition to code for primary procedure) (Use 63044 in conjunction with 63042) (Do not report 63040, 63042, 63043, 63044, in conjunction with 22630, 22632, 22633, 22634 for laminotomy to prepare the interspace for fusion on the same interspace and vertebral segment[s])

(To report decompression performed on the same vertebral segments and/or interspace[s] as posterior interbody fusion that includes laminectomy, removal of facets, and/or opening/widening of the foramen for decompression of nerves or spinal components such as spinal cord, cauda equina, or nerve roots, see 63052, 63053) (For bilateral procedure, report 63044 twice. Do not report modifier 50 in conjunction with 63044) Decompression performed on the same vertebral segments and/or interspace[s] as posterior interbody fusion that includes laminectomy, facetectomy, or foraminotomy may be separately reported using 63052. Codes 63052, 63053 may only be reported for decompression at the same anatomic site(s) when posterior interbody fusion (eg, 22630) requires decompression beyond preparation of the interspace(s) for fusion. 63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical 63046 thoracic 63047 lumbar 63048 each additional vertebral segment, cervical, thoracic or lumbar (List separately in addition to code for primary procedure (Use 63048 in conjunction with 63045-63047) (Do not report 63047, 63048 in conjunction with 22630, 22632, 22633, 22634 for laminectomy performed to prepare the interspace for fusion on the same vertebral segments and/or interspace[s])

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

63052 J5 ZZZ 5.70 Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral

with decompression of spinal cord, cauda equina and/or nerve root[s]

[eg, spinal or lateral recess stenosis]), during posterior interbody

arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) 63053 J6 ZZZ 5.00 each additional segment (List separately in addition to

code for primary procedure)

(Use 63053 in conjunction with 63052)

(Use 63052, 63053 in conjunction with 22630, 22632, 22633, 22634) 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;

63051 with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)

Transpedicular or Costovertebral Approach for Posterolateral Extradural Exploration/Decompression 63055 Transpedicular approach with decompression of spinal cord, equine and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic 63056 lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) 63057 each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure (Use 63057 in conjunction with 63055, 63056) (Do not report 63056, 63057 for a herniated disc, in conjunction with 22630, 22632, 22633, 22634 for decompression to prepare the interspace on the same interspace[s]) (To report decompression performed on the same interspace[s] as posterior interbody fusion that includes laminectomy, removal of facets, or opening/widening of the foramen for decompression of nerves or spinal components such as spinal cord, cauda equina, or nerve roots, see 63052, 63053)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 22630 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:22630 Tracking Number J1 Original Specialty Recommended RVU: 22.09 Presented Recommended RVU: 22.09 Global Period: 090 Current Work RVU: 22.09 RUC Recommended RVU: 22.09

CPT Descriptor: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 48-year-old male with a history of previous discectomy at L4-L5 presents with a spondylolisthesis and intractable back pain that improves with recumbency or back bracing. Non-operative treatments have failed to control his symptoms. Arthrodesis via a unilateral or bilateral approach of L4-L5 is performed using a posterior interbody technique. (Note: Decompression, instrumentation and/or bone preparation or harvesting, when performed, is separately reported.)

Percentage of Survey Respondents who found Vignette to be Typical: 85%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 99% , In the ASC 1%, In the office 0%

Percent of survey respondents who stated they typically perform this procedure in the hospital, stated the patient is; Discharged the same day 0% , Overnight stay-less than 24 hours 13% , Overnight stay-more than 24 hours 88%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 94%

Description of Pre-Service Work: Review preoperative laboratory workup. Write preoperative orders for perioperative medications. Review MRI and/or other spinal imaging studies. Review planned incisions and procedure. Update H&P, review current medications, review surgical procedure, postoperative recovery in and out of the hospital, and the expected outcome(s) with patient and family. Sign and mark operative site. Obtain informed consent. Verify all necessary surgical instruments, supplies, and devices are available in the operative suite. Review length and type of anesthesia with the anesthesiologist. Perform preoperative time out, confirming patient identity, surgical site, procedure, indicated intraoperative medications, and antibiotic and DVT prophylaxis, as necessary. Monitor initial patient positioning for induction of anesthesia. Monitor initial patient positioning for placement of neuromonitoring electrodes. Following induction of anesthesia, assist with positioning of the patient prone. Verify and/or assist with padding of the patient to prevent pressure on neurovascular structures and placement of any traction devices to facilitate intraoperative imaging. Scrub and gown. Supervise preparing and draping of the patient. Perform surgical time out.

Description of Intra-Service Work: Following skin incision, dissection is carried out through the subcutaneous tissue and fascia to the posterior spinal elements. The subcutaneous and muscular tissues are reflected to expose the posterior surface of the lamina and over the facet(s) and/or transverse processes of the segment to be fused. Verification of the levels is confirmed with imaging. Bone cutting tools are used to remove as much of the lamina above and below the facets and to remove as much of the medial edges of the facets as is necessary for adequate exposure of the disc space. The nerve root is carefully mobilized from adhesions and/or peridural membrane. Epidural veins are cauterized and cut. The nerve root(s) and thecal sac are protected by packing and retraction. The annulus is incised, and an ample section of it is removed by sharp dissection. The nucleus is removed within the disc space with rongeurs and curettes. Bone cutting instruments are used to remove cartilaginous and subchondral end-plates of the vertebrae above and below the disc to be fused. The bone dissection is fashioned to accept the graft in a way that will provide for contact, maintenance of disc space height, and stability. The spacer (graft and/or device with graft) is impacted into the recipient site. When appropriate, the entire exposure, bone preparation, and spacer insertion and impaction are repeated from the other side of the table. The neural elements are inspected to confirm that they are free of any impingement from the implants in the canal and neuroforamen. An interposition membrane, as by free fat graft, may be used to cover the exposed dura and nerve root. Muscles and fascia CPT Code: 22630 are sutured. A drain is inserted through a separate stab wound and secured. The subcutaneous tissues and skin are closed. (Note: Decompression of neural elements, instrumentation, and/or bone preparation or harvesting, when performed, are separately reported.)

Description of Post-Service Work: Facility: Apply sterile dressings. Assist with repositioning patient supine. When anesthesia has been reversed, transfer the patient to the recovery room. Write an operative note in the patient’s record. Monitor patient for abnormal neurological findings prior to discharge from recovery to the surgical floor. Sign the OR forms, including pre- and postoperative diagnosis and operations performed. Discuss procedure outcome with family. Dictate postoperative report. Dictate procedure outcome and expected recovery letter for referring physician and/or insurance company. Order and review films to check the alignment of the lumbar spine. Later the same day, review nursing and other provider chart notes, assess patient neurovascular status and pain. Write orders or update orders, as necessary, for medications, diet, and patient activity. Chart patient progress notes. On subsequent days, examine the patient, check wounds and neurovascular status. Review nursing and other provider chart notes. Chart patient progress notes. Discuss (oral/written) patient progress with referring physician. Answer (oral/written) questions from patient and/or family, nursing and other staff, and insurance staff. When safe to discharge patient to home, conduct final exam, including neurovascular and pain status, write orders for follow-up visits, post-discharge laboratory tests, imaging, home care, and physical therapy. Order medications needed post- discharge. Discuss home restrictions and activity levels (ie, diet, bathing, driving, exercise) and follow-up planning with patient/family. Complete all appropriate medical records, including day of discharge progress notes, discharge summary, discharge instructions, and insurance forms.

Office: Examine patient and perform neurological exam and pain assessment. Write orders for medications. Order and review periodic imaging, as appropriate. Monitor wounds and remove sutures and staples when appropriate. Review physical therapy progress and revise orders as needed. Dictate patient progress notes for the medical chart. Answer patient and/or family questions and insurance staff questions. Discuss (oral/written) patient progress with referring physician. CPT Code: 22630 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 22630

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 5.00 10.00 33.00 300.00 Survey RVW: 19.60 25.00 25.52 28.00 35.00 Pre-Service Evaluation Time: 48.00 Pre-Service Positioning Time: 20.00 Pre-Service Scrub, Dress, Wait Time: 15.00 Intra-Service Time: 60.00 120.00 150.00 180.00 270.00 Immediate Post Service-Time: 30.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 100.00 99231x 1.00 99232x 2.00 99233x 0.00 Discharge Day Mgmt: 38.00 99238x 1.00 99239x 0.00 99217x 0.00 Office time/visit(s): 86.00 99211x 0.00 12x 0.00 13x 2.00 14x 1.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 4-FAC Difficult Patient/Difficult Procedure

CPT Code: 22630 Recommended Physician Work RVU: 22.09 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 40.00 40.00 0.00 Pre-Service Positioning Time: 20.00 3.00 17.00 Pre-Service Scrub, Dress, Wait Time: 15.00 20.00 -5.00 Intra-Service Time: 150.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9B General Anes or Complex Regional Blk/Cmplx Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 30.00 33.00 -3.00

CPT Code: 22630

Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 100.00 99231x 1.00 99232x 2.00 99233x 0.00 Discharge Day Mgmt: 38.00 99238x 1.0 99239x 0.0 99217x 0.00 Office time/visit(s): 86.00 99211x 0.00 12x 0.00 13x 2.00 14x 1.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22533 090 24.79 RUC Time

CPT Descriptor Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22612 090 23.53 RUC Time

CPT Descriptor Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 35301 090 21.16 RUC Time 35,904 CPT Descriptor 1 Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 32669 090 23.53 RUC Time 1,894

CPT Descriptor 2 Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy)

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below. CPT Code: 22630

Number of respondents who choose Top Key Reference Code: 30 % of respondents: 27.0 %

Number of respondents who choose 2nd Key Reference Code: 25 % of respondents: 22.5 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 22630 22533 22612

Median Pre-Service Time 75.00 116.00 95.00

Median Intra-Service Time 150.00 180.00 150.00

Median Immediate Post-service Time 30.00 30.00 30.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 100.0 100.00 100.00 Median Discharge Day Management Time 38.0 38.00 38.00 Median Office Visit Time 86.0 85.00 69.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 479.00 549.00 482.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 7% 38% 43% 13%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 7% 53% 40% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 7% 50% 43%

Physical effort required 3% 43% 53% CPT Code: 22630

Psychological Stress Less Identical More

• The risk of significant complications, 17% 47% 37% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 0% 20% 52% 28%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 24% 76% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 20% 80%

Physical effort required 4% 24% 72%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 36% 64% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Describe the process by which your specialty society reached your final recommendation. If your society has used an IWPUT analysis, please refer to the Instructions for Specialty Societies Developing Work Relative Value Recommendations for the appropriate formula and format.

The additional rationale below is the original rationale submitted by the specialty society(ies) prior to the RUC meeting and does not necessarily represent the rationale for the RUC recommendation. To view the RUC’s rationale, please review the separate RUC recommendation document.

CPT Code: 22630 Background

In January 2021, the specialty societies surveyed the two new codes and indicated the existing code changes were editorial. The RUC expressed concern that the base codes were not surveyed with the two new add-on codes. Two of the codes (22630 and 22632) are from 1995 and the other two codes were last RUC reviewed in 2011 (22633 and 22634). The RUC could not accept the specialties’ justification for only surveying the new codes. They questioned how, without the base codes being surveyed, there would be assurance the respondents followed instruction to only consider the work of the add-on codes. Moreover, CMS has made it clear that the Agency expects the base codes and add-on codes to be reviewed at the same time. The RUC recommends that the entire family (CPT codes 22630, 22632, 22633, 22634, 63052 , 63053) be resurveyed for review at the April 2021 RUC meeting and that interim values be established for CPT codes 63052 and 63053 for CY 2022.

Recommendation – 22630 We recommend maintaining the current work RVU of 22.09. Although the intraoperative time decreased, the postoperative work increased and the total time is nearly identical.

Positioning time Additional time was added to the package time of 3 minutes for supine positioning. These patients will typically be positioned prone.

Key Reference Code Comparison KRS1: The respondents who chose 22533 as a reference indicated the intensity/complexity of 22630 is similar to somewhat more than 22533. KRS2: The respondents who chose 22612 as a reference indicated the intensity/complexity of 22630 is more than 22612.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace 22630 22.09 0.078 479 75 150 254 (other than for decompression), single interspace; lumbar Arthrodesis, lateral extracavitary technique, including 22533 minimal discectomy to prepare interspace (other than 24.79 0.076 549 116 180 253 for decompression); lumbar Arthrodesis, posterior or posterolateral technique, single 22612 level; lumbar (with lateral transverse technique, when 23.53 0.088 482 95 150 237 performed)

MPC Code Comparison

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Thromboendarterectomy, including patch graft, if 35301 performed; carotid, vertebral, subclavian, by neck 21.16 0.104 404 75 120 209 incision Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace 22630 22.09 0.078 479 75 150 254 (other than for decompression), single interspace; lumbar CPT Code: 22630 Thoracoscopy, surgical; with removal of a single lung 32669 23.53 0.084 502 75 150 277 segment (segmentectomy)

Other Code Comparison Codes 38720 and 44140 bracket and offer further support of the recommended wRVU of 22.09 for 22630.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST 38720 Cervical lymphadenectomy (complete) 21.95 0.075 482 75 150 257 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace 22630 22.09 0.078 479 75 150 254 (other than for decompression), single interspace; lumbar 44140 Colectomy, partial; with anastomosis 22.59 0.079 480 60 150 270

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

The surveyed code is an add-on code or a base code expected to be reported with an add-on code. Different specialties work together to accomplish the procedure; each specialty codes its part of the physician work using different codes. Multiple codes allow flexibility to describe exactly what components the procedure included. Multiple codes are used to maintain consistency with similar codes. Historical precedents. Other reason (please explain)

2. Please provide a table listing the typical scenario where this code is reported with multiple codes. Include the CPT codes, global period, work RVUs, pre, intra, and post-time for each, summing all of these data and accounting for relevant multiple procedure reduction policies. If more than one physician is involved in the provision of the total service, please indicate which physician is performing and reporting each CPT code in your scenario. Decompression, instrumentation and/or bone preparation or harvesting, when performed, is separately reported.

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 22630

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty neurosurgery How often? Sometimes

Specialty orthopaedic surgery How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. national data not available

CPT Code: 22630 Specialty Frequency Percentage %

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 5,654 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. RUC database

Specialty neurosurgery Frequency 4100 Percentage 72.51 %

Specialty orthopaedic surgery Frequency 1554 Percentage 27.48 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Berenson-Eggers Type of Service (BETOS) Assignment Please pick the appropriate BETOS classification that best corresponds to the clinical nature of this CPT code. Please select the main BETOS classification and sub-classification to the greatest level of specificity possible.

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 22630

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 22632 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:22632 Tracking Number J2 Original Specialty Recommended RVU: 5.22 Presented Recommended RVU: 5.22 Global Period: ZZZ Current Work RVU: 5.22 RUC Recommended RVU: 5.22

CPT Descriptor: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 70-year-old male with a history of previous discectomy and posterolateral fusion of L4-L5, presents with pseudarthrosis of L4-L5, progressive spondylolisthesis of L5-S1, minimal signs of nerve root dysfunction, and intractable back pain that improves with recumbency or back bracing. Non-operative treatments have failed to control his symptoms. During (separately reported) posterior lumbar interbody arthrodesis of L4-L5, he undergoes additional interspace arthrodesis of L5-S1 via a unilateral or bilateral approach using a posterior interbody technique. (Note: This is an add-on procedure. Decompression, instrumentation and/or bone preparation or harvesting, when performed, is separately reported. Only consider the additional work related to the posterior interbody arthrodesis of the additional L5-S1 interspace.)

Percentage of Survey Respondents who found Vignette to be Typical: 81%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: n/a

Description of Intra-Service Work: Skin, muscle, and fascia incisions are extended to provide for enough retraction to safely expose the additional interspace. The ligamentum flavum and/or scar is removed from between the laminae of the additional interspace. The laminae and medial edges of the facets are removed with bone cutting instruments to a degree sufficient to allow safe exposure of the disc space. The nerve root is carefully mobilized from adhesions and/or peridural membrane. Epidural veins are cauterized and cut. The nerve root(s) and thecal sac are protected by packing and retraction. The annulus is incised, and an ample section of it is removed by sharp dissection. The nucleus is removed within the disc space with rongeurs and curettes. Bone cutting instruments are used to remove cartilaginous and subchondral end-plates of the vertebrae above and below the disc to be fused. The bone dissection is fashioned to accept the graft in a way that will provide for contact, maintenance of disc space height, and stability. The spacer (graft and/or device) is impacted into the recipient site. When appropriate, the entire exposure, bone preparation, and spacer insertion and impaction are repeated from the other side of the table. The neural elements are inspected to confirm that they are free of any impingement from the implant(s) in the canal and neuroforamen. An interposition membrane, as by fat graft, is applied over the exposed dura and nerve roots of the additional space. (Note: Decompression of neural elements, instrumentation, and/or bone preparation or harvesting, when performed, are separately reported.)

Description of Post-Service Work: n/a CPT Code: 22632 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 22632

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 1.00 5.00 20.00 300.00 Survey RVW: 3.00 6.23 7.48 9.44 34.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 22.00 45.00 60.00 60.00 240.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 22632 Recommended Physician Work RVU: 5.22 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 60.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 22632

Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.0 99239x 0.0 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22614 ZZZ 6.43 RUC Time

CPT Descriptor Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22552 ZZZ 6.50 RUC Time

CPT Descriptor Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 22632 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 26 % of respondents: 23.4 %

Number of respondents who choose 2nd Key Reference Code: 23 % of respondents: 20.7 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 22632 22614 22552

Median Pre-Service Time 0.00 0.00 5.00

Median Intra-Service Time 60.00 40.00 45.00

Median Immediate Post-service Time 0.00 0.00 0.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 60.00 40.00 50.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 0% 27% 50% 23%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 31% 69% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 35% 65%

Physical effort required 8% 31% 62% CPT Code: 22632

Psychological Stress Less Identical More

• The risk of significant complications, 0% 42% 58% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 4% 35% 57% 4%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 4% 39% 57% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 4% 48% 48%

Physical effort required 0% 30% 70%

Psychological Stress Less Identical More

• The risk of significant complications, 9% 48% 43% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background

In October 2020, the CPT Editorial Panel approved the revision of four codes describing arthrodesis, addition of two codes to report laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar to more appropriately identify the decompression that may be separately reported. A coding change application was created to assist with coding confusion for reporting additional decompression performed at the same interspace as a lumbar CPT Code: 22632 interbody fusion procedure. The coding confusion stemmed from language ("other than for decompression") included in the descriptors for codes 22630-22634. To clarify correct coding, the CCA created two new add-on codes (63052 and 63053) to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace, along with definitions, guidelines, and parenthetical instructions. The terms corpectomy, facetectomy, foraminotomy, hemilaminectomy, lamina, laminectomy, and laminotomy were defined and editorial changes were made to several codes to consistently use the term "interspace" instead of "level" or "segment."

Recommendation – 22632 The current value for 22632 is based on a calculation in 1995 that estimated the add-on code was 25% of the primary procedure for an additional interspace. Although the current survey would suggest an increase is warranted in comparison to other similar codes, we do not have compelling evidence for an increase. Therefore, we recommend maintaining the current work RVU of 5.22. Intraoperative time has not changed.

Key Reference Code Comparison KRS1: The respondents who chose 22614 as a reference indicated the intensity/complexity of 22632 is more/much more than 22614. KRS2: The respondents who chose 22552 as a reference indicated the intensity/complexity of 22632 is similar/more than 22552.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace 22632 (other than for decompression), single interspace; each 5.22 0.087 60 0 60 0 additional interspace (List separately in addition to code for primary procedure) Arthrodesis, posterior or posterolateral technique, single 22614 level; each additional vertebral segment (List separately 6.43 0.161 40 0 40 0 in addition to code for primary procedure) Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and 22552 decompression of spinal cord and/or nerve roots; 6.50 0.142 50 5 45 0 cervical below C2, each additional interspace (List separately in addition to code for primary procedure)

MPC Code Comparison There are few MPC codes with a ZZZ global assignment which makes finding appropriate MPC codes with similar intensity/complexity difficult. MPC code 34812 (with the highest wRVU) involves open femoral artery exposure by groin incision and closure of the wound, typically for separately reported percutaneous delivery of an endovascular prosthesis for an asymptomatic infrarenal AAA. In comparison, the lower intensity exposure and closure for the survey code are performed as part of the primary arthrodesis code.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral 34812 4.13 0.103 40 0 40 0 (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including 22632 5.22 0.087 60 0 60 0 laminectomy and/or discectomy to prepare interspace CPT Code: 22632 (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

Other Code Comparison Codes 11008 and 22854 bracket and offer further support of the recommended wRVU of 5.22 for 22632.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection 11008 5.00 0.087 60 0 60 0 or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace 22632 (other than for decompression), single interspace; each 5.22 0.087 60 0 60 0 additional interspace (List separately in addition to code for primary procedure) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) 22854 5.50 0.092 60 0 60 0 (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 22632

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty. CPT Code: 22632

Specialty neurosurgery How often? Sometimes

Specialty orthopaedic surgery How often? Sometimes

Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 1,875 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. RUC database

Specialty neurosurgery Frequency 1300 Percentage 69.33 %

Specialty orthopaedic surgery Frequency 575 Percentage 30.66 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 22632

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 22633 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:22633 Tracking Number J3 Original Specialty Recommended RVU: 26.80 Presented Recommended RVU: 26.80 Global Period: 090 Current Work RVU: 27.75 RUC Recommended RVU: 26.80

CPT Descriptor: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 68-year-old female presents with a degenerative spondylolisthesis of L4-L5 causing mechanical low back pain. Non-operative treatments have failed to control her symptoms. Via unilateral or bilateral approach to the L4-L5 interspace, arthrodesis is performed using a posterolateral technique with posterior interbody technique. (Note: Decompression, instrumentation, and/or bone preparation or harvesting, when performed, is separately reported.)

Percentage of Survey Respondents who found Vignette to be Typical: 88%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 100% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 94%

Description of Intra-Service Work: Following skin incision, dissection is undertaken through the subcutaneous tissue and fascia to the posterior spinal elements. The subcutaneous and muscular tissues are reflected to expose the posterior surface of the lamina and out over the facet(s) and/or transverse processes of the segment to be fused. Verification of the levels is undertaken with imaging. Bone cutting tools are used to remove as much of the lamina above and below and as much of the medial edges of the facets as is necessary for adequate exposure of the disc space. The nerve root is carefully mobilized from adhesions and/or peridural membrane. Epidural veins are cauterized and cut. The nerve root(s) and thecal sac are protected by packing and retraction. The annulus is incised, and an ample section of it is removed by sharp dissection. The nucleus is removed within the disc space with rongeurs and curettes. Bone cutting instruments are used to remove cartilaginous and subchondral end-plates of the vertebrae above and below the disc to be fused. The bone dissection is fashioned to accept the graft in a way that will provide for contact, maintenance of disc space height, and stability. The spacer (graft and/or device) is impacted into the recipient site. When appropriate, the entire exposure, bone preparation, and spacer insertion and impaction are repeated from the other side of the table. Decortication of the posterolateral elements (transverse process, any remaining lamina, and/or facets) is undertaken, and graft material is packed posterolaterally to complete the arthrodesis preparations for the fusion. The neural elements are inspected to confirm that CPT Code: 22633 they are free of any impingement from the implants in the canal and neuroforamen. An interposition membrane, as by free fat graft, may be used to cover the exposed dura and nerve root. Muscles and fascia are sutured. A drain is inserted through a separate stab wound and secured. The subcutaneous tissues and skin are closed. (Note: Decompression of neural elements, instrumentation, and/or bone preparation or harvesting, when performed, are separately reported.)

Description of Post-Service Work: Facility: Apply sterile dressings. Assist with repositioning patient supine. When anesthesia has been reversed, transfer the patient to the recovery room. Write an operative note in the patient’s record. Monitor patient for abnormal neurological findings prior to discharge from recovery to the surgical floor. Sign the OR forms, including pre- and postoperative diagnosis and operations performed. Discuss procedure outcome with family. Dictate postoperative report. Dictate procedure outcome and expected recovery letter for referring physician and/or insurance company. Order and review films to check the alignment of the cervical spine. Later the same day, review nursing and other provider chart notes, assess patient neurovascular status and pain. Write orders or update orders, as necessary, for medications, diet, and patient activity. Chart patient progress notes. On subsequent days, examine the patient, check wounds and neurovascular status. Review nursing and other provider chart notes. Chart patient progress notes. Discuss (oral/written) patient progress with referring physician. Answer (oral/written) questions from patient and/or family, nursing and other staff, and insurance staff. When safe to discharge patient to home, conduct final exam, including neurovascular and pain status, write orders for follow-up visits, post-discharge laboratory tests, imaging, home care, and physical therapy. Order medications needed post- discharge. Discuss home restrictions and activity levels (ie, diet, bathing, driving, exercise) with patient/family. Complete all appropriate medical records, including day of discharge progress notes, discharge summary, discharge instructions, and insurance forms.

Office: Examine patient and perform neurological exam and pain assessment. Write orders for medications. Order and review periodic imaging, as appropriate. Monitor wounds and remove sutures and staples when appropriate. Review physical therapy progress and revise orders as needed. Dictate patient progress notes for the medical chart. Answer patient and/or family questions and insurance staff questions. Discuss (oral/written) patient progress with referring physician. CPT Code: 22633 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 22633

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 22.00 40.00 75.00 200.00 Survey RVW: 19.00 28.00 30.00 32.00 48.24 Pre-Service Evaluation Time: 48.00 Pre-Service Positioning Time: 20.00 Pre-Service Scrub, Dress, Wait Time: 15.00 Intra-Service Time: 60.00 150.00 180.00 210.00 300.00 Immediate Post Service-Time: 30.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 100.00 99231x 1.00 99232x 2.00 99233x 0.00 Discharge Day Mgmt: 38.00 99238x 1.00 99239x 0.00 99217x 0.00 Office time/visit(s): 86.00 99211x 0.00 12x 0.00 13x 2.00 14x 1.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 4-FAC Difficult Patient/Difficult Procedure

CPT Code: 22633 Recommended Physician Work RVU: 26.80 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 40.00 40.00 0.00 Pre-Service Positioning Time: 20.00 3.00 17.00 Pre-Service Scrub, Dress, Wait Time: 15.00 20.00 -5.00 Intra-Service Time: 180.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9B General Anes or Complex Regional Blk/Cmplx Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 30.00 33.00 -3.00

CPT Code: 22633

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22612 090 23.53 RUC Time

CPT Descriptor Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22857 090 27.13 RUC Time

CPT Descriptor Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 55866 090 26.80 RUC Time 20,334 CPT Descriptor 1 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 33641 090 29.58 RUC Time 1,849

CPT Descriptor 2 Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

Number of respondents who choose Top Key Reference Code: 22 % of respondents: 19.8 %

Number of respondents who choose 2nd Key Reference Code: 21 % of respondents: 18.9 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 22633 22612 22857

Median Pre-Service Time 75.00 95.00 95.00

Median Intra-Service Time 180.00 150.00 180.00

Median Immediate Post-service Time 30.00 30.00 45.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 100.0 100.00 100.00 Median Discharge Day Management Time 38.0 38.00 38.00 Median Office Visit Time 86.0 69.00 92.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 509.00 482.00 550.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 0% 23% 41% 36%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 5% 23% 73% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 23% 77%

Physical effort required 0% 23% 77% CPT Code: 22633

Psychological Stress Less Identical More

• The risk of significant complications, 5% 36% 59% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 0% 38% 52% 10%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 5% 38% 57% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 38% 62%

Physical effort required 0% 33% 67%

Psychological Stress Less Identical More

• The risk of significant complications, 10% 38% 52% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

CPT Code: 22633 Background

Recommendation – 22633 We recommend crosswalking the work RVU of 26.80 for MPC code 55866 to 22633 to account for the slight decrease in intraoperative and total time. This value is less than the 25th percentile.

Positioning time Additional time was added to the package time of 3 minutes for supine positioning. These patients will typically be positioned prone.

Key Reference Code Comparison KRS1: The respondents who chose 22612 as a reference indicated the intensity/complexity of 22633 is more than 22612. KRS2: The respondents who chose 22857 as a reference indicated the intensity/complexity of 22633 is similar to somewhat more than 22857.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, posterior or posterolateral technique, single 22612 level; lumbar (with lateral transverse technique, when 23.53 0.088 482 95 150 237 performed) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including 22633 laminectomy and/or discectomy sufficient to prepare 26.80 0.091 509 75 180 254 interspace (other than for decompression), single interspace; lumbar Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace 22857 27.13 0.086 550 95 180 275 (other than for decompression), single interspace, lumbar

MPC Code Comparison

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Laparoscopy, surgical prostatectomy, retropubic radical, 55866 including nerve sparing, includes robotic assistance, 26.80 0.104 442 68 180 194 when performed Arthrodesis, combined posterior or posterolateral 22633 26.80 0.091 509 75 180 254 technique with posterior interbody technique including CPT Code: 22633 laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar Repair atrial septal defect, secundum, with 33641 29.58 0.094 562 95 164 303 cardiopulmonary bypass, with or without patch

Other Code Comparison Codes 43281 and 33255 bracket and offer further support of the recommended wRVU of 26.80 for 22633.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Laparoscopy, surgical, repair of paraesophageal hernia, 43281 includes fundoplasty, when performed; without 26.60 0.107 424 70 180 174 implantation of mesh Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including 22633 laminectomy and/or discectomy sufficient to prepare 26.80 0.091 509 75 180 254 interspace (other than for decompression), single interspace; lumbar Operative tissue ablation and reconstruction of atria, 33255 extensive (eg, maze procedure); without 29.04 0.106 516 95 180 241 cardiopulmonary bypass

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 22633

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty neurosurgery How often? Commonly

Specialty orthopaedic surgery How often? Commonly

CPT Code: 22633 Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 38,096 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. RUC database

Specialty neurosurgery Frequency 19800 Percentage 51.97 %

Specialty orthopaedic surgery Frequency 18286 Percentage 47.99 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 22633

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 22634 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:22634 Tracking Number J4 Original Specialty Recommended RVU: 7.96 Presented Recommended RVU: 7.96 Global Period: ZZZ Current Work RVU: 8.16 RUC Recommended RVU: 7.96

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 68-year-old female presents with severe disc degeneration with lateral listhesis of L4-L5 above a L5-S1 lytic or isthmic spondylolisthesis. She has significant low back pain that has not responded to non-operative treatment. During (separately reported) interbody arthrodesis of L4-L5, she undergoes additional interspace arthrodesis of L5-S1 via a unilateral or bilateral approach using a posterolateral technique with posterior interbody technique. (Note: This is an add-on service. Decompression, instrumentation, and/or bone preparation or harvesting, when performed, is separately reported. Only consider the additional work related to the arthrodesis of the additional L5-S1 interspace.)

Percentage of Survey Respondents who found Vignette to be Typical: 90%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: n/a

Description of Intra-Service Work: Skin, muscle, and fascia incisions are extended to provide for enough retraction to safely expose the additional interspace. The ligamentum flavum and/or scar is removed from between the laminae of the additional interspace. The laminae and medial edges of the facets are removed with bone cutting instruments to a degree sufficient to allow safe exposure of the disc space. The nerve root is carefully mobilized from adhesions and/or peridural membrane. Epidural veins are cauterized and cut. The nerve root(s) and thecal sac are protected by packing and retraction. The annulus is incised, and an ample section of it is removed by sharp dissection. The nucleus is removed within the disc space with rongeurs and curettes. Bone cutting instruments are used to remove cartilaginous and subchondral end-plates of the vertebrae above and below the disc to be fused. The bone dissection is fashioned to accept the graft in a way that will provide for contact, maintenance of disc space height, and stability. The spacer (graft and/or device) is impacted into the recipient site. When appropriate, the entire exposure, bone preparation, and spacer insertion and impaction are repeated from the other side of the table. Decortication of the posterolateral elements (transverse process, any remaining lamina, and/or facets) is undertaken, and graft material is packed posterolaterally to complete the arthrodesis preparations for the fusion. The neural elements are inspected to confirm that they are free of any impingement from the implant(s) in the canal and neuroforamen. An interposition membrane, as by fat graft, is applied over the exposed dura and nerve roots of the additional space. (Note: Decompression of neural elements instrumentation, and/or bone preparation or harvesting, when performed, are separately reported.)

Description of Post-Service Work: n/a CPT Code: 22634 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 22634

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 10.00 25.00 43.00 200.00 Survey RVW: 3.50 7.96 8.83 10.00 36.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 24.00 48.00 65.00 80.00 220.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 22634 Recommended Physician Work RVU: 7.96 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 65.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 22634

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22614 ZZZ 6.43 RUC Time

CPT Descriptor Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22840 ZZZ 12.52 RUC Time

CPT Descriptor Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 22634 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 25 % of respondents: 22.5 %

Number of respondents who choose 2nd Key Reference Code: 23 % of respondents: 20.7 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 22634 22614 22840

Median Pre-Service Time 0.00 0.00 0.00

Median Intra-Service Time 65.00 40.00 60.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 4% 12% 40% 44%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 4% 20% 76% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 4% 24% 72%

Physical effort required 4% 16% 80% CPT Code: 22634

Psychological Stress Less Identical More

• The risk of significant complications, 4% 32% 64% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 0% 9% 22% 70%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 4% 13% 83% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 4% 17% 78%

Physical effort required 0% 9% 91%

Psychological Stress Less Identical More

• The risk of significant complications, 9% 4% 87% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background

In October 2020, the CPT Editorial Panel approved the revision of four codes describing arthrodesis, addition of two codes to report laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar to more appropriately identify the decompression that may be separately reported. A coding change application was created to assist with coding confusion for reporting additional decompression performed at the same interspace as a lumbar CPT Code: 22634 interbody fusion procedure. The coding confusion stemmed from language ("other than for decompression") included in the descriptors for codes 22630-22634. To clarify correct coding, the CCA created two new add-on codes (63052 and 63053) to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace, along with definitions, guidelines, and parenthetical instructions. The terms corpectomy, facetectomy, foraminotomy, hemilaminectomy, lamina, laminectomy, and laminotomy were defined and editorial changes were made to several codes to consistently use the term "interspace" instead of "level" or "segment."

Recommendation – 22634 The current value for 22634 is based on a calculation in 2011 that estimated the new add-on code was 70% of the survey 25th percentile work RVU. Although the current survey median work RVU would suggest an increase is warranted, we do not have compelling evidence for an increase. We recommend the survey 25th percentile work RVU of 7.96 to account for the slight 5 minute decrease in median intraoperative time.

Key Reference Code Comparison KRS1: The respondents who chose 22614 as a reference indicated the intensity/complexity of 22634 is more/much more than 22614. KRS2: The respondents who chose 22840 as a reference indicated the intensity/complexity of 22634 is more than 22840.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, posterior or posterolateral technique, single 22614 level; each additional vertebral segment (List separately 6.43 0.161 40 0 40 0 in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 22634 interspace (other than for decompression), single 7.96 0.122 65 0 65 0 interspace; each additional interspace and segment (List separately in addition to code for primary procedure) Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 22840 interspace, atlantoaxial transarticular screw fixation, 12.52 0.209 60 0 60 0 sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral 34812 4.13 0.103 40 0 40 0 (List separately in addition to code for primary procedure) 22634 Arthrodesis, combined posterior or posterolateral 7.96 0.122 65 0 65 0 CPT Code: 22634 technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; each additional interspace and segment (List separately in addition to code for primary procedure)

Other Code Comparison The codes below bracket and offer further support of the recommended wRVU of 7.96 for 22634.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by 34820 abdominal or retroperitoneal incision, unilateral (List separately 7.00 0.117 60 0 60 0 in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than 22634 for decompression), single interspace; each additional 7.96 0.122 65 0 65 0 interspace and segment (List separately in addition to code for primary procedure) Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac catheterization for congenital cardiac 33746 anomalies, and target zone angioplasty, when performed (eg, 8.00 0.133 60 0 60 0 atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); each additional intracardiac shunt location (List separately in addition to code for primary procedure) Percutaneous transcatheter closure of paravalvular leak; each 93592 additional occlusion device (List separately in addition to code 8.00 0.133 60 0 60 0 for primary procedure) Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural 33884 hematoma, or traumatic disruption); each additional proximal 8.20 0.137 60 0 60 0 extension (List separately in addition to code for primary procedure)

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

CPT Code: 22634

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 22634

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty neurosurgery How often? Commonly

Specialty orthopaedic surgery How often? Commonly

Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 14,338 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. RUC database

Specialty neurosurgery Frequency 7900 Percentage 55.09 %

Specialty orthopaedic surgery Frequency 6438 Percentage 44.90 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 22634

CPT Code: 22634 If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 63052 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:63052 Tracking Number J5 Original Specialty Recommended RVU: 5.70 Presented Recommended RVU: 5.70 Global Period: ZZZ Current Work RVU: RUC Recommended RVU: 5.70

CPT Descriptor: Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: During (separately reported) posterior lumbar interbody arthrodesis for L4-5 spondylolisthesis with axial mechanical back pain and worsening neurogenic claudication and/or radiculopathy (extremity symptoms), refractory to nonoperative treatment, a 63-year-old female with advanced imaging that demonstrated central canal and bilateral lateral recess and foraminal stenosis at the L4-5 level, requires bilateral laminectomy with extensive decompression of the cauda equina and/or nerve root[s]. This more extensive decompression is beyond the typical dissection needed to complete the interbody arthrodesis approach and intervention. (Note: This is an add-on service. Only consider the additional work related to bilateral laminectomy with decompression of the cauda equina and/or nerve root[s].)

Percentage of Survey Respondents who found Vignette to be Typical: 99%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: n/a

Description of Intra-Service Work: Following bony and soft tissue resection and exposure of the L4-5 disc space for the interbody access and preparation for interbody arthrodesis, attention is turned to the additional bone and nervous system work required for decompression beyond what is required to access the disc space for the interbody arthrodesis. Additional portions of the laminae at the L4 and L5 vertebral segments are removed with a drill or bone biting instruments, and the inferior and superior facets are resected. The neural foraminae are expanded with bone biting instruments. The ligamentum flavum is dissected off the dura and completely removed, decompressing and mobilizing the neural elements. The neural elements are confirmed to be mobilized and decompressed. The additional intraoperative work is documented in the medical record.

Description of Post-Service Work: n/a CPT Code: 63052 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 63052

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 29.00 50.00 100.00 400.00 Survey RVW: 3.20 5.70 6.50 9.83 25.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 15.00 30.00 45.00 60.00 210.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 63052 Recommended Physician Work RVU: 5.70 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 45.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 63052

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22840 ZZZ 12.52 RUC Time

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22208 ZZZ 9.66 RUC Time

CPT Descriptor Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 63052 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 27 % of respondents: 24.3 %

Number of respondents who choose 2nd Key Reference Code: 18 % of respondents: 16.2 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 63052 22840 22208

Median Pre-Service Time 0.00 22840.0 0.00

Median Intra-Service Time 45.00 60.00 120.00

Median Immediate Post-service Time 0.00 0.00 15.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 45.00 60.00 135.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 0% 30% 33% 37%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 26% 74% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 4% 26% 70%

Physical effort required 11% 26% 63% CPT Code: 63052

Psychological Stress Less Identical More

• The risk of significant complications, 4% 22% 74% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 33% 17% 22% 28%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 39% 11% 50% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 28% 17% 56%

Physical effort required 22% 22% 56%

Psychological Stress Less Identical More

• The risk of significant complications, 33% 17% 50% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background

In October 2020, the CPT Editorial Panel approved the revision of four codes describing arthrodesis, addition of two codes to report laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar to more appropriately identify the decompression that may be separately reported. A coding change application was created to assist with coding confusion for reporting additional decompression performed at the same interspace as a lumbar CPT Code: 63052 interbody fusion procedure. The coding confusion stemmed from language ("other than for decompression") included in the descriptors for codes 22630-22634. To clarify correct coding, the CCA created two new add-on codes (63052 and 63053) to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace, along with definitions, guidelines, and parenthetical instructions. The terms corpectomy, facetectomy, foraminotomy, hemilaminectomy, lamina, laminectomy, and laminotomy were defined and editorial changes were made to several codes to consistently use the term "interspace" instead of "level" or "segment."

Recommendation – 63052 We recommend a work RVU of 5.70 (survey 25th percentile) and total time of 45 minutes. This RVW is higher than the interim recommendation of 5.55 which was the prior survey 25th percentile for a total time of 40 minutes. Rationale: The RUC previously accepted the survey 25th percentile as interim, but believed the survey was flawed because the add-on codes were not surveyed in conjunction with the base codes. This new survey included all six codes. In addition, the overall experience of the survey respondents is greater for the new survey of 6 codes when compared to the prior survey of the add on codes (ie, although the median is still 50, there is a shift to the right).

Key Reference Code Comparison KRS1: The respondents who chose 22840 as a reference indicated the intensity/complexity of 63052 is more/much more than 22840. KRS2: The respondents who chose 22208 as a reference indicated the intensity/complexity of 63052 is overall similar to 22208.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 22840 interspace, atlantoaxial transarticular screw fixation, 12.52 0.209 60 0 60 0 sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63052 5.70 0.127 45 0 45 0 stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, 22208 pedicle/vertebral body subtraction); each additional 9.66 0.78 135 0 120 15 vertebral segment (List separately in addition to code for primary procedure)

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST CPT Code: 63052 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral 34812 4.13 0.103 40 0 40 0 (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63052 5.70 0.127 45 0 45 0 stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)

Other Code Comparison Codes 22585 and 22552 bracket and offer further support of the recommended wRVU of 5.70 for 63052.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than 22585 5.52 0.123 45 0 45 0 for decompression); each additional interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63052 5.70 0.127 45 0 45 0 stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and 22552 decompression of spinal cord and/or nerve roots; 6.50 0.142 50 5 45 0 cervical below C2, each additional interspace (List separately in addition to code for primary procedure)

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

CPT Code: 63052 How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) There has been no reporting mechanism for this work since 2015. Please see supplemental file with an historical reporting overview.

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty neurosurgery How often? Sometimes

Specialty orthopaedic surgery How often? Sometimes

Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 11,000 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. specialty estimate

Specialty neurosurgery Frequency 5830 Percentage 53.00 %

Specialty orthopaedic surgery Frequency 5170 Percentage 47.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 63066 CPT Code: 63052

CPT Code: 63053 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:63053 Tracking Number J6 Original Specialty Recommended RVU: 5.00 Presented Recommended RVU: 5.00 Global Period: ZZZ Current Work RVU: RUC Recommended RVU: 5.00

CPT Descriptor: Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: During (separately reported) posterior lumbar interbody arthrodesis for L4-5 and L5-S1 spondylolisthesis with axial mechanical back pain and worsening neurogenic claudication and/or radiculopathy (extremity symptoms), refractory to nonoperative treatment, a 68-year-old male with advanced imaging that demonstrated central canal and bilateral lateral recess and foraminal stenosis at the L4-5 and L5-S1 levels requires bilateral laminectomy with extensive decompression of the cauda equina and/or nerve root[s]. This more extensive decompression is beyond the typical dissection needed to complete the interbody arthrodesis approach and intervention at each level. The first segment laminectomy has been completed (separately reported) and now the additional segment is addressed. (Note: This is an add- on service. Only consider the additional work related to bilateral laminectomy with decompression of the cauda equina and/or nerve root[s] of the additional segment.)

Percentage of Survey Respondents who found Vignette to be Typical: 97%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: n/a

Description of Intra-Service Work: After (separately reported) bony and soft tissue resection and exposure of the L4-L5 and L5-S1 disc spaces for the interbody access and preparation for arthrodesis is completed, along with the (separately reported) decompression of neural elements at the L4-L5 interspace, attention is turned to the additional bone and nervous system work required for decompression of the L5-S1 interspace beyond what is required to access the disc space for the interbody arthrodesis. Additional portions of the laminae at the L5 and S1 vertebral segments are removed with the drill or bone biting instruments, and the inferior and superior facets are resected. The neural foraminae are expanded with bone biting instruments. The ligamentum flavum is dissected off the dura and completely removed, allowing for decompression and mobilization of the neural elements are mobilized. The neural elements are confirmed to be mobilized and decompressed. The additional intraoperative work is documented in the medical record.

Description of Post-Service Work: n/a CPT Code: 63053 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Presenter(s): Swartz MD, Morgan Lorio MD Specialty AANS, CNS, AAOS, NASS, ISASS Society(ies): CPT Code: 63053

Sample Size: 2028 Resp N: 111 Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 15.00 30.00 70.00 400.00 Survey RVW: 3.00 5.00 6.00 7.38 25.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 15.00 30.00 40.00 45.00 210.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 63053 Recommended Physician Work RVU: 5.00 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 40.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 63053

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22614 ZZZ 6.43 RUC Time

CPT Descriptor Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 22840 ZZZ 12.52 RUC Time

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00 RUC Time

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 63053 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 19 % of respondents: 17.1 %

Number of respondents who choose 2nd Key Reference Code: 19 % of respondents: 17.1 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 63053 22614 22840

Median Pre-Service Time 0.00 0.00 0.00

Median Intra-Service Time 40.00 40.00 60.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More Top Key Reference Code Overall intensity/complexity 0% 0% 21% 63% 16%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 32% 68% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 26% 74%

Physical effort required 0% 37% 63% CPT Code: 63053

Psychological Stress Less Identical More

• The risk of significant complications, 0% 26% 74% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Survey Code Compared to Much Somewhat Identical Somewhat Much Less Less More More 2nd Key Reference Code Overall intensity/complexity 0% 0% 11% 32% 58%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 16% 84% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 5% 16% 79%

Physical effort required 11% 21% 68%

Psychological Stress Less Identical More

• The risk of significant complications, 5% 16% 79% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background

In October 2020, the CPT Editorial Panel approved the revision of four codes describing arthrodesis, addition of two codes to report laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar to more appropriately identify the decompression that may be separately reported. A coding change application was created to assist with coding confusion for reporting additional decompression performed at the same interspace as a lumbar CPT Code: 63053 interbody fusion procedure. The coding confusion stemmed from language ("other than for decompression") included in the descriptors for codes 22630-22634. To clarify correct coding, the CCA created two new add-on codes (63052 and 63053) to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace, along with definitions, guidelines, and parenthetical instructions. The terms corpectomy, facetectomy, foraminotomy, hemilaminectomy, lamina, laminectomy, and laminotomy were defined and editorial changes were made to several codes to consistently use the term "interspace" instead of "level" or "segment."

Recommendation – 63053 We recommend a work RVU of 5.00 (survey 25th percentile) and total time of 40 minutes. This RVW is higher than the interim recommendation of 4.44 which was crosswalked to code 33572 with total time = 30 minutes). Rationale: The RUC previously crosswalked a value that was less than the survey 25th percentile based on total time as interim, but believed the survey was flawed because the add-on codes were not surveyed in conjunction with the base codes. This new survey included all six codes. In addition, the overall experience of the survey respondents is greater for the new survey of 6 codes when compared to the prior survey of the add on codes (ie, the 25th pctl, median, 75th pctl, and max 12-month experience is all greater). The new survey, which included all codes, elicited a time that is only 5 minutes less than the work related to 63052 and that we believe is a more accurate reflection of the difference in work between laminectomy/facetectomy/foraminotomy with decompression of the first segment and of an additional segment.

Key Reference Code Comparison KRS1: The respondents who chose 22614 as a reference indicated the intensity/complexity of 63053 is more than 22614. KRS2: The respondents who chose 22840 as a reference indicated the intensity/complexity of 63053 is more/much more than 22840.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Arthrodesis, posterior or posterolateral technique, single 22614 level; each additional vertebral segment (List separately 6.43 0.161 40 0 40 0 in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63053 5.00 0.125 40 0 40 0 stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure) Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 22840 interspace, atlantoaxial transarticular screw fixation, 12.52 0.209 60 0 60 0 sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST CPT Code: 63053 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral 34812 4.13 0.103 40 0 40 0 (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63053 5.00 0.125 40 0 40 0 stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)

Other Code Comparison Codes 44128 and 22585 bracket and offer further support of the recommended wRVU of 5.00 for 63053.

TOTAL CPT DESCRIPTOR RVW IWPUT TIME PRE INTRA POST Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal 44128 segment of intestine; each additional resection and 4.44 0.106 40 0 40 0 anastomosis (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess 63053 5.00 0.125 40 0 40 0 stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure) Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than 22585 5.52 0.123 45 0 45 0 for decompression); each additional interspace (List separately in addition to code for primary procedure)

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

CPT Code: 63053 How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) There has been no reporting mechanism for this work since 2015. Please see supplemental file with an historical reporting overview.

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty neurosurgery How often? Sometimes

Specialty orthopaedic surgery How often? Sometimes

Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 4,000 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. specialty estimate

Specialty neurosurgery Frequency 2120 Percentage 53.00 %

Specialty orthopaedic surgery Frequency 1880 Percentage 47.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Explor/Decompr/Excis disc

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 63066 CPT Code: 63053

SoR Supplement Page 1

+63052 and +63053: Historical Reporting Overview

Coding History

In the 1990's, the work for arthrodesis and decompression was typically performed jointly by an orthopedic surgeon who would perform the arthrodesis and a neurosurgeon who would perform the decompression. Perhaps the single most important aspect of this coding was that the decompression and arthrodesis was being coded at the same spinal level. The codes were surveyed in that manner, and wRVUs were based on each surgeon's work.

In 1998, an AMA CPT workgroup that convened to discuss reporting correct coding for spine procedures via an anterior approach, also reviewed the lumbar interbody fusion code (22630) and decompression code (63047) and determined that each code may be separately and discretely performed and that there was no overlap in intra-service work. The workgroup also agreed that each code was valued based on the specific work of each code (ie, interbody fusion versus decompression). For CPT 2000, the CPT Panel introduced language into code 22630 which made this point clear: “minimal laminectomy and/or discectomy to prepare the interspace.” The spirit of that language continues to this day in the parenthetical “other than for decompression.” That particular position was reinforced in the January 2001 CPT Assistant where a case illustration of a patient requiring a decompression and an interbody fusion was presented and the statement made, “63047-51 should be reported in addition to the code 22630.”

In 2012, in recognition that posterolateral fusions were commonly performed along with interbody fusions, a new bundled code (22633) was established to include the work of interbody fusions (22630) and posterolateral fusions (22612) being bundled together into 22633. It is important to note that the decompression element of the operation (63047) remained a separate entity as intended by the initial valuation of that code and the inclusion of ("other than for decompression") in the code descriptor.

In 2014, confusion, both at education seminars and in print, about correct coding of the additional work of laminectomy persisted, with societies not agreeing on appropriate coding for the additional work of decompression performed concurrently with interbody fusion.

In January 2015, due to misinformed educational materials, CMS took a drastic departure from the application of the CPT codes that had been in place for decades; specifically, the evolution of the codes, the validated surveys for each of the separate codes, and valuation of separate work, by establishing NCCI edits: "CMS payment policy does not allow separate payment for CPT codes 63042 (laminotomy…; lumbar) or 63047 (laminectomy…; lumbar) with CPT codes 22630 or 22633 (arthrodesis; lumbar) when performed at the same interspace. If the two procedures are performed at different interspaces, the two codes of an edit pair may be reported with modifier 59 appended to CPT code 63042 or 63047." [Chapter 4 of the NCCI manual]

In September 2015, the stakeholder societies conducted discussions with NCCI (CMS) about the history and valuation of codes 22630-22634. NCCI staff communicated that CMS had no intention to modify its position on these code pairs and instead recommended proposing an add-on code for use with arthrodesis codes that would describe additional decompression when performed. SoR Supplement Page 2

Overview of CPT Assistant

After the coding changes for CPT 2000, the following CPT Assistant article was published that describes correct reporting of 22630 and 63047 for the same interspace.

January 2001 page 12 Coding Consultation Musculoskeletal System, Surgery, 22554, 22630, 63001-63048, 63075-63078 (Q&A)

Question: The descriptors of codes 22554 and 22630 describe anterior (22554) or posterior (22630) interbody technique arthrodeses to include laminectomy, and/or diskectomy to prepare the interspace (other than for decompression). In what procedural circumstance would the 63001-63048 code(s) be reported in addition to code 22630? Similarly, in what procedural circumstance would code(s) 63075-63078 be reported in addition to code 22554?

AMA Comment For both codes 22554 and 22630… To report code 22554… To report code 22630, Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar, in addition to code 63047-51, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar, again additional procedure(s) must have been performed. For example, in spinal procedures performed on patients having lateral lumbar stenosis, the surgeon may need to perform additional work above and beyond that described by the PLIF, including facetectomy(ies) and/or foraminotomy(ies), to adequately decompress the nerve roots. For the purpose of this example, code 63047-51 should be reported in addition to code 22630. Regarding the issue of laterality… To further clarify, code 22630 may also require the additional performance of a posterior fusion, which involves bone grafting and placement of posterior instrumentation. These procedures should be additionally reported. If the surgeon uses a threaded bone dowel or prosthetic device in the disk space, then code +22851 should be reported. If any other type of bone graft is performed, the appropriate bone graft code should be reported. The anterior fusion procedure described by code 22554…

In 2016, AMA CPTA staff drafted a FAQ based on the NCCI edit that was established. The stakeholder societies were not contacted about this FAQ. If we had been contacted, we would have informed AMA staff that we were in the process of discussions with CMS about coding misinformation.

October 2016 page 11 Frequently Asked Questions: Surgery: Nervous System

Question: The procedures described in code 63047 was performed for decompression, which was documented in the operative note. In addition, the procedure described in code 22633 was also performed at the same interspace. How should this be reported?

Answer: Codes 63047 and 22633 cannot be reported for the same interspace. However, it is appropriate to report codes 63047, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar, and 22633, Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar, if the two procedures are performed at different interspaces. Modifier 59, Distinct Procedural Service, should be appended to indicate that these are two distinct procedures. SoR Supplement Page 3

The October 2016 FAQ added considerable coding confusion and after much effort by the stakeholder societies, including presentation of the historical information in this document, CPTA published a coding correction.

May 2018 page 9 Coding Correction: Reporting Codes 22633 and 63047

In the Frequently Asked Questions (FAQ) section (page 11) of the October 2016 issue of CPT® Assistant, the Surgery: Nervous System answer incorrectly stated that codes 22633, Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar, and 63047, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar, may not be reported for the same interspace. On further analysis of this issue, it was demonstrated that this recommendation was inconsistent with previously published CPT® Assistant advice, which is that codes 22633 and 63047 may be reported for the same interspace when additional work is required to complete a decompression at a single spinal level. It is also appropriate to report codes 22633 and 63047, if the two procedures are performed at different interspaces. Modifier 59, Distinct Procedural Service, should then be appended to indicate that these are two distinct procedures.

This correction aligns the coding advice with historical precedent published prior to the incorrect revisions in advice given in the October 2016 FAQ.

The following is the corrected coding advice:

Surgery: Nervous System Question: The procedure described in code 63047 was performed for decompression, which was documented in the operative note. In addition, the procedure described in code 22633 was also performed at the same interspace. How should this be reported?

Answer: Codes 22633 and 63047 may be reported for the same interspace when additional work is required to complete a decompression at a single spinal level. It is also appropriate to report codes 22633 and 63047, if the two procedures are performed at different interspaces. Modifier 59, Distinct Procedural Service, should then be appended to indicate that these are two distinct procedures.

We appreciate that CPT recognized and corrected an errant FAQ.

Summary

Since the establishment of the CCI edits in 2015, surgeons have not been allowed to report 63047 with 22630- 22634 for the same interspace. This document is meant to explain why the current utilization for decompression at the same interspace is "zero."

The new add-on codes respond to CMS's direction (via NCCI correspondence) that recommends establishing an add-on code for use with arthrodesis codes that would describe additional decompression when performed.

In addition to creation of the add-on codes, numerous new definitions and two instructional guidelines specify when 63052 and 63053 correctly apply:

Decompression performed on the same vertebral segment(s) and/or interspace[s] as posterior lumbar interbody fusion that includes laminectomy, facetectomy, and/or foraminotomy may be separately reported using 630XX, 630X1.

Decompression solely to prepare the interspace for fusion is not separately reported. ISSUE: Arthrodesis Decompression TAB: 4 Review RVW Total PRE INTRA IMMD POST Facility POST-Office 12 Month Svy Experience SOURCE Year CPT DESC Glob Resp IWPUT WPUT MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX P-SD 33 32 31 38 15 14 13 12 11 MIN 25th MED 75th MAX REF1 2003 22533 Arthrodesis, lateral extracavitary technique, includ90 30 0.076 0.045 24.79 549 58 28 30 180 30 1 3 1.0 3 1 REF2 2005 22612 Arthrodesis, posterior or posterolateral technique, 90 25 0.088 0.049 23.53 482 60 20 15 150 30 2 1 1.0 3 Current 1995 22630 Arthrodesis, posterior interbody technique, includi90 0.067 0.045 22.09 487 85 180 32 3 1.0 4 SVY 2021 22630 Arthrodesis, posterior interbody technique, includi90 111 0.100 0.052 19.60 25.00 25.52 28.00 35.00 487 48 20 15 60 120 150 180 270 30 2 1 1.0 1 2 0 5 10 33 300 REC 22630 maintain RVW 90 0.078 0.046 22.09 479 40 20 15 150 30 2 1 1.0 1 2

REF1 1995 22614 Arthrodesis, posterior or posterolateral technique, ZZZ 26 0.161 0.161 6.43 40 40 REF2 2010 22552 Arthrodesis, anterior interbody, including disc spaZZZ 23 0.142 0.130 6.50 50 5 45 Current 1995 22632 Arthrodesis, posterior interbody technique, includiZZZ 0.087 0.087 5.22 60 60 SVY 2021 22632 Arthrodesis, posterior interbody technique, includiZZZ 111 0.125 0.125 3.00 6.23 7.48 9.44 34.00 60 22 45 60 60 240 0 1 5 20 300 REC 22632 maintain RVW ZZZ 0.087 0.087 5.22 60 60

REF1 2005 22612 Arthrodesis, posterior or posterolateral technique, 90 22 0.088 0.049 23.53 482 60 20 15 150 30 2 1 1.0 3 REF2 2006 22857 Total disc arthroplasty (artificial disc), anterior app90 21 0.086 0.049 27.13 550 60 20 15 180 45 2 1 1.0 4 Current 2011 22633 Arthrodesis, combined posterior or posterolateral t90 0.080 0.049 27.75 565 40 18 20 200 30 2 1 1.0 3 SVY 2021 22633 Arthrodesis, combined posterior or posterolateral t90 111 0.108 0.058 19.00 28.00 30.00 32.00 48.24 517 48 20 15 60 150 180 210 300 30 2 1 1.0 1 2 0 22 40 75 200 REC 22633 crosswalk RVW to MPC code 55866 90 0.091 0.053 26.80 509 40 20 15 180 30 2 1 1.0 1 2 MPC 2015 55866 Laparoscopy, surgical prostatectomy, retropubic r90 0.104 0.061 26.80 442 33 20 15 180 30 1 1.0 1 2

REF1 1995 22614 Arthrodesis, posterior or posterolateral technique, ZZZ 25 0.161 0.161 6.43 40 40 REF2 2005 22840 Posterior non-segmental instrumentation (eg, HarrZZZ 23 0.209 0.209 12.52 60 60 Current 2011 22634 Arthrodesis, combined posterior or posterolateral tZZZ 0.117 0.117 8.16 70 70 SVY 22634 Arthrodesis, combined posterior or posterolateral tZZZ 111 0.136 0.136 3.50 7.96 8.83 10.00 36.00 65 24 48 65 80 220 0 10 25 43 200 REC 22634 25th percentile ZZZ 0.122 0.122 7.96 65 65

REF1 2005 22840 Posterior non-segmental instrumentation (eg, HarrZZZ 27 0.209 0.209 12.52 60 60 REF2 2007 22208 Osteotomy of spine, posterior or posterolateral appZZZ 18 0.078 0.072 9.66 135 120 15 SVY 2020 63052 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 141 0.213 0.213 3.50 5.55 8.50 12.75 28.00 40 10 21 40 50 365 0 25 50 80 400 interim 2020 63052 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 0.139 0.139 5.55 40 40 SVY 2021 63052 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 111 0.144 0.144 3.20 5.70 6.50 9.83 25.00 45 15 30 45 60 210 0 29 50 100 400 REC 63052 25th percentile ZZZ 0.127 0.127 5.70 45 45

REF1 1995 22614 Arthrodesis, posterior or posterolateral technique, ZZZ 19 0.161 0.161 6.43 40 40 REF2 2005 22840 Posterior non-segmental instrumentation (eg, HarrZZZ 19 0.209 0.209 12.52 60 60 SVY 2020 63053 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 141 0.217 0.217 3.00 4.70 6.50 9.50 28.00 30 8 20 30 45 370 0 8 25 54 350 interim 2020 63053 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 0.148 0.148 4.44 30 30 SVY 2021 63053 Laminectomy, facetectomy, or foraminotomy (unilaZZZ 111 0.150 0.150 3.00 5.00 6.00 7.38 25.00 40 15 30 40 45 210 0 15 30 70 400 REC 63053 25th percentile ZZZ 0.125 0.125 5.00 40 40 FACILITY DIRECT PE INPUTS

CPT CODE(S): 22630, 22632, 22633, 22634, 63052, 63053 SPECIALTY SOCIETY(IES): AANS, CNS, AAOS, NASS, ISASS PRESENTER(S): John Ratliff MD, Clemens Schirmer MD, William Creevy MD, Hussein Elkousy MD, Karin Swartz MD, Morgan Lorio MD

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

Meeting Date: 04/2021

CPT Global Code Long Descriptor Period Arthrodesis, posterior interbody technique, including laminectomy and/or 22630 discectomy to prepare interspace (other than for decompression), single 090 interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single 22632 ZZZ interspace; each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with posterior 22633 interbody technique including laminectomy and/or discectomy sufficient to 090 prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to 22634 prepare interspace (other than for decompression), single interspace; each ZZZ additional interspace and segment (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or 63052 ZZZ lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or 63053 ZZZ lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)

Vignette(s) (vignette required even if PE only code(s)): CPT Code Vignette 22630 A 48-year-old male with a history of previous discectomy at L4-L5 presents with a spondylolisthesis and intractable back pain that improves with recumbency or back bracing. Non-operative treatments have failed to control his symptoms. Arthrodesis via a unilateral or bilateral approach of L4-L5 is performed using a posterior interbody technique. (Note: Decompression, instrumentation and/or bone preparation or harvesting, when performed, is separately reported.) 22633 A 68-year-old female presents with a degenerative spondylolisthesis of L4-L5 causing mechanical low back pain. Non-operative treatments have failed to control her symptoms. Via unilateral or bilateral approach to the L4-L5 interspace, arthrodesis is performed using a posterolateral technique with posterior interbody technique. (Note: Decompression, instrumentation, and/or bone preparation or harvesting, when performed, is separately reported.) 22632 A 70-year-old male with a history of previous diskectomy and posterolateral fusion of L4- L5, presents with pseudarthrosis of L4-L5, progressive spondylolisthesis of L5-S1, minimal signs of nerve root dysfunction, and intractable back pain that improves with recumbency or 1 FACILITY DIRECT PE INPUTS

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

CPT Code Vignette back bracing. Non-operative treatments have failed to control his symptoms. During (separately reported) posterior lumbar interbody arthrodesis of L4-L5, he undergoes additional interspace arthrodesis of L5-S1 via a unilateral or bilateral approach using a posterior interbody technique. (Note: This is an add-on procedure. Decompression, instrumentation and/or bone preparation or harvesting, when performed, is separately reported. Only consider the additional work related to the posterior interbody arthrodesis of the additional L5-S1 interspace.) 22634 A 68-year-old female presents with severe disc degeneration with lateral listhesis of L4-L5 above a L5-S1 lytic or isthmic spondylolisthesis. She has significant low back pain that has not responded to non-operative treatment. During (separately reported) interbody arthrodesis of L4-L5, she undergoes additional interspace arthrodesis of L5-S1 via a unilateral or bilateral approach using a posterolateral technique with posterior interbody technique. (Note: This is an add-on service. Decompression, instrumentation, and/or bone preparation or harvesting, when performed, is separately reported. Only consider the additional work related to the arthrodesis of the additional L5-S1 interspace.) 63052 During (separately reported) posterior lumbar interbody arthrodesis for L4-5 spondylolisthesis with axial mechanical back pain and worsening neurogenic claudication and/or radiculopathy (extremity symptoms), refractory to nonoperative treatment, a 63-year-old female with advanced imaging that demonstrated central canal and bilateral lateral recess and foraminal stenosis at the L4-5 level, requires bilateral laminectomy with extensive decompression of the cauda equina and/or nerve root[s]. This more extensive decompression is beyond the typical dissection needed to complete the interbody arthrodesis approach and intervention. (Note: This is an add-on service. Only consider the additional work related to bilateral laminectomy with decompression of the cauda equina and/or nerve root[s].) 63053 During (separately reported) posterior lumbar interbody arthrodesis for L4-5 and L5-S1 spondylolisthesis with axial mechanical back pain and worsening neurogenic claudication and/or radiculopathy (extremity symptoms), refractory to nonoperative treatment, a 68-year- old male with advanced imaging that demonstrated central canal and bilateral lateral recess and foraminal stenosis at the L4-5 and L5-S1 levels requires bilateral laminectomy with extensive decompression of the cauda equina and/or nerve root[s]. This more extensive decompression is beyond the typical dissection needed to complete the interbody arthrodesis approach and intervention at each level. The first segment laminectomy has been completed (separately reported) and now the additional segment is addressed. (Note: This is an add-on service. Only consider the additional work related to bilateral laminectomy with decompression of the cauda equina and/or nerve root[s] of the additional segment.)

1. Please provide a brief description of the process used to develop your recommendation and the composition of your Specialty Society RVS Committee Expert Panel: AANS, CNS, AAOS, NASS, ISASS Advisors reviewed the current PE details and adjusted as appropriate,

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

the selection of reference code(s) here (for service reviewed prior to the implementation of clinical activity codes, detail is not provided in the RUC database, please contact Rebecca Gierhahn at [email protected] for PE spreadsheets for your reference codes): Current codes were used as references

3. Is this code(s) typically reported with an E/M service? no

4. If you are recommending more minutes than the PE Subcommittee standards for clinical activities you must provide rationale to justify the time: n/a

5. If you are requesting an increase over the aggregate current cost for clinical staff time, equipment and supplies for the code family, please provide compelling evidence (please see PE compelling evidence guidelines) Please explain if the increase can be entirely accounted for because of an increase in physician time: For code 22630, an exam light has been added for one visit at which the surgical wounds will be assessed and drain and suture/staple removal will occur.

6. If a clinical activity in your reference code(s) is being rolled into a similar clinical activity approved by the PE Subcommittee and assigned a clinical activity code (please see second worksheet in PE spreadsheet workbook), please explain the difference here: n/a

7. Please provide a brief description of the clinical staff work for the following: a. Pre-Service period: Complete pre-service diagnostic Staff reviews all forms with patient and family to ensure all relevant and referral forms history and diagnostic information is included. Coordinate pre-surgery services Staff coordinates collection and documentation of imaging/lab results, (including test results) patient specific information and other relevant patient information for surgical procedure including conducting requisite pre-surgery assessment with anesthesiologist. Enter and record all clinical updates in EHR. Schedule space and equipment in Staff interacts with facility to schedule space, supplies, equipment, and facility review checklists. Provide pre-service Staff reviews procedure, complication risk, process of recovery, and education/obtain consent answers patient/family questions. Complete pre-procedure phone Staff reviews preoperative medication changes, reviews patient

calls and prescription medical status and answers final pre-admission questions. b. Service period (includes pre, intra and post): Prior to discharge, office clinical staff will assist with necessary post-discharge care coordination, such as: Responding to patient/family questions about home activity restrictions and care of drains. Confirmation of discharge antibiotics if needed, and pain medication. Coordination with other physicians and QHPs involved in the care of the patient for transfer of records. Transitioning discharge information to the surgeon's office medical record, including medication list, correspondence and imaging or lab results pending at discharge. c. Post-service period: The clinical staff work includes the standard activities involved in any E/M visit including ensuring the appropriate 3 FACILITY DIRECT PE INPUTS

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

supplies are available in the room, ensuring imaging and lab reports are available, rooming the patient, gowning, reviewing current medications/allergies in EHR, obtaining vital signs, assisting with wound care, coordination of care, and cleaning of the room. 8. If you are recommending a new clinical activity, please provide a detailed explanation of why the new clinical activity is needed and cannot conform to any of the existing clinical activities (please see second worksheet in PE spreadsheet workbook): n/a

9. If you wish to identify a new staff type, please include a very specific staff description, salary estimate and its source. Staff types or an identified and appropriate proxy must be listed by the Bureau of Labor Statistics (BLS). You can find the BLS database at http://www.bls.gov. n/a

INVOICES

10. ☐ Please check the box to confirm that you have provided invoices for all new supplies and/or equipment?

11. ☐ Please check the box to confirm that you have provided an estimate price on the PE spreadsheet for all new supplies and/or equipment?

12. If you wish to include a supply that is not on the list (please see fourth worksheet in PE spreadsheet workbook) please provide a paid invoice. Identify and explain the invoice here: n/a

13. Are you recommending a PE supply pack for this recommendation? Yes or No. If Yes, please indicate if the pack is an established package of supplies as defined by CMS (eg, SA047 pack, E/M visit) or a pack that is commercially available? yes, SA048 and SA053

14. Please provide an itemized list of the contents for all supply kits, packs and trays included in your recommendation. Please include the description, CMS supply code, unit, item quantity and unit price (if available). See documents two and three under PE reference materials on the RUC Collaboration Website for information on the contents of kits, packs and trays. Item Unit DESCRIPTION Code Unit Qty price pack, minimum multi-specialty visit SA048 pack 4.0507 paper, exam table foot 7 gloves, non-sterile pair 2 gown, patient item 1 pillow case item 1 cover, thermometer probe item 1

DESCRIPTION Code Unit Item Unit

4 FACILITY DIRECT PE INPUTS

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

Qty price pack, post-op incision care (suture & SA053 pack 5.63 staple) kit, staple removal kit 1 kit, suture removal kit 1 povidone soln (Betadine) ml 10 gauze, sterile 4in x 4in item 2 gloves, sterile pair 1 steri-strip (6 strip uou) item 2 swab-pad, alcohol item 2 tape, surgical paper 1in (Micropore) inch 12 tincture of benzoin, swab item 1

15. If you wish to include an equipment item that is not on the list (please see fifth worksheet in PE spreadsheet workbook) please provide a paid invoice and the useful life. Identify and explain the invoice here: n/a

16. Have you recommended equipment minutes for a computer or equivalent laptop/integrated computer, equipment item computer, desktop, w-monitor, ED021 or notebook (Dell Latitute D600), ED038? a. If yes, please explain how the computer is used for this service(s). b. Is the computer used exclusively as an integral component of the service or is it also used for other purposes not specific to the code? c. Does the computer include code specific software that is typically used to provide the service(s)? n/a

17. List all the equipment included in your recommendation and the equipment formula chosen (please see document titled Calculating equipment time). If you have selected “other formula” for any of the equipment please explain here: EF 031 table, power – required for all postop office visits EQ168 light, exam – required for one postop office visit

18. If there is any other item(s) on your spreadsheet not covered in the categories above that require greater detail/explanation, please include here: n/a

PROFESSIONAL LIABILITY INSURANCE (PLI) INFORMATION

19. If this is a PE only code please select a crosswalk based on a similar specialty mix: n/a

5 FACILITY DIRECT PE INPUTS

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

ITEMIZED LIST OF CHANGES (FOLLOWING THE PE SUBCOMMITTEE MEETING

During and immediately following the review of this tab at the PE Subcommittee meeting please revise the summary of recommendation (PE SOR) based on modifications made during the meeting. Please submit the revised form electronically to Rebecca Gierhahn at [email protected] immediately following the close of business the same day that the tab is reviewed. On the PE spreadsheet, please highlight the cells and/or use red font to show the changes made during the PE Subcommittee meeting (if you have provided any of this highlighting based on changes from the reference code prior to the PE Subcommittee meeting please remove it, so not to be confused with changes made during the meeting). In addition to those revisions please also provide an itemized list of the modifications made to the PE spreadsheet during the PE Subcommittee meeting in the space below (e.g. clinical activity CA010 obtain vital signs was reduced from 5 minutes to 3 minutes).

NOTE: The virtual meetings have provided for real-time updates to the PE spreadsheets. PE SORs must still be updated and resubmitted asap.

6 A B D E F I J K L M 1 RUC Practice Expense Spreadsheet CURRENT RECOMMENDED CURR 2 22630 22630 226 3 RUC Collaboration Website Arthrodesis, posterior Arthrodesis, posterior Arthro Meeting Date: 04/2021 interbody technique, interbody technique, combined p Clinical Clinical Staff Clinical Revision Date (if applicable): April 7, 2021 Clinical including laminectomy including laminectomy postero Staff Type Type Rate Activity Code Tab: 4 Staff Type and/or discectomy to and/or discectomy to techniq Code Per Minute 4 Specialty: AANS, CNS, AAOS, NASS, ISASS prepare interspace prepare interspace posterior ( f ( f 5 LOCATION Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 90 90 90 90 90 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 103.27 $ - $ 92.65 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 216 0 197 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 60 0 60 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 12 0 12 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 144 0 125 0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ - $ 79.92 $ - $ 72.89 $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms L037D RN/LPN/MTA 0.37 5 5 16 CA002 Coordinate pre-surgery services (including test results) L037D RN/LPN/MTA 0.37 20 20 17 CA003 Schedule space and equipment in facility L037D RN/LPN/MTA 0.37 8 8 18 CA004 Provide pre-service education/obtain consent L037D RN/LPN/MTA 0.37 20 20 19 CA005 Complete pre-procedure phone calls and prescription L037D RN/LPN/MTA 0.37 7 7 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 74 CA036 Discharge day management L037D RN/LPN/MTA 0.37 n/a 12 n/a 12 n/a 77 End: Patient leaves office/facility 78 POST-SERVICE PERIOD 79 Start: Patient leaves office/facility 82 Office visits: List Number and Level of Office Visits MINUTES # visits # visits # visits # visits # visits 83 99211 16 minutes 16 84 99212 27 minutes 27 85 99213 36 minutes 36 4 2 86 99214 53 minutes 53 1 87 99215 63 minutes 63 88 CA039 Post-operative visits (total time) L037D RN/LPN/MTA 0.37 0.0 144.0 0.0 125.0 0.0 A B D E F I J K L M 1 RUC Practice Expense Spreadsheet CURRENT RECOMMENDED CURR 2 22630 22630 226 3 RUC Collaboration Website Arthrodesis, posterior Arthrodesis, posterior Arthro Meeting Date: 04/2021 interbody technique, interbody technique, combined p Clinical Clinical Staff Clinical Revision Date (if applicable): April 7, 2021 Clinical including laminectomy including laminectomy postero Staff Type Type Rate Activity Code Tab: 4 Staff Type and/or discectomy to and/or discectomy to techniq Code Per Minute 4 Specialty: AANS, CNS, AAOS, NASS, ISASS prepare interspace prepare interspace posterior ( f ( f 5 LOCATION Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 90 90 90 90 90 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 103.27 $ - $ 92.65 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 216 0 197 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 60 0 60 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 12 0 12 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0 144 0 125 0 96 Supply Code MEDICAL SUPPLIES PRICE UNIT 97 TOTAL COST OF SUPPLY QUANTITY x PRICE $ - $ 21.07 $ - $ 17.78 $ - 98 SA048 pack, minimum multi-specialty visit 4.0507 pack 4 3 99 SA052 pack, post-op incision care (staple) 4.864 pack 1 100 SA053 pack, post-op incision care (suture & staple) 5.63 pack 1 101 Equipment Purchase Equipment Cost Per EQUIPMENT 103 Code Price Formula Minute 104 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ - $ 2.28 $ - $ 1.98 $ - 105 EF031 table, power 5968.4775 Office Visits 0.015838707 144 125 106 EF014 light, surgical 2064.7828 Office Visits 0.00459289 107 EQ168 light, exam 1332.1952 Office Visits 0.003535282 0 A B N O P Q R S T U V 1 RUC Practice Expense Spreadsheet RENT RECOMMENDED RECOMMENDED RECOMMENDED RECOMMENDED 2 633 22633 22632 22634 63052 3 RUC Collaboration Website desis, Arthrodesis, Arthrodesis, posterior Arthrodesis, Laminectomy, Meeting Date: 04/2021 posterior or combined posterior or interbody technique, combined posterior or facetectomy, or Clinical Revision Date (if applicable): April 7, 2021 olateral posterolateral including laminectomy posterolateral foraminotomy Activity Code Tab: 4 ue with technique with and/or discectomy to technique with (unilateral or bilateral 4 Specialty: AANS, CNS, AAOS, NASS, ISASS interbody posterior interbody prepare interspace posterior interbody with decompression ( f f 5 LOCATION Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility 6 GLOBAL PERIOD 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 86.59 $ - $ 92.65 $ - $ - $ - $ - $ - $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 180 0 197 0 0 0 0 0 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60 0 60 0 0 0 0 0 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 12 0 12 0 0 0 0 0 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 108 0 125 0 0 0 0 0 0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ 66.60 $ - $ 72.89 $ - $ - $ - $ - $ - $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 5 5 16 CA002 Coordinate pre-surgery services (including test results) 20 20 17 CA003 Schedule space and equipment in facility 8 8 18 CA004 Provide pre-service education/obtain consent 20 20 19 CA005 Complete pre-procedure phone calls and prescription 7 7 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 74 CA036 Discharge day management 12 n/a 12 n/a n/a n/a 77 End: Patient leaves office/facility 78 POST-SERVICE PERIOD 79 Start: Patient leaves office/facility 82 Office visits: List Number and Level of Office Visits # visits # visits # visits # visits # visits # visits # visits # visits # visits 83 99211 16 minutes 84 99212 27 minutes 85 99213 36 minutes 3 2 86 99214 53 minutes 1 87 99215 63 minutes 88 CA039 Post-operative visits (total time) 108.0 0.0 125.0 0.0 0.0 0.0 0.0 0.0 0.0 A B N O P Q R S T U V 1 RUC Practice Expense Spreadsheet RENT RECOMMENDED RECOMMENDED RECOMMENDED RECOMMENDED 2 633 22633 22632 22634 63052 3 RUC Collaboration Website desis, Arthrodesis, Arthrodesis, posterior Arthrodesis, Laminectomy, Meeting Date: 04/2021 posterior or combined posterior or interbody technique, combined posterior or facetectomy, or Clinical Revision Date (if applicable): April 7, 2021 olateral posterolateral including laminectomy posterolateral foraminotomy Activity Code Tab: 4 ue with technique with and/or discectomy to technique with (unilateral or bilateral 4 Specialty: AANS, CNS, AAOS, NASS, ISASS interbody posterior interbody prepare interspace posterior interbody with decompression ( f f 5 LOCATION Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility 6 GLOBAL PERIOD 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 86.59 $ - $ 92.65 $ - $ - $ - $ - $ - $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 180 0 197 0 0 0 0 0 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60 0 60 0 0 0 0 0 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 12 0 12 0 0 0 0 0 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 108 0 125 0 0 0 0 0 0 96 Supply Code MEDICAL SUPPLIES 97 TOTAL COST OF SUPPLY QUANTITY x PRICE $ 17.78 $ - $ 17.78 $ - $ - $ - $ - $ - $ - 98 SA048 pack, minimum multi-specialty visit 3 3 99 SA052 pack, post-op incision care (staple) 100 SA053 pack, post-op incision care (suture & staple) 1 1 101 Equipment EQUIPMENT 103 Code 104 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ 2.21 $ - $ 1.98 $ - $ - $ - $ - $ - $ - 105 EF031 table, power 108 125 106 EF014 light, surgical 108 107 EQ168 light, exam 0 A B W X 1 RUC Practice Expense Spreadsheet RECOMMENDED 2 63053 3 RUC Collaboration Website Laminectomy, Meeting Date: 04/2021 facetectomy, or Clinical Revision Date (if applicable): April 7, 2021 foraminotomy Activity Code Tab: 4 (unilateral or bilateral 4 Specialty: AANS, CNS, AAOS, NASS, ISASS with decompression f 5 LOCATION Non Fac Facility 6 GLOBAL PERIOD ZZZ ZZZ TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 0 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 0 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 0 0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ - $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 16 CA002 Coordinate pre-surgery services (including test results) 17 CA003 Schedule space and equipment in facility 18 CA004 Provide pre-service education/obtain consent 19 CA005 Complete pre-procedure phone calls and prescription 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 74 CA036 Discharge day management n/a 77 End: Patient leaves office/facility 78 POST-SERVICE PERIOD 79 Start: Patient leaves office/facility 82 Office visits: List Number and Level of Office Visits # visits # visits 83 99211 16 minutes 84 99212 27 minutes 85 99213 36 minutes 86 99214 53 minutes 87 99215 63 minutes 88 CA039 Post-operative visits (total time) 0.0 0.0 A B W X 1 RUC Practice Expense Spreadsheet RECOMMENDED 2 63053 3 RUC Collaboration Website Laminectomy, Meeting Date: 04/2021 facetectomy, or Clinical Revision Date (if applicable): April 7, 2021 foraminotomy Activity Code Tab: 4 (unilateral or bilateral 4 Specialty: AANS, CNS, AAOS, NASS, ISASS with decompression f 5 LOCATION Non Fac Facility 6 GLOBAL PERIOD ZZZ ZZZ TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 0 0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 0 0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0 0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 0 0 96 Supply Code MEDICAL SUPPLIES 97 TOTAL COST OF SUPPLY QUANTITY x PRICE $ - $ - 98 SA048 pack, minimum multi-specialty visit 99 SA052 pack, post-op incision care (staple) 100 SA053 pack, post-op incision care (suture & staple) 101 Equipment EQUIPMENT 103 Code 104 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ - $ - 105 EF031 table, power 106 EF014 light, surgical 107 EQ168 light, exam AMA/Specialty Society RVS Update Committee Summary of Recommendations

April 2021

Drug Induced Sleep Endoscopy (DISE) – Tab 5

In October 2020, the CPT Editorial Panel created a new code to report drug induced sleep endoscopy (DISE) flexible, diagnostic. At the January 2021 RUC Meeting, the RUC requested that this service be resurveyed for the April 2021 RUC Meeting using a standard 000-day survey template.

42975 Drug induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep disordered breathing, flexible, diagnostic The RUC reviewed the survey results from 89 otolaryngologists for CPT code 42975 and determined that the survey 25th percentile work RVU of 1.95 appropriately accounts for the physician work required to perform this service. The RUC recommends 18 minutes of pre-service evaluation time, 1 minute of pre-service positioning time, 6 minutes of pre-service scrub/dress/wait time, 15 minutes of intra-service time, and 10 minutes of immediate post-service time, and 50 minutes of total time for CPT code 42975. The specialty society noted that this procedure involves endoscopic evaluation of the upper airway for sleep apnea from the tip of the nose down to the larynx to identify the type and location of the airway obstruction and to determine specific maneuvers that would alleviate the obstruction and the effect that interventions have on the collapse. The specialty society noted that the sedation involved in this procedure mimics the conditions of sleep and that the accompanying muscle and tissue collapse of the airway make endoscopic visualization more difficult.

The RUC compared CPT code 42975 to the top key reference service CPT code 31579 Laryngoscopy, flexible or rigid telescopic, with stroboscopy (work RVU = 1.88, 10 minutes intra-service and 34 minutes of total time) and noted that 80 percent of survey respondents determined 42975 to be more complex than key reference service 31579 and that the recommended intra-service time and total time for 42975 support a work RVU of 1.95 in appropriate rank order compared with 31579.

The RUC also compared the survey code with CPT code 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (work RVU = 1.95, 15 minutes of intra-service and 45 minutes of total time), MPC code 64483 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (work RVU = 1.90, 15 minutes of intra-service and 49 minutes of total time), and CPT code 36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age (work RVU = 1.93, 15 minutes of intra- service and 48 minutes of total time) and noted that the recommended total time and work RVU fits appropriately within this range of codes. The RUC recommends a work RVU of 1.95 for CPT code 42975.

Practice Expense The Practice Expense Subcommittee affirmed the practice expense inputs from the January 2021 RUC meeting. The RUC recommends the direct practice expense inputs as submitted by the specialty society.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Tracking Global Work RVU Code Number CPT Descriptor Period Recommendation Respiratory System Larynx Endoscopy 31575 Laryngoscopy, flexible; diagnostic (Do not report 31575 in conjunction with 31231, unless performed for a separate condition using a separate endoscope) (Do not report 31575 in conjunction with 31572, 31573, 31574, 31576, 31577, 31578, 42975, 43197, 43198, 92511, 92612, 92614, 92616) Digestive System Pharynx, Adenoids, and Tonsils Other Procedures 42975 M1 000 1.95 Drug induced sleep endoscopy, with dynamic evaluation of velum, pharynx,

tongue base, and larynx for evaluation of sleep disordered breathing, flexible,

diagnostic (Do not report 42975 in conjunction with 31575, 92511) (Do not report 42975 in conjunction with 31231, unless performed for a separate condition [ie, other than sleep disordered breathing] and using a separate endoscope) Medicine Special Otorhinolaryngologic Services 92511 Nasopharyngoscopy with endoscope (separate procedure) (Do not report 92511 in conjunction with 31575, 42975, 43197, 43198) (For nasopharyngoscopy, surgical, with dilation of eustachian tube, see 69705, 69706)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 42975 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:42975 Tracking Number Original Specialty Recommended RVU: 1.95 Presented Recommended RVU: 1.95 Global Period: 000 Current Work RVU: RUC Recommended RVU: 1.95

CPT Descriptor: Drug induced sleep endoscopy; with dynamic evaluation of velum, pharynx, tongue base, and largynx for evaluation of sleep disordered breathing; flexible, diagnostic

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 45-year old male with moderate to severe obstructive sleep apnea has been unable to tolerate positive airway pressure therapy, sleep endoscopy is performed to identify anatomic and physiologic factors contributing to his obstructive sleep apnea and the selection of non-continuous positive airway pressure (cpap) treatment options

Percentage of Survey Respondents who found Vignette to be Typical: 87%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: Meet with patients and family to describe and discuss in detail the planned procedure. Review and update the medical history. Perform a current physical exam. Reconcile medications and allergies. Address NPO status and timing. Discuss the patient's expected convalescence and educate the patient and caregivers regarding the signs and symptoms of the most common complications. Discussion with the anesthesiologist regarding the level of sedation required and the approximate length of the case. Review and obtain informed consent. The availability of all required instruments and supplies is verified. A timeout is performed with entire surgical team, including confirmation of the procedure, locations, allergies, antibiotic prophylaxis, anesthesia and fire risks, expected duration, and any concerns related to the procedure. The patient is positioned. The surgeon scrubs, gowns and preps the patient for the procedure.

Description of Intra-Service Work: The nasal passages are prepared with application of a decongestant and/or topical anesthesia. Light intravenous sedation is given, which typically is provided by a separate provider, to a point where the patient is non-responsive to verbal stimuli, has snoring or partial upper airway flow limitation, and observed oxygen desaturations. The performing physician then places a flexible endoscope through the nose and advances it to the pharynx. Endoscopic evaluation of the nasopharynx, oropharynx, hypopharynx, and larynx is performed during sleep or sedation over multiple cycles of airway narrowing and/or obstruction. The velopharynx is the term for the distal (no muscular) component of the soft palate and uvula. This is the predominant site of upper pharyngeal collapse. The physician will note the anatomic site of obstruction (velopharynx, oropharynx, tongue, epiglottis), the severity of the obstruction (non, partial, complete), and pattern of obstruction (anteroposterior, circular, lateral).The physician then repositions the patient and/or performs manipulation of the head and neck and repeat endoscopy to determine effect of body position (supine versus lateral); jaw lift, tongue protrusion, or hyoid lift on airway obstruction. A patient’s existing oral appliance (mandibular advancement device) is placed and titrated to optimal effect. In certain cases, a continuous positive airway pressure (CPAP) mask may be applied to determine sites on ongoing obstruction in regular CPAP users who fail to improve with CPAP therapy.

Description of Post-Service Work: The patient is observed during emergence from anesthesia. The procedure is dictated. Discharge medications are reconciled. The prescription drug monitoring database is reviewed. Postoperative orders, medications and instructions are written. There is a discussion with the family and patient regarding the procedure and findings. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, CPT Code: 42975 signs and symptoms of complications, and review of the written postoperative instructions. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. CPT Code: 42975 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 42975

Sample Size: 3963 Resp N: 89 Description of Targeted Random Sample Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 8.00 20.00 35.00 400.00 Survey RVW: 1.00 1.95 2.30 2.75 44.00 Pre-Service Evaluation Time: 19.00 Pre-Service Positioning Time: 5.00 Pre-Service Scrub, Dress, Wait Time: 7.00 Intra-Service Time: 2.00 10.00 15.00 20.00 40.00 Immediate Post Service-Time: 10.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 2-FAC Diff Pat/Straightfor Proc(no sedation/anes)

CPT Code: 42975 Recommended Physician Work RVU: 1.95 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 18.00 18.00 0.00 Pre-Service Positioning Time: 1.00 1.00 0.00 Pre-Service Scrub, Dress, Wait Time: 6.00 6.00 0.00 Intra-Service Time: 15.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 8B IV Sedation/Complex Procedure

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 10.00 28.00 -18.00

CPT Code: 42975 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.0 99239x 0.0 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 31579 000 1.88 RUC Time

CPT Descriptor Laryngoscopy, flexible or rigid telescopic, with stroboscopy

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 31575 000 0.94 RUC Time

CPT Descriptor Laryngoscopy, flexible; diagnostic

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 54150 000 1.90 RUC Time 250 CPT Descriptor 1 Circumcision, using clamp or other device with regional dorsal penile or ring block Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 64483 000 1.90 RUC Time 1,044,547

CPT Descriptor 2 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

Other Reference CPT Code Global Work RVU Time Source 62321 000 1.95 RUC Time

CPT Descriptor Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Number of respondents who choose Top Key Reference Code: 30 % of respondents: 33.7 %

Number of respondents who choose 2nd Key Reference Code: 12 % of respondents: 13.4 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 42975 31579 31575

Median Pre-Service Time 25.00 14.00 14.00

Median Intra-Service Time 15.00 10.00 5.00

Median Immediate Post-service Time 10.00 10.00 5.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 50.00 34.00 24.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 20% 57% 23%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 3% 20% 77% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 3% 63% 33%

Physical effort required 0% 55% 45% CPT Code: 42975

Psychological Stress Less Identical More

• The risk of significant complications, 0% 27% 73% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 25% 58% 17%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 17% 83% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 33% 67%

Physical effort required 0% 8% 82%

Psychological Stress Less Identical More

• The risk of significant complications, 8% 17% 75% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting new code 42975. The Panel approved the CCA and the code is now being valued by the RUC. The new code will be published in the 2022 edition of the CPT Book. The new code was then surveyed for the January 2021 RUC meeting using the 000 global template with CPT Code: 42975 a visit. During the January RUC meeting, it was noted that the specialty should not have been able to use the 000 template with a visit, and the RUC voted to require AAO-HNS to resurvey the code for the April 2021 meeting.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 3963 members from the American Academy of Otolaryngology – Head and Neck Surgery who self-designated as one or more of the following sub-specialties: General Otolaryngology, Sleep Medicine, or Pediatric Otolaryngology.

Recommendation (Work and Intra Time):

We are recommending a work RVU of 1.95 and 15 minutes of intra service time, based on our survey’s 25th percentile RVW.

Time package selection: We have selected pre-time package 2 and post-time package 8B due to this procedure currently being done predominantly in the hospital outpatient setting using conscious sedation.

Pre-time Package 2 Difficult Patient / Straightforward Procedure (No anesthesia care)

Evaluation Time – We are recommending 18 minutes of evaluation time which is one minute less than our median survey time, but identical to the pre-service package time.

Positioning Time – We are recommending 1 minute of positioning time which is a decrease of 4 minutes from the median survey time, but consistent with the pre-service package time for this activity.

Scrub, Dress, Wait Time – We are recommending 6 minutes of scrub, dress and wait time which is a decrease of one minute from the median survey time, but consistent with the pre-service package time for this activity.

This results in a total recommended pre time of 25 minutes, taking the lesser of surveyed time or the pre-service package time.

Post-time Package 8B IV Sedation/ Complex Procedure Our recommended post time is 10 minutes consistent with the survey’s immediate post time of 10 minutes indicated by respondents. This is 18 minutes less than the post-package time, but consistent with our survey results for post work.

CPT Code: 42975 Supporting Reference Codes for the Recommended Value

CPT Long Desc Global Work Intra Total Most Recent IWPUT 2019 Code RVU Time Time RUC Review Medicare Utilization

62320 Injection(s), of diagnostic or therapeutic 000 1.80 15 43 2015-10 0.083 5631 substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

62323 Injection(s), of diagnostic or therapeutic 000 1.80 15 45 2015-10 0.08 699990 substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

15275 Application of skin substitute graft to face, scalp, 000 1.83 15 45 2011-04 0.0829 122551 eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

47537 Removal of biliary drainage catheter, 000 1.84 15 52 2015-10 0.0731 1737 percutaneous, requiring fluoroscopic guidance (eg, with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

62324 Injection(s), including indwelling catheter 000 1.89 15 43 2015-10 0.089 19559 placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

62327 Injection(s), including indwelling catheter 000 1.90 15 45 2015-10 0.0866 1995 placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

11983 Removal with reinsertion, non-biodegradable 000 1.91 15 40 2018-10 0.0938 2345 drug delivery implant

36555 Insertion of non-tunneled centrally inserted 000 1.93 15 48 2016-10 0.0842 26 central venous catheter; younger than 5 years of age CPT Code: 42975 62321 Injection(s), of diagnostic or therapeutic 000 1.95 15 45 2015-10 0.09 217240 substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

92960 Cardioversion, elective, electrical conversion of 000 2.00 15 46 2010-10 0.0918 201622 arrhythmia; external

45338 Sigmoidoscopy, flexible; with removal of 000 2.05 15 48 2013-10 0.0922 5383 tumor(s), polyp(s), or other lesion(s) by snare technique

69801 Labyrinthotomy, with perfusion of 000 2.06 15 43 2010-04 0.1003 24321 vestibuloactive drug(s), transcanal

43235 Esophagogastroduodenoscopy, flexible, 000 2.09 15 49 2013-01 0.0933 323621 transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

31577 Laryngoscopy, flexible; with removal of foreign 000 2.19 15 48 2015-10 0.1053 80 body(s)

62325 Injection(s), including indwelling catheter 000 2.20 15 45 2015-10 0.1066 1225 placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

31573 Laryngoscopy, flexible; with therapeutic 000 2.43 15 52 2015-10 0.1153 2503 injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral

31574 Laryngoscopy, flexible; with injection(s) for 000 2.43 15 55 2015-10 0.1108 4008 augmentation (eg, percutaneous, transoral), unilateral

31578 Laryngoscopy, flexible; with removal of 000 2.43 15 51 2015-10 0.1168 59 lesion(s), non-laser

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

The surveyed code is an add-on code or a base code expected to be reported with an add-on code. Different specialties work together to accomplish the procedure; each specialty codes its part of the physician work using different codes. Multiple codes allow flexibility to describe exactly what components the procedure included. Multiple codes are used to maintain consistency with similar codes. CPT Code: 42975 Historical precedents. Other reason (please explain)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 31599

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otolaryngology How often? Commonly

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 106858 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the Medicare volume predicted below, using the percentages of the three prior codes that were used to report the service.

Specialty Otolaryngology Frequency 106858 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 35,619 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. This takes the percentage estimates of the three codes above which were previously used to report the service and adds the volume together that is anticipated in the new code.

Specialty Otolaryngology Frequency 35619 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Endoscopy CPT Code: 42975

BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 31573

SS Rec Summary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AR AS AT AU AV

24 ISSUE: Drug Induced Sleep Endoscopy - APRIL 2021 25 TAB: 5 26 RVW Total PRE-TIME INTRA-TIME IMMD FAC-inpt/same day SURVEY EXPERIENCE RUC

Review Work Per 27 Source CPT Global DESC Year Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST 91 92 33 32 31 38 39 MIN 25th MED 75th MAX Laryngoscopy, flexible or rigid 1st REF 31579 000 2015 30 0.141 0.055 1.88 34 8 1 5 10 10 28 telescopic, with stroboscopy 29 2nd REF 31575 000 Laryngoscopy, flexible; diagnostic 2015 12 0.117 0.039 0.94 24 8 1 5 5 5 2021 Jan 2021 NEW (interim 0.053 0.028 1.90 68 18 1 6 15 28 RUC Rec 30 rec) Drug induced sleep endoscopy; with 31 SVY 42975 dynamic evaluation of velum, pharynx, 89 0.099 0.041 1.00 1.95 2.30 2.75 44.00 56 19 5 7 2 10 15 20 40 10 0 8 20 35 400 Drug induced sleep endoscopy; with dynamic evaluation of velum, pharynx, REC 42975 000 0.083 0.039 1.95 50 18 1 6 15 10 tongue base, and largynx for evaluation of sleep disordered 32 breathing; flexible, diagnostic FACILITY DIRECT PE INPUTS CPT CODE(S):___42975______SPECIALTY SOCIETY(IES):__AAO-HNS______PRESENTER(S):__R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

Meeting Date: April 2021

CPT Global Code Long Descriptor Period Drug induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep disordered breathing, flexible, 42975 000 diagnostic

Vignette(s) (vignette required even if PE only code(s)): CPT Code Vignette A 45-year old male with moderate to severe obstructive sleep apnea has been unable to tolerate positive airway pressure therapy, sleep endoscopy is performed to identify anatomic 42975 and physiologic factors contributing to his obstructive sleep apnea and the selection of non- continuous positive airway pressure (cpap) treatment options

1. Please provide a brief description of the process used to develop your recommendation and the composition of your Specialty Society RVS Committee Expert Panel: Our specialty formed a panel of experts to develop practice expense recommendations for this family of codes. The panel was comprised of our RUC Advisor and multiple clinical experts who practice in the areas of general otolaryngology, sleep medicine and pediatric otolaryngology. The expert panel members also practice across in settings that vary by size, geography, and represent both private and academic settings.

2. Please provide reference code(s) for comparison on your spreadsheet. If you are making recommendations on an existing code, you are required to use the current direct PE inputs as your reference code, but may provide an additional reference code for support. Provide an explanation for the selection of reference code(s) here (for service reviewed prior to the implementation of clinical activity codes, detail is not provided in the RUC database, please contact Samantha Ashley at [email protected] for PE spreadsheets for your reference codes): 42975 is a new CPT code, therefore, reference code 31576 was selected. The reference code was chosen based on the fact that it was recently valued by the RUC by our specialty, and is also a 000 global service that is typically performed in the hospital outpatient setting.

3. Is this code(s) typically reported with an E/M service? No, however, a discharge management visit is typical based on the typical site of service being the hospital.

4. If you are recommending more minutes than the PE Subcommittee standards for clinical activities you must provide rationale to justify the time: We are recommending clinical staff pre-time above the standard for 000 globals of 0 minutes. This represents extensive use of clinical staff per the PE Subcommittee standards and is consistent with the PE approved in the January 2017 and January 2020 for otolaryngology services typically performed in the hospital setting. The rationale for this time is that staff are essential to scheduling, and completing paperwork necessary, to schedule these procedures in the facility setting. The recommendation for the new code is consistent with these recommendations and includes the standard time for clinical staff activities for endoscopy procedures time in the pre-service.

1 FACILITY DIRECT PE INPUTS CPT CODE(S):___42975______SPECIALTY SOCIETY(IES):__AAO-HNS______PRESENTER(S):__R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

5. If you are requesting an increase over the aggregate current cost for clinical staff time, equipment and supplies for the code family, please provide compelling evidence (please see PE compelling evidence guidelines) Please explain if the increase can be entirely accounted for because of an increase in physician time: N/A, this is a new code. No new inputs are being requested / invoices provided.

7. Please provide a brief description of the clinical staff work for the following: a. Pre-Service period: During the pre-service period the clinical staff are conducting the typical activities for endoscopy procedures, when performed in the facility setting. Those include:

Completing pre-service diagnostic and referral forms Coordinating pre-surgery services (including test results, medical evaluations) Scheduling the space and equipment in the facility Providing pre-service education and obtaining consent Completing pre-procedure phone calls and prescriptions b. Service period (includes pre, intra and post): There are no clinical staff activities during the service period. c. Post-service period: During the post-service period the clinical staff call the patient to check in and see how they’re doing post-procedure. They also inquire about use of CPAP post procedure. 8. If you are recommending a new clinical activity, please provide a detailed explanation of why the new clinical activity is needed and cannot conform to any of the existing clinical activities (please see second worksheet in PE spreadsheet workbook): N/A

INVOICES

10. ☐ Please check the box to confirm that you have provided invoices for all new supplies and/or equipment?

11. ☐ Please check the box to confirm that you have provided an estimate price on the PE spreadsheet for all new supplies and/or equipment?

12. If you wish to include a supply that is not on the list (please see fourth worksheet in PE spreadsheet workbook) please provide a paid invoice. Identify and explain the invoice here: No supplies, only making facility recommendations at this time.

2 FACILITY DIRECT PE INPUTS CPT CODE(S):___42975______SPECIALTY SOCIETY(IES):__AAO-HNS______PRESENTER(S):__R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

13. Please provide an itemized list of the contents for all supply kits, packs and trays included in your recommendation. Please include the description, CMS supply code, unit, item quantity and unit price (if available). See documents two and three under PE reference materials on the RUC Collaboration Website for information on the contents of kits, packs and trays. No supplies, only making facility recommendations at this time.

14. If you wish to include an equipment item that is not on the list (please see fifth worksheet in PE spreadsheet workbook) please provide a paid invoice. Identify and explain the invoice here: No equipment, only making facility recommendations at this time.

15. Have you recommended equipment minutes for a computer or equivalent laptop/integrated computer, equipment item computer, desktop, w-monitor, ED021 or notebook (Dell Latitute D600), ED038? a. If yes, please explain how the computer is used for this service(s). b. Is the computer used exclusively as an integral component of the service or is it also used for other purposes not specific to the code? c. Does the computer include code specific software that is typically used to provide the service(s)? N/A

16. List all the equipment included in your recommendation and the equipment formula chosen (please see document titled Calculating equipment time). If you have selected “other formula” for any of the equipment please explain here: No equipment, only making facility recommendations at this time.

17. If there is any other item(s) on your spreadsheet not covered in the categories above that require greater detail/explanation, please include here: N/A

PROFESSIONAL LIABILITY INSURANCE (PLI) INFORMATION

18. If this is a PE only code please select a crosswalk based on a similar specialty mix: N/A

ITEMIZED LIST OF CHANGES (FOLLOWING THE PE SUBCOMMITTEE MEETING

During and immediately following the review of this tab at the PE Subcommittee meeting please revise the PE spreadsheet and summary of recommendation (PE SOR) documents based on modifications made during the meeting. Please submit the revised documents electronically to Samantha Ashley at [email protected] immediately following the close of business the same day that the tab is reviewed. On the PE spreadsheet, please highlight the cells and/or use red font to show the changes made during the PE Subcommittee meeting (if you have provided any of this highlighting based on changes from the reference code prior to the PE Subcommittee meeting please remove it, so not to be confused with changes made during the meeting). In addition to those revisions please also provide an itemized list of the modifications made to the PE spreadsheet during the PE Subcommittee meeting in the space below (e.g. clinical activity CA010 obtain vital signs was reduced from 5 minutes to 3 minutes).

3 FACILITY DIRECT PE INPUTS CPT CODE(S):___42975______SPECIALTY SOCIETY(IES):__AAO-HNS______PRESENTER(S):__R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

N/A new code.

4 A B D E F G H I 1 RUC Practice Expense Spreadsheet REFERENCE CODE RECOMM 2 CPT Code 31576 429 3 RUC Collaboration Website Drug induced sleep Laryngoscopy, dynamic evaluation Meeting Date: April 2021 Clinical Staff flexible; with tongue base, and la Clinical Revision Date (if applicable): Clinical Staff Clinical Type Rate biopsy(ies) of sleep disordered Activity Code Tab: 5 Type Code Staff Type Per Minute diagn 4 Specialty: AAO-HNS 5 LOCATION Non Fac Facility Non Fac 6 GLOBAL PERIOD 000 000 000 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND EQUIPMENT $ 136.05 $ 86.92 $ - 7 TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 112.0 33.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 18.0 30.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 91.0 0.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 3.0 3.0 0.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ 41.44 $ 12.21 $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms L037D RN/LPN/MTA 0.37 5 5 16 CA002 Coordinate pre-surgery services (including test results) L037D RN/LPN/MTA 0.37 3 10 17 CA003 Schedule space and equipment in facility L037D RN/LPN/MTA 0.37 0 5 18 CA004 Provide pre-service education/obtain consent L037D RN/LPN/MTA 0.37 7 7 19 CA005 Complete pre-procedure phone calls and prescription L037D RN/LPN/MTA 0.37 3 3 20 CA006 Confirm availability of prior images/studies L037D RN/LPN/MTA 0.37 21 CA007 Review patient clinical extant information and questionnaire L037D RN/LPN/MTA 0.37 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) L037D RN/LPN/MTA 0.37 23 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new in 26 L037D RN/LPN/MTA 0.37 column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 L037D RN/LPN/MTA 0.37 3 0 available 34 CA010 Obtain vital signs L037D RN/LPN/MTA 0.37 5 0

CA011 Provide education/obtain consent L037D RN/LPN/MTA 0.37 35 36 CA012 Review requisition, assess for special needs L037D RN/LPN/MTA 0.37 37 CA013 Prepare room, equipment and supplies L037D RN/LPN/MTA 0.37 2 0 38 CA014 Confirm order, protocol exam L037D RN/LPN/MTA 0.37 39 CA015 Setup scope (nonfacility setting only) L037D RN/LPN/MTA 0.37 5 0 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient L037D RN/LPN/MTA 0.37 2 0 41 CA017 Sedate/apply anesthesia L037D RN/LPN/MTA 0.37 42 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new in 45 L037D RN/LPN/MTA 0.37 column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly related to 49 CA018 L037D RN/LPN/MTA 0.37 10 0 Assistphysician physician work time or other (100%) qualified healthcare professional---directly related to 50 CA019 L037D RN/LPN/MTA 0.37 Assistphysician physician work time or other (67%) qualified healthcare professional---directly related to 51 CA020 L037D RN/LPN/MTA 0.37 physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time L037D RN/LPN/MTA 0.37 55 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new in 56 L037D RN/LPN/MTA 0.37 column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 L037D RN/LPN/MTA 0.37 15 0 61 CA023 Monitor patient following procedure/service, no multitasking L037D RN/LPN/MTA 0.37 62 CA024 Clean room/equipment by clinical staff L037D RN/LPN/MTA 0.37 3 0 63 CA025 Clean scope L037D RN/LPN/MTA 0.37 30 0 64 CA026 Clean surgical instrument package L037D RN/LPN/MTA 0.37 10 0 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions L037D RN/LPN/MTA 0.37 3 0 66 CA028 Review/read post-procedure x-ray, lab and pathology reports L037D RN/LPN/MTA 0.37 67 CA029 Check dressings, catheters, wounds L037D RN/LPN/MTA 0.37 3 0 Technologist QC s images in PACS, checking for all images, reformats, and 68 CA030 L037D RN/LPN/MTA 0.37 dose page 69 CA031 Review examination with interpreting MD/DO L037D RN/LPN/MTA 0.37 Scan exam documents into PACS. Complete exam in RIS system to populate 70 CA032 L037D RN/LPN/MTA 0.37 images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) L037D RN/LPN/MTA 0.37 Document procedure (nonPACS) (e.g. mandated reporting, registry logs, EEG 72 CA034 L037D RN/LPN/MTA 0.37 file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions L037D RN/LPN/MTA 0.37 74 CA036 Discharge day management L037D RN/LPN/MTA 0.37 n/a n/a 75 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new in 78 L037D RN/LPN/MTA 0.37 column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications L037D RN/LPN/MTA 0.37 3 3 85 CA038 Coordinate post-procedure services L037D RN/LPN/MTA 0.37 86 Office visits: List Number and Level of Office Visits MINUTES # visits # visits # visits 87 99211 16 minutes 16 88 99212 27 minutes 27 89 99213 36 minutes 36 90 99214 53 minutes 53 91 99215 63 minutes 63 92 CA039 Post-operative visits (total time) L037D RN/LPN/MTA 0.37 0.0 0.0 0.0 93 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new in 96 L037D RN/LPN/MTA 0.37 column A 99 End: with last office visit before end of global period A B D E F G H I 1 RUC Practice Expense Spreadsheet REFERENCE CODE RECOMM 2 CPT Code 31576 429 3 RUC Collaboration Website Drug induced sleep Laryngoscopy, dynamic evaluation Meeting Date: April 2021 Clinical Staff flexible; with tongue base, and la Clinical Revision Date (if applicable): Clinical Staff Clinical Type Rate biopsy(ies) of sleep disordered Activity Code Tab: 5 Type Code Staff Type Per Minute diagn 4 Specialty: AAO-HNS 5 LOCATION Non Fac Facility Non Fac 6 GLOBAL PERIOD 000 000 000 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND EQUIPMENT $ 136.05 $ 86.92 $ - 7 TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 112.0 33.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 18.0 30.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 91.0 0.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 3.0 3.0 0.0 100 Supply Code MEDICAL SUPPLIES PRICE UNIT 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ 74.71 $ 74.71 $ - 102 SA041 pack, basic injection 10.755 pack 1 103 SA048 pack, minimum multi-specialty visit 4.0507 pack 1 104 SB012 drape, sterile, for Mayo stand 1.2245 item 1 105 SB022 gloves, non-sterile 0.246 pair 1 106 SC029 needle, 18-27g 0.0523 item 1 107 SC057 syringe 5-6ml 0.135 item 1 108 SD009 canister, suction 4.2095 item 1 109 SD122 suction tip, Yankauer 0.5865 item 1 110 SD132 tubing, suction, non-latex (6ft uou) 0.9212 item 2 111 SD318 Disposable biopsy forceps 24.02 item 1 112 SG056 gauze, sterile 4in x 4in (10 pack uou) 1.0995 item 1 113 SH050 lidocaine 4% soln, topical (Xylocaine) 0.1733 ml 2 114 SJ010 basin, emesis 0.2415 item 1 115 SJ037 oxymetazoline nasal spray (Afrin) (15ml uou) 1.7025 item 1 116 SJ053 swab-pad, alcohol 0.0333 item 2 117 SK058 paper, photo printing (8.5 x 11) 0.7125 item 2 118 SL036 cup, biopsy-specimen sterile 4oz 0.6433 item 1 119 SL037 cup, medicine (1oz size) 0.009 item 1 120 SM001 atomizer tip shield (RhinoGuard) 0.905 item 1 121 SM010 cleaning brush, endoscope 3.6105 item 2 122 SM014 endoscope anti-fog solution 0.8367 ml 2 123 SM015 enzymatic detergent 0.2223 oz 4 124 SM018 glutaraldehyde 3.4% (Cidex, Maxicide, Wavicide) 2.6212 oz 4 125 SM019 glutaraldehyde test strips (Cidex, Metrex) 0.883 item 1

Other supply item: to add a new supply item please include the name of the item consistent with the paid invoice here, type NEW in column A and enter the type of unit in column E (oz, ml, unit). Please note that you must include a price estimate consistent with the paid invoice in column D.

126 Equipment Purchase Equipment Cost Per EQUIPMENT 128 Code Price Formula Minute 129 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ 19.90 $ - $ - 130 ES084 channeled flexible digital scope, laryngoscopy 18694.39 Scope 0.108312212 57 0 Scope ES031 scope video system (monitor, processor, digital capture, cart, printer, LED light) 53489.691 0.202673463 30 0 131 Systems 132 ES005 endoscope disinfector, rigid or fiberoptic, w-cart 27500 Default 0.086369514 30 0 133 EQ234 suction and pressure cabinet, ENT (SMR) 4032.9248 Default 0.010702279 96 0 134 EQ170 light, fiberoptic headlight w-source 3525.9372 Default 0.013970455 96 0 135 EQ167 light source, xenon 10922.938 Default 0.043278824 30 0 Instrument EQ137 instrument pack, basic ($500-$1499) 500 0.002323783 37 0 136 Packs 137 EF015 mayo stand 524.793 Default 0.001167346 96 0 138 EF008 chair with headrest, exam, reclining 5565.6015 Default 0.01238009 96 0 139 140 141

Other equipment item: to add a new equipment item please include the name of the item consistent with the paid invoice here, type NEW in column A and please note that you must include a purchase price estimate consistent with the paid invoice in column D.

142 A B J K L M N O P 1 RUC Practice Expense Spreadsheet MENDED 2 75 3 RUC Collaboration Website p endoscopy, with of velum, pharynx, Meeting Date: April 2021 rynx for evaluation Clinical Revision Date (if applicable): breathing, flexible, Activity Code Tab: 5 ostic 4 Specialty: AAO-HNS 5 LOCATION Facility 6 GLOBAL PERIOD 000 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND EQUIPMENT $ 8.14 7 TIME 8 TOTAL CLINICAL STAFF TIME 22.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 19.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 3.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ 8.14 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 3 16 CA002 Coordinate pre-surgery services (including test results) 5 17 CA003 Schedule space and equipment in facility 3 18 CA004 Provide pre-service education/obtain consent 5 19 CA005 Complete pre-procedure phone calls and prescription 3 20 CA006 Confirm availability of prior images/studies 21 CA007 Review patient clinical extant information and questionnaire 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) 23 Other activity: please include short clinical description here and type new in 26 column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 available 34 CA010 Obtain vital signs

CA011 Provide education/obtain consent 35 36 CA012 Review requisition, assess for special needs 37 CA013 Prepare room, equipment and supplies 38 CA014 Confirm order, protocol exam 39 CA015 Setup scope (nonfacility setting only) 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient 41 CA017 Sedate/apply anesthesia 42 Other activity: please include short clinical description here and type new in 45 column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly related to 49 CA018 Assistphysician physician work time or other (100%) qualified healthcare professional---directly related to 50 CA019 Assistphysician physician work time or other (67%) qualified healthcare professional---directly related to 51 CA020 physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time 55 Other activity: please include short clinical description here and type new in 56 column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 61 CA023 Monitor patient following procedure/service, no multitasking 62 CA024 Clean room/equipment by clinical staff 63 CA025 Clean scope 64 CA026 Clean surgical instrument package 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions 66 CA028 Review/read post-procedure x-ray, lab and pathology reports 67 CA029 Check dressings, catheters, wounds Technologist QC s images in PACS, checking for all images, reformats, and 68 CA030 dose page 69 CA031 Review examination with interpreting MD/DO Scan exam documents into PACS. Complete exam in RIS system to populate 70 CA032 images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) Document procedure (nonPACS) (e.g. mandated reporting, registry logs, EEG 72 CA034 file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions 74 CA036 Discharge day management 75 Other activity: please include short clinical description here and type new in 78 column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications 3 85 CA038 Coordinate post-procedure services 86 Office visits: List Number and Level of Office Visits # visits 87 99211 16 minutes 88 99212 27 minutes 89 99213 36 minutes 90 99214 53 minutes 91 99215 63 minutes 92 CA039 Post-operative visits (total time) 0.0 93 Other activity: please include short clinical description here and type new in 96 column A 99 End: with last office visit before end of global period A B J K L M N O P 1 RUC Practice Expense Spreadsheet MENDED 2 75 3 RUC Collaboration Website p endoscopy, with of velum, pharynx, Meeting Date: April 2021 rynx for evaluation Clinical Revision Date (if applicable): breathing, flexible, Activity Code Tab: 5 ostic 4 Specialty: AAO-HNS 5 LOCATION Facility 6 GLOBAL PERIOD 000 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND EQUIPMENT $ 8.14 7 TIME 8 TOTAL CLINICAL STAFF TIME 22.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 19.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 3.0 100 Supply Code MEDICAL SUPPLIES 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ - 102 SA041 pack, basic injection 103 SA048 pack, minimum multi-specialty visit 104 SB012 drape, sterile, for Mayo stand 105 SB022 gloves, non-sterile 106 SC029 needle, 18-27g 107 SC057 syringe 5-6ml 108 SD009 canister, suction 109 SD122 suction tip, Yankauer 110 SD132 tubing, suction, non-latex (6ft uou) 111 SD318 Disposable biopsy forceps 112 SG056 gauze, sterile 4in x 4in (10 pack uou) 113 SH050 lidocaine 4% soln, topical (Xylocaine) 114 SJ010 basin, emesis 115 SJ037 oxymetazoline nasal spray (Afrin) (15ml uou) 116 SJ053 swab-pad, alcohol 117 SK058 paper, photo printing (8.5 x 11) 118 SL036 cup, biopsy-specimen sterile 4oz 119 SL037 cup, medicine (1oz size) 120 SM001 atomizer tip shield (RhinoGuard) 121 SM010 cleaning brush, endoscope 122 SM014 endoscope anti-fog solution 123 SM015 enzymatic detergent 124 SM018 glutaraldehyde 3.4% (Cidex, Maxicide, Wavicide) 125 SM019 glutaraldehyde test strips (Cidex, Metrex)

126 Equipment EQUIPMENT 128 Code 129 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ - 130 ES084 channeled flexible digital scope, laryngoscopy ES031 scope video system (monitor, processor, digital capture, cart, printer, LED light) 131 132 ES005 endoscope disinfector, rigid or fiberoptic, w-cart 133 EQ234 suction and pressure cabinet, ENT (SMR) 134 EQ170 light, fiberoptic headlight w-source 135 EQ167 light source, xenon EQ137 instrument pack, basic ($500-$1499) 136 137 EF015 mayo stand 138 EF008 chair with headrest, exam, reclining 139 140 141

142 AMA/Specialty Society RVS Update Committee Summary of Recommendations

April 2021

Transcutaneous Passive Implant-Temporal Bone – Tab 6

In October 2020, the CPT Editorial Panel revised two codes to replace “temporal bone” with “skull” and delete “or transcutaneous” and “cochlear stimulator: without mastoidectomy” from the descriptors. The Panel also replaced two codes for mastoidectomy with new codes for magnetic transcutaneous attachment to external speech processor. Additional revisions and codes were added to differentiate implantation, removal, and replacement of the implants.

At the January 2021 RUC Meeting, the RUC reviewed these services and determined that they need to be resurveyed for the April 2021 RUC Meeting with a revised Reference Service List (RSL) to encompass a larger range of relative values, specifically the lower end of the RVU spectrum. The specialty society submitted a letter to the RUC requesting that this service be referred to CPT in May 2021 to clarify the percutaneous implant removal by describing the procedure as removal of the entire implant, add a parenthetical to report removal of the abutment alone to be an included component of the evaluation and management visit and to bifurcate the transcutaneous codes into placement within the mastoid and/or resulting in removal of less than 100 mm2 surface area of cranium beyond its outer cortex versus those that are placed outside of the mastoid and resulting in removal of greater than or equal to 100 mm2 surface area of cranium beyond its outer cortex. The specialty society will survey these codes for the October 2021 RUC Meeting.

The RUC recommends affirming the January 2021 interim RUC recommendations for work and practice expense inputs for CPT codes 69714, 69716, 69717, 69719, 69726, and 69727 and resurveying these codes for the October 2021 RUC meeting following revisions at the May 2021 CPT Editorial Panel meeting.

CPT Tracking Global Work RVU Code Number CPT Descriptor Period Recommendation Auditory System Middle Ear Osseointegrated Implants The following codes are for implantation of an osseointegrated implant into the skull. These devices treat hearing loss through surgical placement of an abutment or device into the skull that facilitates transduction of acoustic energy to be received by the better-hearing inner ear or both inner ears when the implant is coupled to a speech processor and vibratory element. This coupling may occur in a percutaneous or a transcutaneous fashion. Other reparative middle ear and mastoid procedures (69501-69676) may be performed for different indications and may be reported separately when performed.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

69714 U1 090 Refer to CPT May 2021/ Implantation, osseointegrated implant, temporal bone skull;, with Survey October 2021 percutaneous attachment to external speech processor/cochlear

stimulator; without mastoidectomy (Interim January 2021 RUC Recommendation affirmed for 2022 MFS = 8.69)

69716 U2 with magnetic transcutaneous attachment to external 090 Refer to CPT May 2021/ speech processor Survey October 2021

(Interim January 2021 RUC Recommendation affirmed for 2022 MFS = 9.77) 69715 - 090 N/A with mastoidectomy

(69715 has been deleted. To report mastoidectomy performed at the same operative session as osseointegrated implant placement, revision/replacement, or removal, see 69501-69676) 69717 U3 090 Refer to CPT May 2021/ Revision/Rreplacement (including removal of existing device), Survey October 2021 osseointegrated implant, temporal bone, skull; with percutaneous

attachment to external speech processor/ cochlear stimulator; (Interim January 2021 RUC without mastoidectomy Recommendation affirmed for 2022 MFS = 8.80)

69719 U4 090 Refer to CPT May 2021/ with magnetic transcutaneous attachment to external Survey October 2021 speech processor

(Interim January 2021 RUC Recommendation affirmed for 2022 MFS = 9.77)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

69718 - 090 N/A with mastoidectomy

(69718 has been deleted. To report mastoidectomy performed at the same operative session as osseointegrated implant placement, revision/replacement, or removal, see 69501-69676) 69726 U5 090 Refer to CPT May 2021/ Removal, osseointegrated implant, skull; with percutaneous Survey October 2021 attachment to external speech processor

(Interim January 2021 RUC Recommendation affirmed for 2022 MFS = 5.93)

69727 U6 090 Refer to CPT May 2021/ with magnetic transcutaneous attachment to external Survey October 2021 speech processor

(Interim January 2021 RUC Recommendation affirmed for 2022 MFS = 7.13)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

February 9, 2021

Ezequiel Silva III, MD Chair, Relative Value Scale Update Committee (RUC) American Medical Association AMA Plaza 330 N. Wabash Ave., Suite 39300 Chicago, IL 60611-5885

RE: Referral of Transcutaneous Passive Implant – Temporal Bone family of codes (CPT 69714, 69717, 69716, 69719, 69726, and 69727) to the CPT Editorial Panel

Dear Dr. Silva,

On behalf of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS), we would like to respectfully request that the Transcutaneous Passive Implant – Temporal Bone family of codes (CPT 69714, 69717, 69716, 69719, 69726, and 69727) be referred to the CPT Editorial Panel for the May 2021 meeting. As you know, these codes were surveyed and presented to the RUC for valuation at the January 2021 meeting. After a lengthy facilitation meeting, it was determined that there was an issue with the survey responses for at least one code in the family, due to resulting rank order anomalies in intra-service time. In response, the RUC assigned interim values for the codes, and requested that the family be resurveyed for the April 2021 RUC meeting.

The Academy agreed with this recommendation, and indicated our intent to resurvey for the April meeting in the recently released LOIs. After discussing the possible issues with the survey responses with Academy leadership, as well as our otology colleagues and sister-societies, we believe there may be problems with the way the code family was revised at CPT in October 2020, resulting in the anomalous survey responses. Specifically, the 69726 code survey, removal of the percutaneous device, created a rank order anomaly. We discussed this dilemma with representatives from American Otological Society (AOS)/American Neurotology Society (ANS) and determined that the variation in the removal of the percutaneous device, 69726, was likely due to misinterpretation of the descriptor.

A frequent clinical scenario that occurs in removing the percutaneous device is that the implant is not truly removed. Very commonly with percutaneous implant wound problems, an appendage to the implant, known as the bone anchored implant abutment, which is the component that traverses the scalp, is simply uncoupled from the implant in the office setting. The resulting wound is subsequently left to heal by primary intention. The intent of CPT 69726 is for total removal of the implant and abutment which requires an operative environment and, most commonly, an otologic drill. Therefore, we are submitting a CCA that clarifies the percutaneous implant removal by describing the procedure as removal of the entire implant and have added a parenthetical to report removal of the abutment alone to be an included component of the evaluation and management visit.

Additionally, there is variation in the method of transcutaneous implant placement, and we noted problems with the distribution of the intraservice times in the 69716 code that is intended to report this procedure. Discussion with the AOS/ANS leadership revealed that there are different techniques that vary in time and intensity depending on the indication for the procedure, device chosen, and patient anatomy. A patient with chronic ear infection and resulting mixed or conductive hearing loss will often require placement of the device outside the mastoid to allow for adequate physical space for the device as well as mitigating infection risk. In these cases, some transcutaneous implants require removal of a significant amount of cranium down to or sometimes beyond the inner cortex in the retrosigmoid area or temporal squama. These cases are technically more difficult, time consuming, and risky. In other cases, such as single-sided deafness, conductive, or mixed hearing loss not resulting from chronic ear inflammatory disease, when the mastoid is well pneumatized, placement of a transcutaneous device in the mastoid is the preferred, less time consuming and less risky location for device placement. We have chosen to bifurcate the transcutaneous codes into placement within the mastoid and/or resulting in removal of less than 100 mm2 surface area of cranium beyond its outer cortex versus those that are placed outside of the mastoid and resulting in removal of greater than or equal to 100 mm2 surface area of cranium beyond its outer cortex as an effort to clarify the intraservice work for CPT 69716. Mirroring replacement and removal codes are also being proposed.

Given this additional information, we think it best to refer the family back to the CPT Editorial Panel for further clarification prior to resurvey. We therefore, request that the RUC approve referral of the family to CPT at the next opportunity in May 2021, and allow resurvey of the revised code set at the October 2021 RUC meeting. Thank you in advance for your consideration of this request. If you have any questions, please contact Jenna Minton, AAO-HNS RUC staff, at [email protected] or 517.927.8696.

Sincerely,

R. Peter Manes, MD AAO-HNS RUC Advisor AMA/Specialty Society RVS Update Committee Summary of Recommendations

January 2021

Transcutaneous Passive Implant-Temporal Bone – Tab 18

In October 2020, the CPT Editorial replaced two codes for mastoidectomy with new codes for magnetic transcutaneous attachment to external speech processor. Additional revisions and codes were added to differentiate implantation, removal, and replacement of the implants.

69714 Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor The RUC reviewed the survey results from 73 physicians and determined that a work RVU of 8.69 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 33 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 40 minutes of intra-service time, 15 minutes of immediate post-service time, ½ discharge day management (99238), one office visit(s) (1x 99212), and two office visit(s) (2x 99213).

The RUC recommends a direct work RVU crosswalk to CPT code 52400 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds (work RVU= 8.69, intra-service time of 40 minutes and 197.5 minutes of total time) and noted that both codes have identical intra-service time, similar total time, and should be valued identically. The RUC agreed that due to the lack of 090-day global codes with 40 minutes of intra-service time, CPT code 52400 is an appropriate crosswalk for the work value, resulting in a work intensity that closely aligns with the revision/replacement of implant code 69717 (0.110 and 0.100 IWPUT respectively). The RUC agreed that code 52400 and the survey code have similar intra-service and total times and should be valued identically, below the survey’s 25th percentile. The RUC recommends an interim work RVU of 8.69 for CPT code 69714.

69716 Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor The RUC reviewed the survey results from 67 physicians and determined that a work RVU of 9.77 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 32 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 60 minutes of intra-service time, 15 minutes of immediate post-service time, ½ discharge day management (99238), and two office visit(s) (2x 99213).

After thorough discussion, the RUC recommends a direct work RVU crosswalk to MPC code 50590 Lithotripsy, extracorporeal shock wave (work RVU= 9.77, intra-service time of 60, immediate post service time of 15 minutes and total time of 207 minutes) and noted that both codes have identical intra-service time, identical post-service time and similar total time, and should be valued identically. The RUC agreed that an IWPUT of 0.100 is appropriate and that the recommended work value of 9.77 places the survey code well within the relativity of the family.

Additionally, the RUC agreed that the work value of 9.77 for code 69716 is appropriately bracketed by codes 43180 Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed (work RVU = 9.03 and total time of 201 minutes) and 57240 Anterior CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed (work RVU = 10.08 and total time of 211 minutes), further supporting a recommended work RVU of 9.77 for code 69716. The RUC recommends an interim work RVU of 9.77 for CPT code 69716.

69717 Revision/replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor The RUC reviewed the survey results from 64 physicians and determined that a work RVU of 8.80 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 33 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 45 minutes of intra-service time, 15 minutes of immediate post-service time, ½ discharge day management (99238), one office visit(s) (1x 99212), and two office visit(s) (2x 99213).

The RUC recommends a direct work RVU crosswalk to CPT code 27829 Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed (work RVU= 8.80 and intra-service time of 45 minutes) to appropriately account for the physician work involved in this service. The RUC agreed that code 27829 is an appropriate crosswalk, the recommended work value of 8.80 for the survey code results in an IWPUT of 0.100. Additionally, the RUC agreed that the survey code should be valued identically to code 27829 because both services have identical intra-service time. The RUC recommends an interim work RVU of 8.80 for CPT code 69717.

69719 Revision/replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor The RUC reviewed the survey results from 59 physicians and determined that the work RVU of 9.77 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 33 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 60 minutes of intra-service time, 15 minutes of immediate post-service time, ½ discharge day management (99238), and two office visit(s) (2x 99213).

After thorough discussion, the RUC recommends a direct work RVU crosswalk to MPC code 50590 Lithotripsy, extracorporeal shock wave (work RVU = 9.77, intra-service time of 60 minutes and total time of 207 minutes). The RUC agreed that the crosswalk to MPC code 50590 and recommended work value of 9.77 appropriately accounts for the physician work involved in this service because both codes have identical intra- service time, identical post-service time and similar total time. The RUC agreed that an IWPUT of 0.099 is appropriate and that the recommended work value of 9.77 places the survey code well within the relativity of the family.

Additionally, the RUC agreed that the work value of 9.77 for code 69719 is appropriately bracketed by codes 43180 Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed (work RVU = 9.03 and total time of 201 minutes) and 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed (work RVU = 10.08 and total time of 211 minutes), further warranting a recommended work RVU of 9.77 for code 69719. The RUC recommends an interim work RVU of 9.77 for CPT code 69719.

69726 Removal, osseointegrated implant, skull; with percutaneous attachment to external speech processor CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

The RUC reviewed the survey results from 66 physicians and determined that the work RVU of 5.93 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 32 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 30 minutes of intra-service time, and 15 minutes of immediate post-service time, ½ discharge day management (99238), one office visit(s) (1x 99212), and one office visit(s) (1x 99213).

After thorough discussion, the RUC recommends a direct work RVU crosswalk to code 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy (work RVU = 5.93, intra-service time of 30 minutes and total time of 142 minutes). The RUC agreed that the work value of 5.93 appropriately accounts for the physician work involved in this service. The RUC noted that the survey code and crosswalk code 53852 have identical intra-service time and similar total time. The RUC agreed that an IWPUT of 0.088 is appropriate and that the recommended work value of 5.93 places the survey code well within the relativity of the entire family. Additionally, the RUC agreed that the recommended work value of 5.93 is appropriate because this (removal) service has a lower intensity, in comparison to the implantation and revision/replacement services in the family. The RUC recommends an interim work RVU of 5.93 for CPT code 69726.

69727 Removal, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor The RUC reviewed the survey results from 59 physicians and determined that the work RVU of 7.13 accurately reflects the typical physician work necessary to perform this service. The RUC recommends 33 minutes of pre-service evaluation time, 3 minutes of pre-service positioning time, 10 minutes of pre-service scrub/dress/wait time, 45 minutes of intra-service time, 15 minutes of immediate post-service time, ½ discharge day management (99238), one office visit(s) (1x 99212), and one office visit(s) (1x 99213).

After thorough discussion, the RUC recommends a direct work RVU crosswalk to code 37718 Ligation, division, and stripping, short saphenous vein (work RVU = 7.13, intra-service time of 45 minutes and total time of 178 minutes). The RUC agreed that the crosswalk to code 37718 and recommended value of 7.13 appropriately accounts for the physician work involved in this service because the survey code and crosswalk code have identical intra-service time and similar total time. The RUC agreed that an IWPUT of 0.085 is appropriate and is like (removal) code 69726 (IWPUT = 0.088) in the family, therefore the recommended work value of 7.13 places the survey code well within the relativity of the entire family. Additionally, the RUC agreed that the recommended work value of 7.13 is appropriate because this (removal) service has a lower intensity, in comparison to the implantation and revision/replacement services in the family.

The RUC agreed that the recommended work value of 7.13 is appropriately bracketed by codes 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid (work RVU = 6.81, intra-service time of 45 minutes and total time of 161 minutes) and 67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach (work RVU = 7.97, intra-service time of 45 minutes and total time of 185 minutes). The RUC recommends an interim work RVU of 7.13 for CPT code 69727.

Resurvey for April 2021 RUC Meeting In January 2021, the RUC reviewed these services and determined that they need to be interim and resurveyed for the April 2021 RUC meeting with a revised Reference Service List (RSL) to encompass a larger range of relative values, specifically relative values on the lower end of the spectrum. Additionally, there was concern from the specialty that survey respondents may not have fully understood the new removal codes based on the anomalous intra-service time response for code 69726 which was less than all other codes in the family.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Practice Expense The Practice Expense Subcommittee replaced one SA053 pack, post-op incision care (suture and staple) with one SA054 pack, post-op incision care (suture). The RUC recommends the direct practice expense inputs as modified by the Practice Expense Subcommittee.

Work Neutrality The RUC’s recommendation for this family of codes will result in an overall work savings that should be redistributed back to the Medicare conversion factor.

CPT Tracking Global Work RVU Code Number CPT Descriptor Period Recommendation Surgery Auditory System Middle Ear Osseointegrated Implants The following codes are for implantation of an osseointegrated implant into the skull. These devices treat hearing loss through surgical placement of an abutment or device into the skull that facilitates transduction of acoustic energy to be received by the better-hearing inner ear or both inner ears when the implant is coupled to a speech processor and vibratory element. This coupling may occur in a percutaneous or a transcutaneous fashion. Other reparative middle ear and mastoid procedures (69501-69676) may be performed for different indications and may be reported separately when performed.

69714 U1 090 8.69 Implantation, osseointegrated implant, temporal bone skull;, with (Interim) percutaneous attachment to external speech processor/cochlear

stimulator; without mastoidectomy (Resurvey for April 2021)

69716 U2 with magnetic transcutaneous attachment to external 090 9.77 speech processor (Interim)

(Resurvey for April 2021)

69715 - 090 N/A with mastoidectomy

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

(69715 has been deleted. To report mastoidectomy performed at the same operative session as osseointegrated implant placement, revision/replacement, or removal, see 69501-69676)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

69717 U3 090 8.80 Revision/Rreplacement (including removal of existing device), (Interim) osseointegrated implant, temporal bone, skull; with percutaneous

attachment to external speech processor/ cochlear stimulator; (Resurvey for April 2021) without mastoidectomy

69719 U4 090 9.77 with magnetic transcutaneous attachment to external (Interim) speech processor

(Resurvey for April 2021)

69718 - 090 N/A with mastoidectomy

(69718 has been deleted. To report mastoidectomy performed at the same operative session as osseointegrated implant placement, revision/replacement, or removal, see 69501-69676) 69726 U5 090 5.93 Removal, osseointegrated implant, skull; with percutaneous (Interim) attachment to external speech processor

(Resurvey for April 2021)

69727 U6 090 7.13 with magnetic transcutaneous attachment to external (Interim) speech processor

(Resurvey for April 2021)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 69714 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69714 Tracking Number Original Specialty Recommended RVU: 11.00 Presented Recommended RVU: 8.69 Global Period: 090 Current Work RVU: 14.45 RUC Recommended RVU: 8.69

CPT Descriptor: Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 56-year-old male suffers from chronic otitis media resulting in otorrhea and mixed hearing loss. He is unalbe to wear traditional hearing aids. Implantation of an osseointegrated bone anchored device with a percutaneous attachment to an external speech processor is performed.

Percentage of Survey Respondents who found Vignette to be Typical: 96%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 49% , In the ASC 49%, In the office 1%

Percent of survey respondents who stated they typically perform this procedure in the hospital, stated the patient is; Discharged the same day 100% , Overnight stay-less than 24 hours 0% , Overnight stay-more than 24 hours 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: Meet with patient and family to describe and discuss in detail the planned procedure. Review and update the medical history. Review the CT scan to ensure that there is adequate bone quality and quantity in the area of implantation to support a successful implantation. Perform a current physical exam paying special attention to the patient’s skin condition and skin thickness in the area of the actuator and coil to avoid potential post-surgical skin breakdown and implant extrusion. Reconcile medications and allergies. Address NPO status and timing. Discuss preoperative home medications and postoperative prescriptions and check the prescription drug monitoring database, discuss. Plan the patient's expected convalescence and educate the patient and caregivers regarding the signs and symptoms of the most common and serious complications. There is confirmation of site of proposed insertion site, and a detailed description is given of the postoperative changes in wound and incision and the expected cosmetic and functional results. Review and obtain informed consent. Verify that all required instruments and supplies are available. Following induction of anesthesia, the patient is positioned and prepped for the procedure. A timeout is performed with entire surgical team, including confirmation of the procedure, locations, allergies, antibiotic prophylaxis, anesthesia and fire risks, expected duration, and any concerns related to the procedure. The postauricular hair is shaved and the proposed implant recipient site is precisely measured and then marked using the implant template. The location of the implant transducer is marked using a hypodermic needle inserted down to the bone with marking ink, such as Methylene blue. The incision is injected with local anesthetic.

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection to the pericranium. A dissection is performed and the pericranium is incised and dissected away from the cranial bone to expose an area for implant placement. A pilot guide hole through the cranium is drilled, and the deep portion of the guide hole is instrumented to ascertain the possible presence of dural contact and lack of sigmoid sinus exposure. Depending on this deep instrumentation, the pilot hole is possibly deepened. The final guide hole is then widened with spiral drilling to achieve a larger opening to receive the implant. The implanted fixture is installed in the cranial bone to very specific torque settings. This implanted fixture is then secured to the transcutaneous abutment. The overlying flap and surrounding soft tissues are thinned to a maximal thickness to allow for transcutaneous attachment to the processor. A separate incision is made in the overlying skin of the flap to allow the percutaneous abutment to extend through the soft tissue flap. The wound is irrigated and hemostasis is obtained. The wound is closed in a layered fashion. A small bolster is created immediately surrounding the abutment and a locking cap is fixed to the abutment to keep the bolster in place and with appropriate pressure. CPT Code: 69714

Description of Post-Service Work: The prepped area of the recipient site is cleaned. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions.

Post op visit 1: 99213 The mastoid dressing is removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. Flap viability is assessed. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. Antibiotic ointment is placed on the surgical wound.

Post op visit 2: 99213 The patient's convalescence to that point is reviewed. The small abutment bolster and associated locking cap device are removed. The sutures are removed. The area around the percutaneous abutment is vigorously cleaned and possibly debrided. The wound is again inspected and palpated. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated.

Post op visit 3: 99212 The patient's convalescence to that point is reviewed. The wounds are inspected and palpated for full incisional healing prior to fitting the sound processor. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Long term care, strategies to maximize function, and expected outcomes are discussed in detail. Counseling regarding the device, its function, and signs and symptoms of trouble with the device are discussed with the patient and family. CPT Code: 69714 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69714

Sample Size: 533 Resp N: 73 Description of Targeted, random selection of 533 members from the AAO-HNS, the American Sample: Neurotology Society, and the AOS (American Otological Society). Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 3.00 8.00 12.00 45.00 Survey RVW: 1.00 11.00 12.00 14.00 17.40 Pre-Service Evaluation Time: 34.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 10.00 25.00 40.00 46.00 155.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 62.00 99211x 0.00 12x 1.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69714 Recommended Physician Work RVU: 8.69 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 33.00 33.00 0.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 40.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69714 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 62.00 99211x 0.00 12x 1.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15120 090 10.15 RUC Time

CPT Descriptor Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 31610 090 12.00 RUC Time

CPT Descriptor Tracheostomy, fenestration procedure with skin flaps

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 67904 090 7.97 RUC Time 54,853 CPT Descriptor 1 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 26615 090 7.07 RUC Time 1,057,533

CPT Descriptor 2 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone

Other Reference CPT Code Global Work RVU Time Source 66183 090 13.20 RUC Time

CPT Descriptor Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach

CPT Code: 69714

Number of respondents who choose Top Key Reference Code: 14 % of respondents: 19.1 %

Number of respondents who choose 2nd Key Reference Code: 14 % of respondents: 19.1 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69714 15120 31610

Median Pre-Service Time 46.00 72.00 60.00

Median Intra-Service Time 40.00 75.00 45.00

Median Immediate Post-service Time 15.00 30.00 20.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 19.00 173.00 Median Discharge Day Management Time 19.0 0.00 0.00 Median Office Visit Time 62.0 62.00 69.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 182.00 258.00 367.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 14% 36% 36% 14%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 21% 29% 50% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 21% 36% 43%

Physical effort required 29% 36% 36% CPT Code: 69714

Psychological Stress Less Identical More

• The risk of significant complications, 24% 43% 36% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 21% 50% 14% 14%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 14% 64% 21% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 21% 36% 43%

Physical effort required 31% 54% 16%

Psychological Stress Less Identical More

• The risk of significant complications, 42% 50% 8% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69714 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Note re: Key Reference Code #2

We recognize that KRS code 2, 31610, was selected as a KRS for this code, and some others in this family of codes by survey respondents. That code is marked “Do not use to value physician work” in the RUC database. The RUC database further states the following rationale: “The RUC recommends to flag CPT codes 31605 and 31610 as do not use for validation of work as 31605 physician time and work recommendations are based on only the 20 survey respondents who performed this service in the past 12 months and 31610 recommendation was based on the survey 75th percentile work RVU.” We do not agree that simply because the 75th percentile was approved in valuing this service, that it should be viewed as unreliable as a comparison to other services, and therefore, we included it in our RSL as a recently valued, and familiar service that our members would understand.

Recommendation (Work and Intra Time):

We are recommending a work RVU of 8.69 and 40 minutes of intra service time, based on a crosswalk to CPT 52400. This is below the survey’s 25th percentile.

Time package selection: We have selected pre-time package 3 and post-time package 9A due to this procedure currently being done predominantly in the hospital outpatient setting under general anesthesia.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 33 minutes of evaluation time which is identical to the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 46 minutes, taking the lesser of surveyed time or the pre-service package time.

Post-time Package 9A General Anesthesia or Complex Regional Block/ Straightforward Procedure Recommended time has been reduced to 15 minutes which is a decrease of 15 minutes from the post package time selected to match our survey time. This results in a total recommended post time of 15 minutes, taking the lesser of surveyed time or the pre-service package time.

Discharge Management / Post-Operative Visits Given that this procedure is almost exclusively performed in the hospital outpatient or ASC setting, and general anesthesia sedation is utilized, patients must be monitored closely following the procedure. This results in a discharge management visit being performed after the procedure, before the patient is discharged from the hospital. Our survey did not indicate that this was typical, however, it is the RUC standard for 090 global services when performed in the hospital, so we have included .5 discharge management visit in our recommendations for this CPT code.

Survey respondents also indicated that three post-operative office visits are typically conducted after the procedure. Two level three office visits, 99213; and one level two office visit, 99212.

Post op visit 1: 99213 CPT Code: 69714 The mastoid dressing is removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. Flap viability is assessed. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. Antibiotic ointment is placed on the surgical wound.

Supporting Reference Codes for the Recommended Value

CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 Code RVU Time Time Recent Medicare RUC Utilizatio Review n

46707 Repair of anorectal 090 0.06 6.39 40 187 2009-04 COLORECTAL SURGERY (PROCTOLOGY) 39 fistula with plug (eg, porcine small intestine submucosa [SIS]) 59870 Uterine evacuation and 090 0.0084 6.57 40 256 2000-08 OBSTETRICS/GYNECOLOGY 4 curettage for hydatidiform mole 24358 Tenotomy, elbow, 090 0.0669 6.66 40 193 2007-04 ORTHOPEDIC SURGERY 664 lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open 25109 Excision of tendon, 090 0.0632 6.94 40 191 2006-04 HAND SURGERY 268 forearm and/or wrist, flexor or extensor, each 26715 Open treatment of 090 0.0461 7.03 40 220 2007-02 ORTHOPEDIC SURGERY 216 metacarpophalangeal dislocation, single, includes internal fixation, when performed 29881 Arthroscopy, knee, 090 0.0637 7.03 40 194 2011-04 ORTHOPEDIC SURGERY 51597 surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed 52400 Cystourethroscopy with 090 0.126 8.69 40 197.5 2008-04 UROLOGY 115 incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive CPT Code: 69714 hypertrophic mucosal folds

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69714

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otoloaryngology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 279 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the Medicare volume estimated below.

Specialty Otolaryngology Frequency 279 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 93 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. The current 2019 volume indicated by the RUC database for this code is 993 cases, however, we anticipate the majority of this volume (94% or so) will transfer to the new X codes. CPT Code: 69714

Specialty Otolaryngology Frequency 93 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 69714

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 69716 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69716 Tracking Number Original Specialty Recommended RVU: 12.00 Presented Recommended RVU: 9.77 Global Period: 090 Current Work RVU: RUC Recommended RVU: 9.77

CPT Descriptor: Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 48-year-old male with left mixed hearing loss seeks intervention for improved quality of life at work and socially. Placement of a magnetic transcutaneous bone anchored heraing device is performed.

Percentage of Survey Respondents who found Vignette to be Typical: 85%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 49% , In the ASC 49%, In the office 1%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection through the pericranium. A subpericranial dissection is performed and a subpericranial pocket for the implant coil and magnet are created. The area for the transducer is then identified using the template and marked on the outer table of the skull in the region of the sinodural angle. Surgical guide and fixation holes are then drilled taking care not to penetrate the sigmoid sinus or the dura overlying the temporal lobe of the brain. This area is measured for appropriate depth to accommodate the fixation screw. The skull overlying the sinodural angle is then drilled to create a well in the bone to accommodate the transducer device, again staying just superficial to the dura and sigmoid sinus. The entire device including the coil, magnet, and transducer portions are then placed. The device is then fixed to the skull using the fixation screw to a specific torque setting. The thickness of the flap overlying the magnet and coil portion of the device is then carefully measure and precisely trimmed to a specific thickness to allow for transcutaneous transmission. The wound is irrigated and hemostasis is obtained. The wound is closed in a layered fashion.

CPT Code: 69716 Description of Post-Service Work: The prepped areas of the respective donor and recipient sites are cleaned. A dressing is applied to the donor site. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions.

Post op visit 1: 99213 The dressing is removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. Flap viability overlying the coil is assessed. The sutures are removed. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. Antibiotic ointment is placed on the surgical wound.

Post op visit 2: 99213 The patient's convalescence to that point is reviewed. The wound is inspected and palpated for full incisional healing prior to fitting the sound processor. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Long term care, strategies to maximize function, and expected outcomes are discussed in detail. Counseling regarding the device, its function, and signs and symptoms of trouble with the device are discussed with the patient and family. CPT Code: 69716 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69716

Sample Size: 533 Resp N: 67 Description of Targeted, random survey of 533 otolaryngologist members of the AAO-HNS, the Sample: American Neurotology Society, and the AOS (American Otological Society) Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 2.00 4.00 10.00 30.00 Survey RVW: 1.00 12.00 13.00 15.39 25.00 Pre-Service Evaluation Time: 32.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 10.00 40.00 60.00 70.00 159.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 46.00 99211x 0.00 12x 0.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69716 Recommended Physician Work RVU: 9.77 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 32.00 33.00 -1.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 60.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69716 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 46.00 99211x 0.00 12x 0.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 31610 090 12.00 RUC Time

CPT Descriptor Tracheostomy, fenestration procedure with skin flaps

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15730 090 13.50 RUC Time

CPT Descriptor Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 57288 090 12.13 RUC Time 25,452 CPT Descriptor 1 Sling operation for stress incontinence (eg, fascia or synthetic) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 54437 090 11.50 RUC Time 54

CPT Descriptor 2 Repair of traumatic corporeal tear(s)

Other Reference CPT Code Global Work RVU Time Source 27279 090 12.13 RUC Time

CPT Descriptor Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

CPT Code: 69716

Number of respondents who choose Top Key Reference Code: 12 % of respondents: 6.0 %

Number of respondents who choose 2nd Key Reference Code: 6 % of respondents: 8.9 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69716 31610 15730

Median Pre-Service Time 45.00 6960.00 58.00

Median Intra-Service Time 60.00 45.00 90.00

Median Immediate Post-service Time 15.00 20.00 17.50 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 173.00 19.00 Median Discharge Day Management Time 19.0 0.00 0.00 Median Office Visit Time 46.0 69.00 71.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 185.00 367.00 255.50 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 8% 0% 58% 17% 17%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 8% 58% 34% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 8% 42% 50%

Physical effort required 0% 75% 25% CPT Code: 69716

Psychological Stress Less Identical More

• The risk of significant complications, 42% 33% 25% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 33% 33% 33%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 33% 67% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 17% 50% 33%

Physical effort required 0% 50% 50%

Psychological Stress Less Identical More

• The risk of significant complications, 17% 50% 33% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69716 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Note re: Key Reference Code #2

We recognize that KRS code 2, 31610, was selected as a KRS for this code, and some others in this family of codes by survey respondents. That code is marked “Do not use to value physician work” in the RUC database. The RUC database further states the following rationale: “The RUC recommends to flag CPT codes 31605 and 31610 as do not use for validation of work as 31605 physician time and work recommendations are based on only the 20 survey respondents who performed this service in the past 12 months and 31610 recommendation was based on the survey 75th percentile work RVU.” We do not agree that simply because the 75th percentile was approved in valuing this service that it should be viewed as unreliable as a comparison to other services, and therefore, we included it in our RSL as a recently valued, and familiar service that our members would understand.

Recommendation (Work and Intra Time):

We are recommending a work RVU of 9.77 and 60 minutes of intra service time, based on a crosswalk to CPT 50590. This is below our survey’s 25th percentile RVW.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 32 minutes of evaluation time which is 1 minute less than the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 45 minutes, taking the lesser of surveyed time or the pre-service package time.

Regarding post-operative visits, our survey respondents indicated that two post-operative visits were needed, two 99213 visits. Our expert panel agreed.

Post op visit 1: 99213 CPT Code: 69716 The dressing is removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. Flap viability overlying the coil is assessed. The sutures are removed. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. Antibiotic ointment is placed on the surgical wound.

Supporting Reference Codes for the Recommended Value CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 Code RVU Time Time Recent Medicare RUC Utilization Review

Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal 25607 fixation 090 0.0523 9.56 60 275 2006-02 ORTHOPEDIC SURGERY 9419 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each 26356 tendon 090 0.0551 9.56 60 277 2015-04 ORTHOPEDIC SURGERY 1150 Revision of aqueous shunt to extraocular equatorial plate 66184 reservoir; without graft 090 0.0485 9.58 60 254 2014-01 OPHTHALMOLOGY 594

Open treatment of tarsal bone dislocation, includes internal fixation, when 28555 performed 090 0.0503 9.65 60 281 2007-02 ORTHOPEDIC SURGERY 242

Arthroscopy, subtalar joint, 29906 surgical; with debridement 090 0.0662 9.65 60 244 2007-04 ORTHOPEDIC SURGERY 139

Open treatment of proximal fibula or shaft fracture, includes internal fixation, 27784 when performed 090 0.0507 9.67 60 281 2007-02 ORTHOPEDIC SURGERY 423

Open treatment of humeral epicondylar fracture, medial or lateral, includes internal 24575 fixation, when performed 090 0.0357 9.71 60 308 2007-02 ORTHOPEDIC SURGERY 125 Lithotripsy, extracorporeal 50590 shock wave 090 0.0908 9.77 60 207 2012-04 UROLOGY 54658

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, 42145 uvulopharyngoplasty) 090 0.0613 9.78 60 262 2008-04 OTOLARYNGOLOGY 518

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15100 (except 15050) 090 0.0533 9.90 60 281 2005-08 PLASTIC AND RECONSTRUCTIVE SURGERY 13549

Removal of prosthesis, includes debridement and synovectomy when 24164 performed; radial head 090 0.0812 10.00 60 228 2013-01 ORTHOPEDIC SURGERY 103 CPT Code: 69716 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when 57240 performed 090 0.0965 10.08 60 211 2017-01 OBSTETRICS/GYNECOLOGY 9026 Posterior colporrhaphy, repair of rectocele with or 57250 without perineorrhaphy 090 0.0965 10.08 60 211 2017-01 OBSTETRICS/GYNECOLOGY 8757

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, 19301 segmentectomy); 090 0.0934 10.13 60 216 2007-02 GENERAL SURGERY 62740

Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including 43284 cruroplasty when performed 090 0.0947 10.13 60 218 2016-01 GENERAL SURGERY 28

Open treatment of posterior malleolus fracture, includes internal fixation, when 27769 performed 090 0.0648 10.14 60 279 2007-04 ORTHOPEDIC SURGERY 208 Tenodesis of long tendon of 23430 biceps 090 0.0842 10.17 60 237 2009-10 ORTHOPEDIC SURGERY 19997 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, 15240 and/or feet; 20 sq cm or less 090 0.0528 10.41 60 288 2005-08 DERMATOLOGY 13328 44950 Appendectomy; 090 0.0778 10.60 60 252 2000-08 GENERAL SURGERY 1101

Open treatment of tarsometatarsal joint dislocation, includes internal 28615 fixation, when performed 090 0.0426 10.70 60 323 2007-02 ORTHOPEDIC SURGERY 1662

Open treatment of greater trochanteric fracture, includes internal fixation, 27248 when performed 090 0.0198 10.78 60 384 2007-04 ORTHOPEDIC SURGERY 1248 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when 63662 performed 090 0.0943 11.00 60 243 2009-04 NEUROSURGERY 2414

Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of 27826 fibula only 090 0.0484 11.10 60 328 2007-02 ORTHOPEDIC SURGERY 174 Glossectomy; less than one- 41120 half tongue 090 0.0715 11.14 60 278 2005-08 OTOLARYNGOLOGY 2232 Removal or revision of sling for stress incontinence (eg, 57287 fascia or synthetic) 090 0.0942 11.15 60 239 2010-10 OBSTETRICS/GYNECOLOGY 1737 65850 Trabeculotomy ab externo 090 0.1109 11.39 60 233 2005-08 OPHTHALMOLOGY 620 Repair of traumatic 54437 corporeal tear(s) 090 0.0872 11.50 60 264 2015-01 UROLOGY 54

Paravaginal defect repair (including repair of cystocele, if performed); 57285 vaginal approach 090 0.0923 11.60 60 267 2007-04 OBSTETRICS/GYNECOLOGY 986 CPT Code: 69716

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69714

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otoloaryngology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 2979 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the 2019 volume for 69714 in the AMA RUC database

Specialty Otolaryngology Frequency 2979 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 900 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. We believe the majority (94% or so) of existing volume for the predecessor code 69714 will move to this new code. Volume for 69714 in 2019 was 993 cases.

Specialty Otolarngology Frequency 900 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

CPT Code: 69716 Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 31070

CPT Code: 69717 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69717 Tracking Number Original Specialty Recommended RVU: 11.48 Presented Recommended RVU: 8.80 Global Period: 090 Current Work RVU: 15.43 RUC Recommended RVU: 8.80

CPT Descriptor: Revision/replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 16-year-old female with chronic otitis media and conductive hearing loss who previously received a percutaneous bone anchored implant has chronic inflammation at the abutment site that has been unresponsive to medical therapy. The device is removed and a new device is placed at a different site.

Percentage of Survey Respondents who found Vignette to be Typical: 88%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 48% , In the ASC 50%, In the office 2%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection to the pericranium. A subpericranial dissection is performed and the previous implant abutment is removed. The cranial bone surrounding the osseointegrated titanium fixture in the patient’s skull is drilled around the implant. The fixture is removed. The wound is thoroughly inspected for the cause of the patient’s original complication related to the implant. The area for the new placement of the implant is then identified, templated, and marked on the outer table of the skull. A dissection is performed and the pericranium is incised and dissected away from the cranial bone to expose an area for implant placement. A new pilot guide hole through the cranium is drilled, and the deep portion of the guide hole is instrumented to ascertain the possible presence of dural contact and lack of sigmoid sinus exposure. Depending on this deep instrumentation, the pilot hole is possibly deepened. The final guide hole is then widened with spiral drilling to achieve a larger opening to receive the implant. The implanted fixture is installed in the cranial bone to very specific torque settings. This implanted fixture is then secured to the transcutaneous abutment. The overlying flap and surrounding soft tissues are thinned to a maximal CPT Code: 69717 thickness to allow for transcutaneous attachment to the processor. A separate incision is made in the overlying skin of the flap to allow the percutaneous abutment to extend through the soft tissue flap. The wound is irrigated and hemostasis is obtained. The wound is closed in a layered fashion. A small bolster is created immediately surrounding the abutment and a locking cap is fixed to the abutment to keep the small abutment bolster in place and with appropriate pressure.

Description of Post-Service Work: he prepped area of the recipient site is cleaned. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions.

Post op visit 3: 99212 The patient's convalescence to that point is reviewed. The wounds are inspected and palpated for full incisional healing prior to fitting the sound processor. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Long term care, strategies to maximize function, and expected outcomes are discussed in detail. Counseling regarding the device, its function, and signs and symptoms of trouble with the device are discussed with the patient and family. CPT Code: 69717 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69717

Sample Size: 533 Resp N: 64 Description of Targeted, random selection of 533 members from the AAO-HNS, the American Sample: Neurotology Society, and the AOS (American Otological Society). Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 0.00 1.00 2.00 10.00 Survey RVW: 10.00 11.48 12.50 14.00 25.00 Pre-Service Evaluation Time: 37.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 10.00 30.00 45.00 60.00 201.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 69.00 99211x 0.00 12x 0.00 13x 3.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69717 Recommended Physician Work RVU: 8.80 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 33.00 33.00 0.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 45.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69717 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 62.00 99211x 0.00 12x 1.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15260 090 11.64 RUC Time

CPT Descriptor Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15120 090 10.15 RUC Time

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 67904 090 7.97 RUC Time 54,853 CPT Descriptor 1 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 26615 090 7.07 RUC Time 1,057,533

CPT Descriptor 2 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone

Other Reference CPT Code Global Work RVU Time Source 66183 090 13.20 RUC Time

CPT Descriptor Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach

CPT Code: 69717

Number of respondents who choose Top Key Reference Code: 9 % of respondents: 14.0 %

Number of respondents who choose 2nd Key Reference Code: 9 % of respondents: 14.0 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69717 15260 15120

Median Pre-Service Time 46.00 28.00 72.00

Median Intra-Service Time 45.00 100.00 75.00

Median Immediate Post-service Time 15.00 30.00 30.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 19.00 Median Discharge Day Management Time 19.0 0.00 0.00 Median Office Visit Time 62.0 115.00 62.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 187.00 273.00 258.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 22% 67% 11%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 33% 66% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 11% 22% 67%

Physical effort required 0% 33% 67% CPT Code: 69717

Psychological Stress Less Identical More

• The risk of significant complications, 0% 56% 44% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 11% 0% 33% 44% 11%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 22% 33% 44% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 33% 22% 44%

Physical effort required 44% 33% 22%

Psychological Stress Less Identical More

• The risk of significant complications, 33% 33% 33% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69717 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Recommendation (Work and Intra Time):

We are recommending a work RVU of 8.80 and 45 minutes of intra service time, based on a crosswalk to CPT 27829. This is below our survey’s 25th percentile RVW.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 33 minutes of evaluation time which is identical to the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 46 minutes, taking the lesser of surveyed time or the pre-service package time.

Survey respondents also indicated that three post-operative office visits are typically conducted after the procedure. Three level three office visits, 99213. Our expert panel agreed that three visits are necessary, but amended them to two level three visits (99213) and one level two office visit (99212) consistent with code 69714.

Supporting Reference Codes for the Recommended Value CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 2019 Code RVU Time Time Recent Medicare Medicare RUC Utilizatio Allowed Review n Charges 45171 Excision of rectal tumor, transanal approach; 090 0.0761 8.13 45 209 2009-02 COLORECTAL 2516 1560949 not including muscularis propria (ie, partial SURGERY thickness) (PROCTOLOGY)

52500 Transurethral resection of bladder neck 090 0.0582 8.14 45 230.5 2008-04 UROLOGY 3173 1544895 (separate procedure)

25606 Percutaneous skeletal fixation of distal radial 090 0.0419 8.31 45 260 2006-02 ORTHOPEDIC 2015 1262949 fracture or epiphyseal separation SURGERY

67255 Scleral reinforcement (separate procedure); 090 0.0595 8.38 45 216 2014-01 OPHTHALMOLO 833 430830 with graft GY

45020 Incision and drainage of deep supralevator, 090 0.0511 8.56 45 255 2005-08 GENERAL 199 110926 pelvirectal, or retrorectal abscess SURGERY

27829 Open treatment of distal tibiofibular joint 090 0.0457 8.80 45 271 2007-02 ORTHOPEDIC 7628 3853250 (syndesmosis) disruption, includes internal SURGERY fixation, when performed

31610 Tracheostomy, fenestration procedure with 090 0.0278 12.00 45 367 2016-10 OTOLARYNGOL 1593 1406921 skin flaps OGY

66183 Insertion of anterior segment aqueous 090 0.126 13.20 45 257 2013-04 OPHTHALMOLO 4674 4894644 drainage device, without extraocular GY reservoir, external approach

66170 Fistulization of sclera for glaucoma; 090 0.1293 13.94 45 278 2015-04 OPHTHALMOLO 6957 7907614 trabeculectomy ab externo in absence of GY previous surgery

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

The surveyed code is an add-on code or a base code expected to be reported with an add-on code. Different specialties work together to accomplish the procedure; each specialty codes its part of the physician work using different codes. Multiple codes allow flexibility to describe exactly what components the procedure included. CPT Code: 69717 Multiple codes are used to maintain consistency with similar codes. Historical precedents. Other reason (please explain)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69717

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otoloaryngology How often? Rarely

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 18 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the Medicare volume estimated below.

Specialty Otolaryngology Frequency 18 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 6 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. The current 2019 volume indicated by the RUC database for this code is 68, however, we esitmate that only about 7% of existing cases will be reported in the future by the percutaneous codes. We anticipate that the remainder of the volume will transition to the new transcutaneous codes.

Specialty Otolaryngology Frequency 6 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: CPT Code: 69717 Major procedure

BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 69717

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 69719 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69719 Tracking Number Original Specialty Recommended RVU: 12.00 Presented Recommended RVU: 9.77 Global Period: 090 Current Work RVU: RUC Recommended RVU: 9.77

CPT Descriptor: Revision/replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 59-year-old female with right mixed hearing loss previously had placement of a magnetic transcutaneous bone anchored implant. It worked well, but she has developed discomfort at the device site. The device is removed and a new device is placed at a different site.

Percentage of Survey Respondents who found Vignette to be Typical: 83%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 47% , In the ASC 51%, In the office 2%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: Meet with patient and family to describe and discuss in detail the planned procedure. Review and update the medical history. Review the CT scan to ensure that there is adequate bone quality and quantity in the area of implantation to support a successful implantation. Perform a current physical exam paying special attention to the patient’s skin condition and skin thickness in the area of the actuator and coil to avoid potential repeat post-surgical skin breakdown, pain, and possible implant extrusion. Reconcile medications and allergies. Address NPO status and timing. Discuss preoperative home medications and postoperative prescriptions and check the prescription drug monitoring database, discuss. Plan the patient's expected convalescence and educate the patient and caregivers regarding the signs and symptoms of the most common and serious complications. There is confirmation of site of proposed insertion site, and a detailed description is given of the postoperative changes in wound and incision and the expected cosmetic and functional results. Review and obtain informed consent. Verify that all required instruments and supplies are available. Following induction of anesthesia, the patient is positioned and prepped for the procedure. A timeout is performed with entire surgical team, including confirmation of the procedure, locations, allergies, antibiotic prophylaxis, anesthesia and fire risks, expected duration, and any concerns related to the procedure. The postauricular hair is shaved and the proposed NEW implant recipient site is precisely measured and then marked using the implant template. The incision is injected with local anesthetic

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection through the pericranium. A subpericranial dissection is performed and the previous implant is removed. The wound is thoroughly inspect for the cause of the patient’s original complication related to the implant. A subpericranial pocket for the implant coil and magnet are created. The area for the new placement of the transducer is then identified using the template and marked on the outer table of the skull. Surgical guide and fixation holes are then drilled taking care not to penetrate the dura overlying the temporal lobe of the brain. This area is measured for appropriate depth to accommodate the fixation screw. The skull is then drilled to create a well in the bone to accommodate the transducer device, again staying just superficial to the dura. The entire device including the coil, magnet, and transducer portions are then placed. The device is then fixed to the skull using the fixation screw to a specific torque setting. The thickness of the flap overlying the magnet and coil portion of the device is then carefully measure and precisely trimmed to a specific thickness to allow for transcutaneous transmission. The wound is irrigated and hemostasis is obtained. The wound is closed in a layered fashion.

CPT Code: 69719 Description of Post-Service Work: The prepped areas of the respective donor and recipient sites are cleaned. A dressing is applied to the donor site. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions.

Post op visit 2: 99213 The patient's convalescence to that point is reviewed. The wound is inspected and palpated for full incisional healing prior to fitting the sound processor. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Long term care, strategies to maximize function, and expected outcomes are discussed in detail. Counseling regarding the device, its function, and signs and symptoms of trouble with the device are discussed with the patient and family. CPT Code: 69719 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69719

Sample Size: 533 Resp N: 59 Description of Targeted, random selection of 533 members from the AAO-HNS, the American Sample: Neurotology Society, and the AOS (American Otological Society). Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 0.00 1.00 2.00 10.00 Survey RVW: 10.15 12.00 13.00 15.48 27.00 Pre-Service Evaluation Time: 37.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 14.00 43.00 60.00 80.00 201.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 46.00 99211x 0.00 12x 0.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69719 Recommended Physician Work RVU: 9.77 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 33.00 33.00 0.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 60.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69719 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 46.00 99211x 0.00 12x 0.00 13x 2.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 31610 090 12.00 RUC Time

CPT Descriptor Tracheostomy, fenestration procedure with skin flaps

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15730 090 13.50 RUC Time

CPT Descriptor Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 57288 090 12.13 RUC Time 25,452 CPT Descriptor 1 Sling operation for stress incontinence (eg, fascia or synthetic) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 54437 090 11.50 RUC Time 54

CPT Descriptor 2 Repair of traumatic corporeal tear(s)

Other Reference CPT Code Global Work RVU Time Source 27279 090 12.13 RUC Time

CPT Code: 69719

Number of respondents who choose Top Key Reference Code: 8 % of respondents: 13.5 %

Number of respondents who choose 2nd Key Reference Code: 7 % of respondents: 11.8 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69719 31610 15730

Median Pre-Service Time 46.00 60.00 58.00

Median Intra-Service Time 60.00 45.00 90.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 50% 38% 12%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 63% 37% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 13% 88%

Physical effort required 0% 50% 50% CPT Code: 69719

Psychological Stress Less Identical More

• The risk of significant complications, 13% 75% 13% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 57% 14% 29%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 57% 43% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 57% 43%

Physical effort required 0% 71% 30%

Psychological Stress Less Identical More

• The risk of significant complications, 29% 43% 29% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69719 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Note re: Key Reference Code #1

We recognize that KRS code 1, 31610, was selected as a KRS for this code, and some others in this family of codes by survey respondents. That code is marked “Do not use to value physician work” in the RUC database. The RUC database further states the following rationale: “The RUC recommends to flag CPT codes 31605 and 31610 as do not use for validation of work as 31605 physician time and work recommendations are based on only the 20 survey respondents who performed this service in the past 12 months and 31610 recommendation was based on the survey 75th percentile work RVU.” We do not agree that simply because the 75th percentile was approved in valuing this service that it should be viewed as unreliable as a comparison to other services, and therefore, we included it in our RSL as a recently valued, and familiar service that our members would understand.

Recommendation (Work and Intra Time):

We are recommending a work RVU of 9.77 and 60 minutes of intra service time, based on a crosswalk to CPT 50590. This is below our survey’s 25th percentile RVW.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 33 minutes of evaluation time which is identical to the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 46 minutes, taking the lesser of surveyed time or the pre-service package time.

Survey respondents also indicated that two post-operative office visits are typically conducted after the procedure. Two level three office visits, 99213.

Post op visit 1: 99213 CPT Code: 69719 The dressing is removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. Flap viability overlying the coil is assessed. The sutures are removed. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. Antibiotic ointment is placed on the surgical wound.

Supporting Reference Codes for the Recommended Value CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 Code RVU Time Time Recent Medicare RUC Utilization Review

Open treatment of tarsal bone dislocation, includes internal fixation, when 28555 performed 090 0.0503 9.65 60 281 2007-02 ORTHOPEDIC SURGERY 242

Arthroscopy, subtalar joint, 29906 surgical; with debridement 090 0.0662 9.65 60 244 2007-04 ORTHOPEDIC SURGERY 139

Open treatment of proximal fibula or shaft fracture, includes internal fixation, 27784 when performed 090 0.0507 9.67 60 281 2007-02 ORTHOPEDIC SURGERY 423

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, 42145 uvulopharyngoplasty) 090 0.0613 9.78 60 262 2008-04 OTOLARYNGOLOGY 518

Removal of prosthesis, includes debridement and synovectomy when 24164 performed; radial head 090 0.0812 10.00 60 228 2013-01 ORTHOPEDIC SURGERY 103 CPT Code: 69719 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when 57240 performed 090 0.0965 10.08 60 211 2017-01 OBSTETRICS/GYNECOLOGY 9026 Posterior colporrhaphy, repair of rectocele with or 57250 without perineorrhaphy 090 0.0965 10.08 60 211 2017-01 OBSTETRICS/GYNECOLOGY 8757

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, 19301 segmentectomy); 090 0.0934 10.13 60 216 2007-02 GENERAL SURGERY 62740

Open treatment of tarsometatarsal joint dislocation, includes internal 28615 fixation, when performed 090 0.0426 10.70 60 323 2007-02 ORTHOPEDIC SURGERY 1662

Paravaginal defect repair (including repair of cystocele, if performed); 57285 vaginal approach 090 0.0923 11.60 60 267 2007-04 OBSTETRICS/GYNECOLOGY 986 CPT Code: 69719

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69714

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otoloaryngology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 27 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the estimated Medicare volume cited below

Specialty Otolaryngology Frequency 27 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 9 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Industry data indicates that approximately .5-1% of cases of 69716 will be revised, we estimate 900 cases per year of 69716, and 9 is 1% of that volume.

Specialty Otolaryngology Frequency 9 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

CPT Code: 69719 Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 31070

CPT Code: 69726 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69726 Tracking Number Original Specialty Recommended RVU: 10.00 Presented Recommended RVU: 5.93 Global Period: 090 Current Work RVU: RUC Recommended RVU: 5.93

CPT Descriptor: Removal, osseointegrated implant, skull; with percutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 59-year-old female with a right mixed hearing loss had previous placement of a percutaneous bone anchored implant. It worked well, but she has developed discomfort at the device site. The device is removed without replacement.

Percentage of Survey Respondents who found Vignette to be Typical: 95%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 33% , In the ASC 36%, In the office 30%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: Meet with patient and family to describe and discuss in detail the planned procedure. Review and update the medical history. Perform a current physical exam paying special attention to the patient’s skin condition adequacy for closure following implant removal. Reconcile medications and allergies. Address NPO status and timing. Discuss preoperative home medications and postoperative prescriptions and check the prescription drug monitoring database, discuss. Plan the patient's expected convalescence and educate the patient and caregivers regarding the signs and symptoms of the most common and serious complications. There is confirmation of site of proposed removal site, and a detailed description is given of the postoperative changes in wound and incision and the expected cosmetic and functional results. Review and obtain informed consent. Verify that all required instruments and supplies are available. Following induction of anesthesia, the patient is positioned and prepped for the procedure. A timeout is performed with entire surgical team, including confirmation of the procedure, locations, allergies, antibiotic prophylaxis, anesthesia and fire risks, expected duration, and any concerns related to the procedure. The postauricular hair is shaved and the incision is marked in the region of the previous incision. The incision is injected with local anesthetic.

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection through the pericranium. A subpericranial dissection is performed and the previous implant is exposed. The cranial bone surrounding the osseointegrated titanium fixture in the patient’s skull is drilled around the implant. The wound is thoroughly inspected for the cause of the patient’s original complication related to the implant. The wound is irrigated and hemostasis is obtained. The wound where the external abutment of the implant is debrided then closed followed by closure of the linear incision anterior to the implant site in a layered fashion.

Description of Post-Service Work: The prepped areas of the respective donor and recipient sites are cleaned. A dressing is applied to the donor site. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other CPT Code: 69726 complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions.

Post op visit 1: 99213 The mastoid dressing is removed. The sutures are removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The incisions and wound are inspected and palpated. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Antibiotic ointment is placed on the wound. Patient and family questions and concerns are addressed. Ongoing care is reiterated.

Post op visit 2: 99212 The patient's convalescence to that point is reviewed. The wound is again inspected and palpated to insure full healing. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. A discussion occurs regarding different hearing options now that the previous osseointegrated implant has been removed and not replaced. CPT Code: 69726 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69726

Sample Size: 533 Resp N: 66 Description of Targeted, random selection of 533 members from the AAO-HNS, the American Sample: Neurotology Society, and the AOS (American Otological Society). Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 0.00 1.00 2.00 10.00 Survey RVW: 5.00 10.00 10.90 12.00 20.45 Pre-Service Evaluation Time: 32.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 5.00 20.00 30.00 45.00 187.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 39.00 99211x 0.00 12x 1.00 13x 1.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69726 Recommended Physician Work RVU: 5.93 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 32.00 33.00 -1.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 30.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69726 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 39.00 99211x 0.00 12x 1.00 13x 1.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15120 090 10.15 RUC Time

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 66185 090 10.58 RUC Time

CPT Descriptor Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 67904 090 7.97 RUC Time 54,853 CPT Descriptor 1 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 26615 090 7.07 RUC Time 1,057,533

CPT Descriptor 2 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone

Other Reference CPT Code Global Work RVU Time Source 27829 090 8.80 RUC Time

CPT Descriptor Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed

CPT Code: 69726

Number of respondents who choose Top Key Reference Code: 29 % of respondents: 43.9 %

Number of respondents who choose 2nd Key Reference Code: 8 % of respondents: 12.1 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69726 15120 66185

Median Pre-Service Time 45.00 72.00 25.00

Median Intra-Service Time 30.00 75.00 65.00

Median Immediate Post-service Time 15.00 30.00 10.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 19.00 19.00 Median Discharge Day Management Time 19.0 0.00 0.00 Median Office Visit Time 39.0 62.00 140.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 148.00 258.00 259.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 7% 31% 48% 14% 0%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 31% 41% 28% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 45% 31% 24%

Physical effort required 34% 38% 27% CPT Code: 69726

Psychological Stress Less Identical More

• The risk of significant complications, 44% 48% 6% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 63% 38% 0% 0%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 26% 63% 13% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 63% 38% 0%

Physical effort required 50% 50% 0%

Psychological Stress Less Identical More

• The risk of significant complications, 38% 62% 0% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69726 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Recommendation (Work and Intra Time):

We are recommending a work RVU of 5.93 and 30 minutes of intra service time, based on a crosswalk to CPT 53852. This is below our survey’s 25th percentile RVW and utilizes our survey’s median intra-service time.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 32 minutes of evaluation time which is identical to the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 45 minutes, taking the lesser of surveyed time or the pre-service package time.

Survey respondents also indicated that two post-operative office visits are typically conducted after the procedure. One level three office visit, 99213; and one level two office visit, 99212. Our expert panel agreed.

Supporting Reference Codes for the Recommended Value CPT Code: 69726 CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 Code RVU Time Time Recent Medicare RUC Utilizatio Review n 46262 Hemorrhoidectomy, internal and external, 2 090 0.0888 7.91 45 179 2000 General Surgery 106 or more columns/groups; with fistulectomy, including fissurectomy, when performed

67904 Repair of blepharoptosis; (tarso) levator 090 0.0892 7.97 45 185 2005 Ophthalmology 54853 resection or advancement, external approach

45171 Excision of rectal tumor, transanal approach; 090 0.0761 8.13 45 209 2009-02 COLORECTAL 2516 not including muscularis propria (ie, partial SURGERY thickness) (PROCTOLOGY)

52500 Transurethral resection of bladder neck 090 0.0582 8.14 45 230.5 2008-04 UROLOGY 3173 (separate procedure)

25606 Percutaneous skeletal fixation of distal radial 090 0.0419 8.31 45 260 2006-02 ORTHOPEDIC 2015 fracture or epiphyseal separation SURGERY

67255 Scleral reinforcement (separate procedure); 090 0.0595 8.38 45 216 2014-01 OPHTHALMOLO 833 with graft GY

45020 Incision and drainage of deep supralevator, 090 0.0511 8.56 45 255 2005-08 GENERAL 199 pelvirectal, or retrorectal abscess SURGERY

27829 Open treatment of distal tibiofibular joint 090 0.0457 8.80 45 271 2007-02 ORTHOPEDIC 7628 (syndesmosis) disruption, includes internal SURGERY fixation, when performed

31610 Tracheostomy, fenestration procedure with 090 0.0278 12.00 45 367 2016-10 OTOLARYNGOL 1593 skin flaps OGY

66183 Insertion of anterior segment aqueous 090 0.126 13.20 45 257 2013-04 OPHTHALMOLO 4674 drainage device, without extraocular GY reservoir, external approach

66170 Fistulization of sclera for glaucoma; 090 0.1293 13.94 45 278 2015-04 OPHTHALMOLO 6957 trabeculectomy ab externo in absence of GY previous surgery

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69714

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otolaryngology How often? Rarely

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 3 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. This is three times the estimated Medicare data below.

Specialty Otolaryngology Frequency 3 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 1 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. We estimate that 1% of future 69714 volume will have to be removed. The 2019 volume of 69714 was 993 cases, which we anticipate will drop approximately 94% to 93 cases going forward. One percent of 93 is .93, or one case per year.

Specialty Otolaryngology Frequency 1 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

CPT Code: 69726 BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 31070

CPT Code: 69727 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:69727 Tracking Number Original Specialty Recommended RVU: 10.98 Presented Recommended RVU: 7.13 Global Period: 090 Current Work RVU: RUC Recommended RVU: 7.13

CPT Descriptor: Removal, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 62-year-old male with right mixed hearing loss previously had placement of a magnetic transcutaneous bone anchored implant which worked well, but has now become infected. The device is removed without replacement.

Percentage of Survey Respondents who found Vignette to be Typical: 95%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 46% , In the ASC 51%, In the office 3%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Intra-Service Work: An incision is performed followed by a meticulous dissection through the pericranium. A subpericranial dissection is performed and the previous implant is exposed. The cranial bone surrounding the osseointegrated titanium transducer and the respective fixture screws in the patient’s skull is drilled out to free the implant. The wound is thoroughly inspected for the cause of the patient’s original complication related to the implant. The wound is irrigated and hemostasis is obtained. The wound is closed in a layered fashion.

Description of Post-Service Work: The prepped areas of the respective donor and recipient sites are cleaned. A dressing is applied to the donor site. A compression dressing is fashioned and is wrapped around the head to compress the recipient site. The patient is observed during emergence from anesthesia. Dictation and postoperative orders are performed. Discharge medications are reconciled and prescriptions are written. Instructions, appropriate discharge timing, follow up, and precautions are discussed with the postoperative nursing team. Communication with the referring physician is then performed. There is a discussion with the family regarding the procedure and findings. The patient is then seen after emergence from general anesthesia to check the patient’s neurologic status, wound for signs of hematoma, or other complications. There is reiteration of the convalescence, precautions, follow up appointments, expected postoperative course, signs and symptoms of complications, and review the written postoperative instructions. CPT Code: 69727

Post op visit 1: 99213 The mastoid dressing is removed. The sutures are removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Antibiotic ointment is placed on the wound. Patient and family questions and concerns are addressed. Ongoing care is reiterated.

Post op visit 2: 99212 The patient's convalescence to that point is reviewed. The wound is again inspected and palpated to insure full healing. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Patient and family questions and concerns are addressed. Ongoing care is reiterated. A discussion occurs regarding different hearing options now that the previous osseointegrated implant has been removed and not replaced. CPT Code: 69727 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2021 Presenter(s): R. Peter Manes, MD Specialty AAO-HNS Society(ies): CPT Code: 69727

Sample Size: 533 Resp N: 59 Description of Targeted, random selection of 533 members from the AAO-HNS, the American Sample: Neurotology Society, and the AOS (American Otological Society). Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 0.00 0.00 1.00 10.00 Survey RVW: 5.00 10.98 12.00 12.75 28.00 Pre-Service Evaluation Time: 36.00 Pre-Service Positioning Time: 10.00 Pre-Service Scrub, Dress, Wait Time: 10.00 Intra-Service Time: 12.00 30.00 45.00 60.00 164.00 Immediate Post Service-Time: 15.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 39.00 99211x 0.00 12x 1.00 13x 1.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 3-FAC Straightforward Patient/Difficult Procedure

CPT Code: 69727 Recommended Physician Work RVU: 7.13 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 33.00 33.00 0.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 10.00 15.00 -5.00 Intra-Service Time: 45.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9A General Anes or Complex Reg Blk/Strghtforw Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 15.00 30.00 -15.00

CPT Code: 69727 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 19.00 99238x 0.5 99239x 0.0 99217x 0.00 Office time/visit(s): 39.00 99211x 0.00 12x 1.00 13x 1.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 15120 090 10.15 RUC Time

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 41120 090 11.14 RUC Time

CPT Descriptor Glossectomy; less than one-half tongue

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 67904 090 7.97 RUC Time 54,853 CPT Descriptor 1 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 28003 090 9.06 RUC Time 5,470

CPT Descriptor 2 Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas

Other Reference CPT Code Global Work RVU Time Source 51647 090 11.30 RUC Time

CPT Descriptor Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed)

CPT Code: 69727

Number of respondents who choose Top Key Reference Code: 13 % of respondents: 22.0 %

Number of respondents who choose 2nd Key Reference Code: 8 % of respondents: 13.5 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 69727 15120 41120

Median Pre-Service Time 46.00 72.00 60.00

Median Intra-Service Time 45.00 75.00 60.00

Median Immediate Post-service Time 15.00 30.00 30.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 19.00 19.00 Median Discharge Day Management Time 19.0 0.00 0.00 Median Office Visit Time 39.0 62.00 109.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 164.00 258.00 278.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 38% 38% 23% 0%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 15% 46% 39% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 46% 15% 38%

Physical effort required 38% 38% 23% CPT Code: 69727

Psychological Stress Less Identical More

• The risk of significant complications, 31% 46% 23% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 38% 50% 13% 0%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 25% 50% 25% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 38% 50% 12%

Physical effort required 38% 50% 12%

Psychological Stress Less Identical More

• The risk of significant complications, 63% 38% 0% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

Background:

In October 2020, the Academy brought forward a Code Change Application requesting the revision of two existing codes, 69714 and 69717, as well as the addition of four new codes 69716-727. These new codes represent implantation, revision/replacement, and removal of a transcutaneous and percutaneous osseointegrated implants, respectively. The CPT Code: 69727 Panel approved the CCA and the code is now being valued by the RUC. The new codes will be published in the 2022 edition of the CPT Book.

Survey Sample and Process:

A survey request was sent to a targeted, random selection of 533 members from the AAO-HNS, the American Neurotology Society, and the AOS (American Otological Society).

Recommendation (Work and Intra Time):

We are recommending a work RVU of 7.13 and 45 minutes of intra service time, based on a crosswalk to CPT 37718. This is below our survey’s 25th percentile RVW.

Pre-time Package 3 Straightforward Patient/Difficult Procedure

Evaluation Time – We are recommending 33 minutes of evaluation time which is identical to the pre-service package time, based on our survey median.

Positioning Time – We are recommending 3 minutes of positioning time which is 7 minutes less than the survey median time, but consistent with the preservice package.

Scrub, Dress, Wait Time – We are recommending 10 minutes of scrub, dress and wait time which is 5 minutes less than the pre-service package time, based on our survey median.

This results in a total recommended pre time of 46 minutes, taking the lesser of surveyed time or the pre-service package time.

Survey respondents also indicated that two post-operative office visits are typically conducted after the procedure. One level three office visit, 99213 and one level two office visit, 99212.Our expert panel agreed.

Post op visit 1: 99213 The mastoid dressing is removed. The sutures are removed. The patient's convalescence to that point is reviewed and discussed. The neurological status is assessed. The wound is inspected and palpated. The middle ear is inspected. Tuning forks are utilized to evaluate the patients hearing. Antibiotic ointment is placed on the wound. Patient and family questions and concerns are addressed. Ongoing care is reiterated.

Supporting Reference Codes for the Recommended Value CPT Code: 69727

CPT Long Desc Global IWPUT Work Intra Total Most Top_Specialty 2019 Medicare Code RVU Time Time Recent Utilization RUC Review 46262 Hemorrhoidectomy, internal and 090 0.0888 7.91 45 179 2000 General Surgery 106 external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed 67904 Repair of blepharoptosis; (tarso) 090 0.0892 7.97 45 185 2005 Ophthalmology 54853 levator resection or advancement, external approach 45171 Excision of rectal tumor, transanal 090 0.0761 8.13 45 209 2009-02 COLORECTAL 2516 approach; not including muscularis SURGERY propria (ie, partial thickness) (PROCTOLOGY)

52500 Transurethral resection of bladder 090 0.0582 8.14 45 230.5 2008-04 UROLOGY 3173 neck (separate procedure)

25606 Percutaneous skeletal fixation of 090 0.0419 8.31 45 260 2006-02 ORTHOPEDIC 2015 distal radial fracture or epiphyseal SURGERY separation

67255 Scleral reinforcement (separate 090 0.0595 8.38 45 216 2014-01 OPHTHALMOLOGY 833 procedure); with graft

45020 Incision and drainage of deep 090 0.0511 8.56 45 255 2005-08 GENERAL SURGERY 199 supralevator, pelvirectal, or retrorectal abscess

27829 Open treatment of distal 090 0.0457 8.80 45 271 2007-02 ORTHOPEDIC 7628 tibiofibular joint (syndesmosis) SURGERY disruption, includes internal fixation, when performed

31610 Tracheostomy, fenestration 090 0.0278 12.00 45 367 2016-10 OTOLARYNGOLOGY 1593 procedure with skin flaps

66183 Insertion of anterior segment 090 0.126 13.20 45 257 2013-04 OPHTHALMOLOGY 4674 aqueous drainage device, without extraocular reservoir, external approach

66170 Fistulization of sclera for glaucoma; 090 0.1293 13.94 45 278 2015-04 OPHTHALMOLOGY 6957 trabeculectomy ab externo in absence of previous surgery

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

The surveyed code is an add-on code or a base code expected to be reported with an add-on code. Different specialties work together to accomplish the procedure; each specialty codes its part of the physician work using different codes. Multiple codes allow flexibility to describe exactly what components the procedure included. Multiple codes are used to maintain consistency with similar codes. CPT Code: 69727 Historical precedents. Other reason (please explain)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 69714

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Otoloaryngology How often? Sometimes

Specialty How often?

Specialty Otolaryngology Frequency 27 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 9 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Industry data estimates .5-1% of 69716 cases will have to be removed. We estimated 900 cases per year of 69716, and 1% of that is 9.

Specialty Otolaryngology Frequency 9 Percentage 100.00 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

CPT Code: 69727 BETOS Sub-classification Level II: Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. 31070

SS Rec Summary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AH AI AJ AK AL AQ AR AS AT AU AV AW AX AY AZ BA 11 12

13 ISSUE: Transcutaneous Passive Implant Temporal Bone (BAHA) 14 TAB: 18 15 RVW Total PRE-TIME INTRA-TIME IMMD FAC-inpt/same day Office SURVEY EXPERIENCE Work Per 16 Source CPT Global DESC Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST 91 92 33 32 31 38 39 15 14 13 12 11 MIN 25th MED 75th MAX Split-thickness autograft, face, scalp, eyelids, 1st REF 15120 90 mouth, neck, ears, orbits, genitalia, hands, 14 0.068 0.039 10.15 258 40 12 20 75 30 0.5 2 1 feet, and/or multiple digits; first 100 sq cm or 17 less or 1% of body area of infants and Tracheostomy, fenestration procedure with 0.028 0.033 12.00 367 40 10 10 45 20 1 1 2 1.0 3 18 2nd REF 31610 90 skin flaps 14 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment CURRENT 69714 90 to external speech processor/cochlear 0.098 0.051 14.45 284 55 90 30 1.0 1 3 19 stimulator; without mastoidectomy Implantation, osseointegrated implant, skull; SVY 69714 with percutaneous attachment to external 73 0.188 0.063 1.00 11.00 12.00 14.00 17.40 190 34 10 10 10 25 40 46 155 15 0.5 2 1 0 3 8 12 45 20 speech processor

21 W/ EXP 69 0.194 0.063 1.00 11.00 12.00 14.00 17.40 189 35 10 10 10 25 40 45 155 32 2 1 1 5 8 13 45

22 W/OUT EXP 4 0.188 0.067 1.00 10.39 10.88 11.74 13.20 162 29 9 20 20 24 42 67 90 23 1 1 Cystourethroscopy with incision, fulguration, 0.126 0.044 8.69 198 72.5 10 15 40 25 0.5 1 23 CROSSWALK 52400 90 or resection of congenital posterior urethral

Implantation, osseointegrated implant, skull; REC 69714 90 with percutaneous attachment to external 0.110 0.048 8.69 182 33 3 10 40 15 0.5 2 1 speech processor 24

25 Tracheostomy, fenestration procedure with 0.028 0.033 12.00 367 40 10 10 45 20 1 1 2 1.0 3 26 1st REF 31610 90 skin flaps 12 Midface flap (ie, zygomaticofacial flap) with 0.100 0.053 13.50 256 40 3 15 90 17.5 0.5 1 3 27 2nd REF 15730 90 preservation of vascular pedicle(s) 6

CURRENT NEW #DIV/0! #DIV/0! 28 Implantation, osseointegrated implant, skull; 0.151 0.068 13.00 15.39 25.00 192 32 10 10 60 70 159 15 0.5 2 4 10 30 29 SVY 69716 with magnetic transcutaneous attachment to 67 1.00 12.00 10 40 0 2

30 W/ EXP 58 0.183 0.070 1.00 12.00 13.13 15.68 25.00 187 35 10 10 10 40 48 60 159 15 3 1 3 5 10 30

31 W/OUT EXP 9 0.141 0.064 10.50 11.25 12.00 12.50 17.40 187 40 15 10 20 45 65 90 150 25 2

32 CROSSWALK 50590 90 Lithotripsy, extracorporeal shock wave 0.091 0.047 9.77 207 33 3 15 60 15 0.5 2 1 Implantation, osseointegrated implant, skull; REC 69716 90 with magnetic transcutaneous attachment to 0.100 0.053 9.77 185 32 3 10 60 15 0.5 2 33 external speech processor 34 Full thickness graft, free, including direct 0.056 0.043 11.64 273 17 1 10 100 30 5 35 1st REF 15260 90 closure of donor site, nose, ears, eyelids, 9

Split-thickness autograft, face, scalp, eyelids, 0.068 0.039 10.15 258 40 12 20 75 30 0.5 2 1 36 2nd REF 15120 90 mouth, neck, ears, orbits, genitalia, hands, 9 Replacement (including removal of existing device), osseointegrated implant, temporal CURRENT 69717 90 bone, with percutaneous attachment to 0.105 0.055 15.43 282 50 95 28 1.0 1 3 37 external speech processor/cochlear

Revision/replacement (including removal of 0.166 0.061 12.50 14.00 25.00 205 37 10 10 45 60 201 15 0.5 3 1 2 10 38 SVY 69717 existing device), osseointegrated implant, 64 10.00 11.48 10 30 0 0

39 W/ EXP 40 0.200 0.071 10.00 11.69 13.00 16.25 25.00 183 40 11 10 10 30 45 60 201 15 2 1 1 1 2 3 10

40 W/OUT EXP 24 0.225 0.077 10.00 11.12 12.00 13.62 17.30 155 37 10 11 15 30 40 60 120 18 1 1

Open treatment of distal tibiofibular CROSSWALK 27829 90 joint (syndesmosis) disruption, includes 0.046 0.032 8.80 271 45 10 15 45 20 1 1.0 2 2 41 internal fixation, when performed Revision/replacement (including removal of existing device), osseointegrated implant, 0.100 0.047 8.80 187 33 3 10 45 15 0.5 2 1 REC 69717 90 skull; with percutaneous attachment to 44 external speech processor 45 Tracheostomy, fenestration procedure with 0.028 0.033 12.00 367 40 10 10 45 20 1 1 2 1.0 3 46 1st REF 31610 90 skin flaps 8 Midface flap (ie, zygomaticofacial flap) with 0.100 0.053 13.50 256 40 3 15 90 17.5 0.5 1 3 47 2nd REF 15730 90 preservation of vascular pedicle(s) 7

CURRENT NEW 90 #DIV/0! #DIV/0! 0 48 Revision/replacement (including removal of 0.149 0.066 13.00 15.48 27.00 197 37 10 10 60 80 201 15 0.5 2 1 2 10 49 SVY 69719 existing device), osseointegrated implant, 59 10.14 12.00 14 43 0 0

50 W/ EXP 31 0.167 0.073 10.15 12.04 13.60 16.67 27.00 186 35 15 10 24 45 60 90 201 20 2 1 1 2 3 10

51 W/OUT EXP 0.164 0.073 10.50 12.00 12.85 14.56 20.00 175 40 10 11 14 30 60 75 120 15 1 1

CROSSWALK 50590 90 Lithotripsy, extracorporeal shock wave 0.091 0.047 9.77 207 33 3 15 60 15 0.5 2 1 52 Revision/replacement (including removal of existing device), osseointegrated implant, 0.099 0.053 9.77 186 33 3 10 60 15 0.5 2 REC 69719 90 skull; with magnetic transcutaneous 53 attachment to external speech processor 54 Split-thickness autograft, face, scalp, eyelids, 0.068 0.039 10.15 258 40 12 20 75 30 0.5 2 1 55 1st REF 15120 90 mouth, neck, ears, orbits, genitalia, hands, 29

Revision of aqueous shunt to extraocular 0.060 0.041 10.58 259 19 1 5 65 10 0.5 4 3 56 2nd REF 66185 90 equatorial plate reservoir; with graft 8

CURRENT NEW 90 #DIV/0! #DIV/0! 0 57 Removal, osseointegrated implant, skull; with percutaneous attachment to external speech SVY 69726 processor 66 0.248 0.070 5.00 10.00 10.90 12.00 20.45 155 32 10 10 5 20 30 45 187 15 0.5 1 1 0 0 1 2 10 58

59 W/ EXP 48 0.277 0.081 5.00 10.00 10.69 12.24 20.45 132 35 10 10 5 20 30 45 128 15 2 1 1 2 3 10

60 W/OUT EXP 18 0.265 0.074 8.00 10.04 11.07 11.89 14.50 150 35 15 11 5 21 30 45 187 20 1 1 Transurethral destruction of prostate tissue; 0.071 0.042 5.93 142 17 6 5 30 15 3 61 CROSSWALK 53852 90 by radiofrequency thermotherapy Removal, osseointegrated implant, skull; with REC 69726 90 percutaneous attachment to external speech 0.088 0.040 5.93 148 32 3 10 30 15 0.5 1 1 62 processor 63 Split-thickness autograft, face, scalp, eyelids, 0.068 0.039 10.15 258 40 12 20 75 30 0.5 2 1 64 1st REF 15120 90 mouth, neck, ears, orbits, genitalia, hands, 13 Glossectomy; less than one-half tongue 65 2nd REF 41120 90 8 0.071 0.040 11.14 278 30 15 15 60 30 0.5 1 3

CURRENT NEW 90 #DIV/0! #DIV/0! 0 66 Removal, osseointegrated implant, skull; with 0.188 0.069 12.00 12.75 28.00 174 36 10 10 45 60 164 15 0.5 1 1 0 1 10 67 SVY 69727 magnetic transcutaneous attachment to 59 5.00 10.98 12 30 0 0

68 W/ EXP 27 0.179 0.066 10.00 11.27 12.00 14.00 28.00 182 35 10 10 12 30 45 60 164 20 2 1 1 1 1 2 10

69 W/OUT EXP 32 0.271 0.091 5.00 10.75 11.50 12.13 25.00 127 40 10 11 14 23 35 53 120 15 1

Ligation, division, and stripping, short CROSSWALK 37718 90 0.078 0.040 7.13 178 35 10 10 45 20 0.5 1 1 70 saphenous vein Removal, osseointegrated implant, skull; with REC 69727 90 magnetic transcutaneous attachment to 0.085 0.043 7.13 164 33 3 10 45 15 0.5 1 1 71 external speech processor FACILITY DIRECT PE INPUTS CPT CODE(S):_69714, 69717, 69716-27______SPECIALTY SOCIETY(IES):_AAO-HNS______PRESENTER(S):_R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

Meeting Date: January 2021

CPT Global Code Long Descriptor Period Implantation, osseointegrated implant, skull;, with percutaneous attachment to 69714 external speech processor 090

CPT Long Descriptor Global Code Period 69716 Implantation, osseointegrated implant, skull; with magnetic transcutaneous 090 attachment to external speech processor

CPT Long Descriptor Global Code Period 69717 Revision/replacement (including removal of existing device), osseointegrated 090 implant, skull; with percutaneous attachment to external speech processor

CPT Long Descriptor Global Code Period 69719 Revision/replacement (including removal of existing device), osseointegrated 090 implant, skull; with magnetic transcutaneous attachment to external speech processor

CPT Long Descriptor Global Code Period 69726 Removal, osseointegrated implant, skull; with percutaneous attachment to 090 external speech processor

CPT Long Descriptor Global Code Period 69727 Removal, osseointegrated implant, skull; with magnetic transcutaneous 090 attachment to external speech processor

Vignette(s) (vignette required even if PE only code(s)): CPT Code Vignette A 56-year-old male suffers from chronic otitis media resulting in otorrhea and mixed hearing loss. He is unable to wear traditional hearing aids. Implantation of an osseointegrated bone 69714 anchored device with a percutaneous attachment to an external speech processor is performed. CPT Vignette Code 69716 A 48-year-old male with a left mixed hearing loss seeks intervention for improved quality of life at work and socially. Placement of a magnetic transcutaneous bone anchored hearing device is performed. CPT Vignette Code

1 FACILITY DIRECT PE INPUTS CPT CODE(S):_69714, 69717, 69716-27______SPECIALTY SOCIETY(IES):_AAO-HNS______PRESENTER(S):_R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

69717 A 16-year-old female with chronic otitis media and conductive hearing loss who previously received a percutaneous bone anchored implant has chronic inflammation at the abutment site that has been unresponsive to medical therapy. The device is removed and a new device is placed at a different site. CPT Vignette Code 69719 A 59-year-old female with a right mixed hearing loss previously had placement of a magnetic transcutaneous bone anchored implant. It worked well, but she has developed discomfort at the device site. The device is removed and a new device is placed at a different site. CPT Vignette Code 69726 A 59-year-old female with a right mixed hearing loss had previous placement of a percutaneous bone anchored implant. It worked well, but she has developed discomfort at the device site. The device is removed without replacement. CPT Vignette Code 69727 A 62-year-old male with a right mixed hearing loss previously had placement of a magnetic transcutaneous bone anchored implant which worked well, but has now become infected. The device is removed without replacement.

1. Please provide a brief description of the process used to develop your recommendation and the composition of your Specialty Society RVS Committee Expert Panel: Our specialty formed a panel of experts to develop practice expense recommendations for this family of codes. The panel was comprised of our RUC Advisor and multiple clinical experts who practice in the areas of general otolaryngology, sleep medicine, and otology. The expert panel members also practice across in settings that vary by size, geography, and represent both private and academic settings.

2. Please provide reference code(s) for comparison on your spreadsheet. If you are making recommendations on an existing code, you are required to use the current direct PE inputs as your reference code, but may provide an additional reference code for support. Provide an explanation for the selection of reference code(s) here (for service reviewed prior to the implementation of clinical activity codes, detail is not provided in the RUC database, please contact Samantha Ashley at [email protected] for PE spreadsheets for your reference codes): Existing codes 69714 and 69717 were utilized as comparison codes for all new codes in the family.

3. Is this code(s) typically reported with an E/M service? No

4. If you are recommending more minutes than the PE Subcommittee standards for clinical activities you must provide rationale to justify the time: N/A

2 FACILITY DIRECT PE INPUTS CPT CODE(S):_69714, 69717, 69716-27______SPECIALTY SOCIETY(IES):_AAO-HNS______PRESENTER(S):_R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

guidelines) Please explain if the increase can be entirely accounted for because of an increase in physician time: N/A

7. Please provide a brief description of the clinical staff work for the following: a. Pre-Service period: During the pre-service clinical staff are completing pre-service diagnostic and referral forms, coordinating pre-surgery services including test results, scheduling space and equipment in the facility, providing pre-service education and obtaining consent from the patient, and completing pre- procedure phone calls and prescriptions. b. Service period (includes pre, intra and post): During the service period the clinical staff assist with a half discharge management visit for the patient. This includes post-procedure care instructions. They also clean the instruments used during each post operative visit. c. Post-service period: During post operative visits the patient is checked in via front-desk staff. Clinical staff collects vitals from the patient. An exam chair/table and light are required with paper covering for the exam furniture. A postoperative wound kit for removal of sutures/stapes is required. The clinical staff assists the physician with removal of the sutures.

8. If you are recommending a new clinical activity, please provide a detailed explanation of why the new clinical activity is needed and cannot conform to any of the existing clinical activities (please see second worksheet in PE spreadsheet workbook): N/A

INVOICES

10. ☐ Please check the box to confirm that you have provided invoices for all new supplies and/or equipment?

11. ☐ Please check the box to confirm that you have provided an estimate price on the PE spreadsheet for all new supplies and/or equipment?

12. If you wish to include a supply that is not on the list (please see fourth worksheet in PE spreadsheet workbook) please provide a paid invoice. Identify and explain the invoice here: N/A

3 FACILITY DIRECT PE INPUTS CPT CODE(S):_69714, 69717, 69716-27______SPECIALTY SOCIETY(IES):_AAO-HNS______PRESENTER(S):_R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

13. Please provide an itemized list of the contents for all supply kits, packs and trays included in your recommendation. Please include the description, CMS supply code, unit, item quantity and unit price (if available). See documents two and three under PE reference materials on the RUC Collaboration Website for information on the contents of kits, packs and trays. Item Unit DESCRIPTION Code Unit Qty price pack, minimum multi-specialty visit SA048 pack 4.0507 paper, exam table foot 7 gloves, non-sterile pair 2 gown, patient item 1 pillow case item 1 cover, thermometer probe item 1

Item Unit DESCRIPTION Code Unit Qty price pack, cleaning, surgical instruments SA043 pack 1 10.7922 gloves, non-sterile pair 2 gown, staff, impervious item 1 face shield, splash protection item 1 autoclave bag item 1 autoclave tape yd 0.33 enzymatic detergent oz 1 cleaning brush, instruments item 1

Item Unit DESCRIPTION Code Unit Qty price pack, post-op incision care (suture) SA054 pack 4.6918 kit, suture removal kit 1 povidone soln (Betadine) ml 10

gauze, sterile 4in x 4in item 2 gloves, sterile pair 1 steri-strip (6 strip uou) item 2 swab-pad, alcohol item 2 tape, surgical paper 1in (Micropore) inch 12 tincture of benzoin, swab item 1

4 FACILITY DIRECT PE INPUTS CPT CODE(S):_69714, 69717, 69716-27______SPECIALTY SOCIETY(IES):_AAO-HNS______PRESENTER(S):_R. Peter Manes, MD______

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

14. If you wish to include an equipment item that is not on the list (please see fifth worksheet in PE spreadsheet workbook) please provide a paid invoice. Identify and explain the invoice here: N/A

16. List all the equipment included in your recommendation and the equipment formula chosen (please see document titled Calculating equipment time). If you have selected “other formula” for any of the equipment please explain here: EQ234 suction and pressure cabinet, ENT (SMR) EQ183 microscope, operating EQ170 light, fiberoptic headlight w-source EF008 chair with headrest, exam, reclining

The office visit formula was used for all these pieces of equipment.

EQ137 basic instrument pack

The instrument pack formula was used for this item.

17. If there is any other item(s) on your spreadsheet not covered in the categories above that require greater detail/explanation, please include here: N/A

PROFESSIONAL LIABILITY INSURANCE (PLI) INFORMATION

18. If this is a PE only code please select a crosswalk based on a similar specialty mix: N/A

ITEMIZED LIST OF CHANGES (FOLLOWING THE PE SUBCOMMITTEE MEETING

AMA/SPECIALTY SOCIETY RELATIVE VALUE UPDATE COMMITTEE (RUC) PRACTICE EXPENSE SUMMARY OF RECOMMENDATION (SOR)

reviewed. On the PE spreadsheet, please highlight the cells and/or use red font to show the changes made during the PE Subcommittee meeting (if you have provided any of this highlighting based on changes from the reference code prior to the PE Subcommittee meeting please remove it, so not to be confused with changes made during the meeting). In addition to those revisions please also provide an itemized list of the modifications made to the PE spreadsheet during the PE Subcommittee meeting in the space below (e.g. clinical activity CA010 obtain vital signs was reduced from 5 minutes to 3 minutes).

Clinical staff time in the preservice period remains unchanged for all codes in the family. All codes have cleaning time added in the intra service time period to allocate time to cleaning the instruments used at each post op visit. Post-operative time has changed, commensurate with the survey data and recommended post op visits. Two codes (64714/64717) have 3 post op visits and the rest of the family has 2 post op visits.

Some supplies were reduced commensurate with reducing the post-operative visits per our survey data. Additionally, we added a minimum multi-specialty pack for each post op visit and reduced individual, unnecessary line items. We also added a basic instrument pack and cleaning pack for the instruments which will be used at each post op visit. The items include a tuning fork, Frasier tip suctions, and ear curettes. We removed the suture/staple pack and replaced it with just a suture pack.

Equipment times were reduced based on less office visits and lower overall office visit post time. The instrument pack formula was used for the new instrument pack and cleaning time was accounted for.

6 A B D E F G H I J K 1 RUC Practice Expense Spreadsheet CURRENT RECOMMENDED REFER 2 CPT Code 69714 CPT Code 69714 CPT Cod 3 RUC Collaboration Website Implantation, Implantation, Implan osseointegrated osseointegrated implant, osseoint Meeting Date: January 2021 skull;, with percutaneous Clinical Clinical Staff implant, temporal implant, Clinical Revision Date (if applicable): Clinical attachment to external Staff Type Type Rate bone; with bone Activity Code Tab: 18 Staff Type speech processor Code Per Minute percutaneous percuta Specialty: AAO-HNS attachment to attachm 4 external speech external 5 LOCATION Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 225.41 $ - $ 138.38 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 183.0 0.0 204.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 60.0 0.0 60.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 6.0 0.0 36.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 117.0 0.0 108.0 0.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ - $ 67.71 $ - $ 75.48 $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms L037D RN/LPN/MTA 0.37 5 5 16 CA002 Coordinate pre-surgery services (including test results) L037D RN/LPN/MTA 0.37 20 20 17 CA003 Schedule space and equipment in facility L037D RN/LPN/MTA 0.37 8 8 18 CA004 Provide pre-service education/obtain consent L037D RN/LPN/MTA 0.37 20 20 19 CA005 Complete pre-procedure phone calls and prescription L037D RN/LPN/MTA 0.37 7 7 20 CA006 Confirm availability of prior images/studies L037D RN/LPN/MTA 0.37 21 CA007 Review patient clinical extant information and questionnaire L037D RN/LPN/MTA 0.37 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) L037D RN/LPN/MTA 0.37 23 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new 26 L037D RN/LPN/MTA 0.37 in column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 L037D RN/LPN/MTA 0.37 available 34 CA010 Obtain vital signs L037D RN/LPN/MTA 0.37 35 CA011 Provide education/obtain consent L037D RN/LPN/MTA 0.37 36 CA012 Review requisition, assess for special needs L037D RN/LPN/MTA 0.37 37 CA013 Prepare room, equipment and supplies L037D RN/LPN/MTA 0.37 38 CA014 Confirm order, protocol exam L037D RN/LPN/MTA 0.37 39 CA015 Setup scope (nonfacility setting only) L037D RN/LPN/MTA 0.37 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient L037D RN/LPN/MTA 0.37 41 CA017 Sedate/apply anesthesia L037D RN/LPN/MTA 0.37 42 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new 45 L037D RN/LPN/MTA 0.37 in column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly 49 CA018 L037D RN/LPN/MTA 0.37 Assistrelated physician to physician or other work qualifiedtime (100%) healthcare professional---directly 50 CA019 L037D RN/LPN/MTA 0.37 Assistrelated physician to physician or other work qualifiedtime (67%) healthcare professional---directly 51 CA020 L037D RN/LPN/MTA 0.37 related to physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time L037D RN/LPN/MTA 0.37 55 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new 56 L037D RN/LPN/MTA 0.37 in column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 L037D RN/LPN/MTA 0.37 61 CA023 Monitor patient following procedure/service, no multitasking L037D RN/LPN/MTA 0.37 62 CA024 Clean room/equipment by clinical staff L037D RN/LPN/MTA 0.37 63 CA025 Clean scope L037D RN/LPN/MTA 0.37 64 CA026 Clean surgical instrument package L037D RN/LPN/MTA 0.37 30 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions L037D RN/LPN/MTA 0.37 66 CA028 Review/read post-procedure x-ray, lab and pathology reports L037D RN/LPN/MTA 0.37 67 CA029 Check dressings, catheters, wounds L037D RN/LPN/MTA 0.37 Technologist QC s images in PACS, checking for all images, reformats, 68 CA030 L037D RN/LPN/MTA 0.37 and dose page 69 CA031 Review examination with interpreting MD/DO L037D RN/LPN/MTA 0.37 Scan exam documents into PACS. Complete exam in RIS system to 70 CA032 L037D RN/LPN/MTA 0.37 populate images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) L037D RN/LPN/MTA 0.37 Document procedure (nonPACS) (e.g. mandated reporting, registry logs, 72 CA034 L037D RN/LPN/MTA 0.37 EEG file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions L037D RN/LPN/MTA 0.37 74 CA036 Discharge day management L037D RN/LPN/MTA 0.37 n/a 6 n/a 6 n/a 75 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new 78 L037D RN/LPN/MTA 0.37 in column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications L037D RN/LPN/MTA 0.37 85 CA038 Coordinate post-procedure services L037D RN/LPN/MTA 0.37 86 Office visits: List Number and Level of Office Visits MINUTES # visits # visits # visits # visits # visits 87 99211 16 minutes 16 88 99212 27 minutes 27 3 89 99213 36 minutes 36 1 3 90 99214 53 minutes 53 91 99215 63 minutes 63 92 CA039 Post-operative visits (total time) L037D RN/LPN/MTA 0.37 0.0 117.0 0.0 108.0 0.0 93 L037D RN/LPN/MTA 0.37 Other activity: please include short clinical description here and type new 96 L037D RN/LPN/MTA 0.37 in column A 99 End: with last office visit before end of global period A B D E F G H I J K 1 RUC Practice Expense Spreadsheet CURRENT RECOMMENDED REFER 2 CPT Code 69714 CPT Code 69714 CPT Cod 3 RUC Collaboration Website Implantation, Implantation, Implan osseointegrated osseointegrated implant, osseoint Meeting Date: January 2021 skull;, with percutaneous Clinical Clinical Staff implant, temporal implant, Clinical Revision Date (if applicable): Clinical attachment to external Staff Type Type Rate bone; with bone Activity Code Tab: 18 Staff Type speech processor Code Per Minute percutaneous percuta Specialty: AAO-HNS attachment to attachm 4 external speech external 5 LOCATION Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 225.41 $ - $ 138.38 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 183.0 0.0 204.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 60.0 0.0 60.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 6.0 0.0 36.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME L037D RN/LPN/MTA 0.37 0.0 117.0 0.0 108.0 0.0 100 Supply Code MEDICAL SUPPLIES PRICE UNIT 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ - $ 150.10 $ - $ 55.81 $ - 102 SA043 pack, cleaning, surgical instruments 10.7922 pack 3 103 SA048 pack, minimum multi-specialty visit 4.0507 pack 3 104 SA053 pack, post-op incision care (suture & staple) 5.63 pack 1 0 105 SA054 pack, post-op incision care (suture) 4.6918 pack 1 106 SB012 drape, sterile, for Mayo stand 1.2245 item 4 107 SB024 gloves, sterile 0.8925 pair 1 108 SB026 gown, patient 0.5757 item 4 109 SB027 gown, staff, impervious 1.186 item 8 110 SB034 mask, surgical, with face shield 3.4 item 8 111 SB044 underpad 2ft x 3ft (Chux) 0.2975 item 4 112 SD009 canister, suction 4.2095 item 4 1 113 SD132 tubing, suction, non-latex (6ft uou) 0.9212 item 8 2 114 SG006 adhesive remover, pad (acetone) 0.035 item 1 115 SG016 bandage, Kerlix, sterile 4.5in 0.863 item 1 116 SG020 bandage, Kling, sterile 4in 0.4975 item 1 117 SG031 cottonoid 0.7933 item 4 118 SG042 dressing, ear (Glasscock) 13.11 item 1 119 SG055 gauze, sterile 4in x 4in 0.1823 item 14 2 120 SG079 tape, surgical paper 1in (Micropore) 0.008 inch 48 121 SG081 applicator, cotton-tipped, sterile, 6in 0.0562 item 16 1 122 SG082 cotton balls, sterile 0.0279 item 4 123 SH024 Cipro HC otic soln 10.23 ml 4 124 SJ007 bacitracin oint (0.9gm uou) 0.1202 item 20 1 125 SJ010 basin, emesis 0.2415 item 4 126 SJ028 hydrogen peroxide 0.0307 ml 40 127 SJ046 silver nitrate applicator 0.16 item 20 128 SJ060 tincture of benzoin, swab 0.3275 item 1 129 SM001 atomizer tip shield (RhinoGuard) 0.905 item 4 130 Other supply item: to add a new supply item please include the name of the item consistent with the paid invoice here, type NEW in column A and enter the type of unit in column E (oz, ml, unit). Please note that you must include a price estimate consistent with the paid invoice in column D. 131 Equipment Purchase Equipment Cost Per EQUIPMENT 133 Code Price Formula Minute 134 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ - $ 7.60 $ - $ 7.09 $ - 135 EQ234 suction and pressure cabinet, ENT (SMR) 4032.9248 Office Visits 0.010702279 117 108.0 136 EQ183 microscope, operating 7047.5 Office Visits 0.027923578 117 108.0 137 EQ170 light, fiberoptic headlight w-source 3525.9372 Office Visits 0.013970455 117 108.0 138 EF008 chair with headrest, exam, reclining 5565.6015 Office Visits 0.01238009 117 108.0 Instrument EQ137 instrument pack, basic ($500-$1499) 500 0.002323783 30.0 139 Packs 146 Other equipment item: to add a new equipment item please include the name of the item consistent with the paid invoice here, type NEW in column A and please note that you must include a purchase price estimate consistent with the paid invoice in column D. 147 A B L M N O P Q R S T 1 RUC Practice Expense Spreadsheet RENCE RECOMMENDED CURRENT RECOMMENDED REFERENCE 2 de 69714 CPT Code 69716 CPT Code 69717 CPT Code 69717 CPT Code 69717 3 RUC Collaboration Website tation, Implantation, Replacement (including Revision/replacement Replacement tegrated osseointegrated implant, removal of existing (including removal of (including removal of Meeting Date: January 2021 temporal skull; with magnetic device), existing device), existing device), Clinical Revision Date (if applicable): ; with transcutaneous osseointegrated osseointegrated implant, osseointegrated Activity Code Tab: 18 attachment to external skull; with percutaneous aneous speech processor implant, temporal bone; attachment to external implant, temporal Specialty: AAO-HNS ment to with percutaneous bone; with 4 speech processor speech attachment to external percutaneous 5 LOCATION Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility 6 GLOBAL PERIOD 090 090 090 090 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 225.41 $ - $ 104.16 $ - $ 219.36 $ - $ 138.38 $ - $ 225.41 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 183.0 0.0 158.0 0.0 183.0 0.0 204.0 0.0 183.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60.0 0.0 60.0 0.0 60.0 0.0 60.0 0.0 60.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 6.0 0.0 26.0 0.0 6.0 0.0 36.0 0.0 6.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 117.0 0.0 72.0 0.0 117.0 0.0 108.0 0.0 117.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ 67.71 $ - $ 58.46 $ - $ 67.71 $ - $ 75.48 $ - $ 67.71 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 5 5 5 5 5 16 CA002 Coordinate pre-surgery services (including test results) 20 20 20 20 20 17 CA003 Schedule space and equipment in facility 8 8 8 8 8 18 CA004 Provide pre-service education/obtain consent 20 20 20 20 20 19 CA005 Complete pre-procedure phone calls and prescription 7 7 7 7 7 20 CA006 Confirm availability of prior images/studies 21 CA007 Review patient clinical extant information and questionnaire 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) 23 Other activity: please include short clinical description here and type new 26 in column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 available 34 CA010 Obtain vital signs 35 CA011 Provide education/obtain consent 36 CA012 Review requisition, assess for special needs 37 CA013 Prepare room, equipment and supplies 38 CA014 Confirm order, protocol exam 39 CA015 Setup scope (nonfacility setting only) 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient 41 CA017 Sedate/apply anesthesia 42 Other activity: please include short clinical description here and type new 45 in column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly 49 CA018 Assistrelated physician to physician or other work qualifiedtime (100%) healthcare professional---directly 50 CA019 Assistrelated physician to physician or other work qualifiedtime (67%) healthcare professional---directly 51 CA020 related to physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time 55 Other activity: please include short clinical description here and type new 56 in column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 61 CA023 Monitor patient following procedure/service, no multitasking 62 CA024 Clean room/equipment by clinical staff 63 CA025 Clean scope 64 CA026 Clean surgical instrument package 20 30 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions 66 CA028 Review/read post-procedure x-ray, lab and pathology reports 67 CA029 Check dressings, catheters, wounds Technologist QC s images in PACS, checking for all images, reformats, 68 CA030 and dose page 69 CA031 Review examination with interpreting MD/DO Scan exam documents into PACS. Complete exam in RIS system to 70 CA032 populate images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) Document procedure (nonPACS) (e.g. mandated reporting, registry logs, 72 CA034 EEG file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions 74 CA036 Discharge day management 6 n/a 6 n/a 6 n/a 6 n/a 6 75 Other activity: please include short clinical description here and type new 78 in column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications 85 CA038 Coordinate post-procedure services 86 Office visits: List Number and Level of Office Visits # visits # visits # visits # visits # visits # visits # visits # visits # visits 87 99211 16 minutes 88 99212 27 minutes 3 3 3 89 99213 36 minutes 1 2 1 3 1 90 99214 53 minutes 91 99215 63 minutes 92 CA039 Post-operative visits (total time) 117.0 0.0 72.0 0.0 117.0 0.0 108.0 0.0 117.0 93 Other activity: please include short clinical description here and type new 96 in column A 99 End: with last office visit before end of global period A B L M N O P Q R S T 1 RUC Practice Expense Spreadsheet RENCE RECOMMENDED CURRENT RECOMMENDED REFERENCE 2 de 69714 CPT Code 69716 CPT Code 69717 CPT Code 69717 CPT Code 69717 3 RUC Collaboration Website tation, Implantation, Replacement (including Revision/replacement Replacement tegrated osseointegrated implant, removal of existing (including removal of (including removal of Meeting Date: January 2021 temporal skull; with magnetic device), existing device), existing device), Clinical Revision Date (if applicable): ; with transcutaneous osseointegrated osseointegrated implant, osseointegrated Activity Code Tab: 18 attachment to external skull; with percutaneous aneous speech processor implant, temporal bone; attachment to external implant, temporal Specialty: AAO-HNS ment to with percutaneous bone; with 4 speech processor speech attachment to external percutaneous 5 LOCATION Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility 6 GLOBAL PERIOD 090 090 090 090 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 225.41 $ - $ 104.16 $ - $ 219.36 $ - $ 138.38 $ - $ 225.41 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 183.0 0.0 158.0 0.0 183.0 0.0 204.0 0.0 183.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60.0 0.0 60.0 0.0 60.0 0.0 60.0 0.0 60.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 6.0 0.0 26.0 0.0 6.0 0.0 36.0 0.0 6.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 117.0 0.0 72.0 0.0 117.0 0.0 108.0 0.0 117.0 100 Supply Code MEDICAL SUPPLIES 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ 150.10 $ - $ 40.97 $ - $ 144.04 $ - $ 55.81 $ - $ 150.10 102 SA043 pack, cleaning, surgical instruments 2 3 103 SA048 pack, minimum multi-specialty visit 2 3 104 SA053 pack, post-op incision care (suture & staple) 1 0 1 0 1 105 SA054 pack, post-op incision care (suture) 1 1 106 SB012 drape, sterile, for Mayo stand 4 4 4 107 SB024 gloves, sterile 1 1 1 108 SB026 gown, patient 4 4 4 109 SB027 gown, staff, impervious 8 8 8 110 SB034 mask, surgical, with face shield 8 4 8 111 SB044 underpad 2ft x 3ft (Chux) 4 4 4 112 SD009 canister, suction 4 1 4 1 4 113 SD132 tubing, suction, non-latex (6ft uou) 8 2 8 2 8 114 SG006 adhesive remover, pad (acetone) 1 1 1 115 SG016 bandage, Kerlix, sterile 4.5in 1 1 1 116 SG020 bandage, Kling, sterile 4in 1 1 1 117 SG031 cottonoid 4 4 4 118 SG042 dressing, ear (Glasscock) 1 1 1 119 SG055 gauze, sterile 4in x 4in 14 2 14 2 14 120 SG079 tape, surgical paper 1in (Micropore) 48 48 48 121 SG081 applicator, cotton-tipped, sterile, 6in 16 1 16 1 16 122 SG082 cotton balls, sterile 4 4 4 123 SH024 Cipro HC otic soln 4 4 4 124 SJ007 bacitracin oint (0.9gm uou) 20 1 4 1 20 125 SJ010 basin, emesis 4 20 4 126 SJ028 hydrogen peroxide 40 4 40 127 SJ046 silver nitrate applicator 20 40 20 128 SJ060 tincture of benzoin, swab 1 20 1 129 SM001 atomizer tip shield (RhinoGuard) 4 1 4 130 4 Other supply item: to add a new supply item please include the name of the item consistent with the paid invoice here, type NEW in column A and enter the type of unit in column E (oz, ml, unit). Please note that you must include a price estimate consistent with the paid invoice in column D. 131 Equipment EQUIPMENT 133 Code 134 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ 7.60 $ - $ 4.72 $ - $ 7.60 $ - $ 7.09 $ - $ 7.60 135 EQ234 suction and pressure cabinet, ENT (SMR) 117 72.0 117 108.0 117 136 EQ183 microscope, operating 117 72.0 117 108.0 117 137 EQ170 light, fiberoptic headlight w-source 117 72.0 117 108.0 117 138 EF008 chair with headrest, exam, reclining 117 72.0 117 108.0 117 EQ137 instrument pack, basic ($500-$1499) 20.0 30.0 139 146 Other equipment item: to add a new equipment item please include the name of the item consistent with the paid invoice here, type NEW in column A and please note that you must include a purchase price estimate consistent with the paid invoice in column D. 147 A B U V W X Y Z AA AB AC 1 RUC Practice Expense Spreadsheet RECOMMENDED REFERENCE RECOMMENDED REFERENCE RECOMM 2 CPT Code 69719 CPT Code 69717 CPT Code 69726 CPT Code 69717 CPT Cod 3 RUC Collaboration Website Revision/replacement Replacement Removal, Replacement Rem (including removal of (including removal of osseointegrated implant, (including removal of osseointegra Meeting Date: January 2021 existing device), existing device), skull; with percutaneous existing device), skull; with Clinical Revision Date (if applicable): osseointegrated implant, osseointegrated attachment to external osseointegrated transcu Activity Code Tab: 18 skull; with magnetic speech processor attachment transcutaneous implant, temporal implant, temporal speech p Specialty: AAO-HNS bone; with bone; with 4 attachment to external h percutaneous percutaneous 5 LOCATION Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 090 090 090 090 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 104.16 $ - $ 225.41 $ - $ 100.24 $ - $ 225.41 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 0.0 158.0 0.0 183.0 0.0 149.0 0.0 183.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 0.0 60.0 0.0 60.0 0.0 60.0 0.0 60.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0.0 26.0 0.0 6.0 0.0 26.0 0.0 6.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 0.0 72.0 0.0 117.0 0.0 63.0 0.0 117.0 0.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ - $ 58.46 $ - $ 67.71 $ - $ 55.13 $ - $ 67.71 $ - 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 5 5 5 5 16 CA002 Coordinate pre-surgery services (including test results) 20 20 20 20 17 CA003 Schedule space and equipment in facility 8 8 8 8 18 CA004 Provide pre-service education/obtain consent 20 20 20 20 19 CA005 Complete pre-procedure phone calls and prescription 7 7 7 7 20 CA006 Confirm availability of prior images/studies 21 CA007 Review patient clinical extant information and questionnaire 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) 23 Other activity: please include short clinical description here and type new 26 in column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 available 34 CA010 Obtain vital signs 35 CA011 Provide education/obtain consent 36 CA012 Review requisition, assess for special needs 37 CA013 Prepare room, equipment and supplies 38 CA014 Confirm order, protocol exam 39 CA015 Setup scope (nonfacility setting only) 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient 41 CA017 Sedate/apply anesthesia 42 Other activity: please include short clinical description here and type new 45 in column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly 49 CA018 Assistrelated physician to physician or other work qualifiedtime (100%) healthcare professional---directly 50 CA019 Assistrelated physician to physician or other work qualifiedtime (67%) healthcare professional---directly 51 CA020 related to physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time 55 Other activity: please include short clinical description here and type new 56 in column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 61 CA023 Monitor patient following procedure/service, no multitasking 62 CA024 Clean room/equipment by clinical staff 63 CA025 Clean scope 64 CA026 Clean surgical instrument package 20 20 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions 66 CA028 Review/read post-procedure x-ray, lab and pathology reports 67 CA029 Check dressings, catheters, wounds Technologist QC s images in PACS, checking for all images, reformats, 68 CA030 and dose page 69 CA031 Review examination with interpreting MD/DO Scan exam documents into PACS. Complete exam in RIS system to 70 CA032 populate images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) Document procedure (nonPACS) (e.g. mandated reporting, registry logs, 72 CA034 EEG file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions 74 CA036 Discharge day management n/a 6 n/a 6 n/a 6 n/a 6 n/a 75 Other activity: please include short clinical description here and type new 78 in column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications 85 CA038 Coordinate post-procedure services 86 Office visits: List Number and Level of Office Visits # visits # visits # visits # visits # visits # visits # visits # visits # visits 87 99211 16 minutes 88 99212 27 minutes 3 1 3 89 99213 36 minutes 2 1 1 1 90 99214 53 minutes 91 99215 63 minutes 92 CA039 Post-operative visits (total time) 0.0 72.0 0.0 117.0 0.0 63.0 0.0 117.0 0.0 93 Other activity: please include short clinical description here and type new 96 in column A 99 End: with last office visit before end of global period A B U V W X Y Z AA AB AC 1 RUC Practice Expense Spreadsheet RECOMMENDED REFERENCE RECOMMENDED REFERENCE RECOMM 2 CPT Code 69719 CPT Code 69717 CPT Code 69726 CPT Code 69717 CPT Cod 3 RUC Collaboration Website Revision/replacement Replacement Removal, Replacement Rem (including removal of (including removal of osseointegrated implant, (including removal of osseointegra Meeting Date: January 2021 existing device), existing device), skull; with percutaneous existing device), skull; with Clinical Revision Date (if applicable): osseointegrated implant, osseointegrated attachment to external osseointegrated transcu Activity Code Tab: 18 skull; with magnetic speech processor attachment transcutaneous implant, temporal implant, temporal speech p Specialty: AAO-HNS bone; with bone; with 4 attachment to external h percutaneous percutaneous 5 LOCATION Non Fac Facility Non Fac Facility Non Fac Facility Non Fac Facility Non Fac 6 GLOBAL PERIOD 090 090 090 090 090 090 090 090 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ - $ 104.16 $ - $ 225.41 $ - $ 100.24 $ - $ 225.41 $ - 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 0.0 158.0 0.0 183.0 0.0 149.0 0.0 183.0 0.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 0.0 60.0 0.0 60.0 0.0 60.0 0.0 60.0 0.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 0.0 26.0 0.0 6.0 0.0 26.0 0.0 6.0 0.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 0.0 72.0 0.0 117.0 0.0 63.0 0.0 117.0 0.0 100 Supply Code MEDICAL SUPPLIES 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ - $ 40.97 $ - $ 150.10 $ - $ 40.97 $ - $ 150.10 $ - 102 SA043 pack, cleaning, surgical instruments 2 2 103 SA048 pack, minimum multi-specialty visit 2 2 104 SA053 pack, post-op incision care (suture & staple) 0 1 0 1 105 SA054 pack, post-op incision care (suture) 1 1 106 SB012 drape, sterile, for Mayo stand 4 4 107 SB024 gloves, sterile 1 1 108 SB026 gown, patient 4 4 109 SB027 gown, staff, impervious 8 8 110 SB034 mask, surgical, with face shield 8 8 111 SB044 underpad 2ft x 3ft (Chux) 4 4 112 SD009 canister, suction 1 4 1 4 113 SD132 tubing, suction, non-latex (6ft uou) 2 8 2 8 114 SG006 adhesive remover, pad (acetone) 1 1 115 SG016 bandage, Kerlix, sterile 4.5in 1 1 116 SG020 bandage, Kling, sterile 4in 1 1 117 SG031 cottonoid 4 4 118 SG042 dressing, ear (Glasscock) 1 1 119 SG055 gauze, sterile 4in x 4in 2 14 2 14 120 SG079 tape, surgical paper 1in (Micropore) 48 48 121 SG081 applicator, cotton-tipped, sterile, 6in 1 16 1 16 122 SG082 cotton balls, sterile 4 4 123 SH024 Cipro HC otic soln 4 4 124 SJ007 bacitracin oint (0.9gm uou) 1 20 1 20 125 SJ010 basin, emesis 4 4 126 SJ028 hydrogen peroxide 40 40 127 SJ046 silver nitrate applicator 20 20 128 SJ060 tincture of benzoin, swab 1 1 129 SM001 atomizer tip shield (RhinoGuard) 4 4 130 Other supply item: to add a new supply item please include the name of the item consistent with the paid invoice here, type NEW in column A and enter the type of unit in column E (oz, ml, unit). Please note that you must include a price estimate consistent with the paid invoice in column D. 131 Equipment EQUIPMENT 133 Code 134 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ - $ 4.72 $ - $ 7.60 $ - $ 4.14 $ - $ 7.60 $ - 135 EQ234 suction and pressure cabinet, ENT (SMR) 72.0 117 63.0 117 136 EQ183 microscope, operating 72.0 117 63.0 117 137 EQ170 light, fiberoptic headlight w-source 72.0 117 63.0 117 138 EF008 chair with headrest, exam, reclining 72.0 117 63.0 117 EQ137 instrument pack, basic ($500-$1499) 20.0 20.0 139 146 Other equipment item: to add a new equipment item please include the name of the item consistent with the paid invoice here, type NEW in column A and please note that you must include a purchase price estimate consistent with the paid invoice in column D. 147 A B AD 1 RUC Practice Expense Spreadsheet MENDED 2 de 69727 3 RUC Collaboration Website oval, ated implant, Meeting Date: January 2021 magnetic Clinical Revision Date (if applicable): taneous Activity Code Tab: 18 t to external processor Specialty: AAO-HNS 4 5 LOCATION Facility 6 GLOBAL PERIOD 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 100.24 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 149.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 26.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 63.0 12 TOTAL COST OF CLINICAL STAFF TIME x RATE PER MINUTE $ 55.13 13 PRE-SERVICE PERIOD 14 Start: Following visit when decision for surgery/procedure made 15 CA001 Complete pre-service diagnostic and referral forms 5 16 CA002 Coordinate pre-surgery services (including test results) 20 17 CA003 Schedule space and equipment in facility 8 18 CA004 Provide pre-service education/obtain consent 20 19 CA005 Complete pre-procedure phone calls and prescription 7 20 CA006 Confirm availability of prior images/studies 21 CA007 Review patient clinical extant information and questionnaire 22 CA008 Perform regulatory mandated quality assurance activity (pre-service) 23 Other activity: please include short clinical description here and type new 26 in column A 29 End: When patient enters office/facility for surgery/procedure 30 SERVICE PERIOD 31 Start: When patient enters office/facility for surgery/procedure: 32 Pre-Service (of service period) Greet patient, provide gowning, ensure appropriate medical records are 33 CA009 available 34 CA010 Obtain vital signs 35 CA011 Provide education/obtain consent 36 CA012 Review requisition, assess for special needs 37 CA013 Prepare room, equipment and supplies 38 CA014 Confirm order, protocol exam 39 CA015 Setup scope (nonfacility setting only) 40 CA016 Prepare, set-up and start IV, initial positioning and monitoring of patient 41 CA017 Sedate/apply anesthesia 42 Other activity: please include short clinical description here and type new 45 in column A 48 Intra-service (of service period) Assist physician or other qualified healthcare professional---directly 49 CA018 Assistrelated physician to physician or other work qualifiedtime (100%) healthcare professional---directly 50 CA019 Assistrelated physician to physician or other work qualifiedtime (67%) healthcare professional---directly 51 CA020 related to physician work time (other%) 52 CA021 Perform procedure/service---NOT directly related to physician work time 55 Other activity: please include short clinical description here and type new 56 in column A 59 Post-Service (of service period) 60 CA022 Monitor patient following procedure/service, multitasking 1:4 61 CA023 Monitor patient following procedure/service, no multitasking 62 CA024 Clean room/equipment by clinical staff 63 CA025 Clean scope 64 CA026 Clean surgical instrument package 20 65 CA027 Complete post-procedure diagnostic forms, lab and x-ray requisitions 66 CA028 Review/read post-procedure x-ray, lab and pathology reports 67 CA029 Check dressings, catheters, wounds Technologist QC s images in PACS, checking for all images, reformats, 68 CA030 and dose page 69 CA031 Review examination with interpreting MD/DO Scan exam documents into PACS. Complete exam in RIS system to 70 CA032 populate images into work queue 71 CA033 Perform regulatory mandated quality assurance activity (service period) Document procedure (nonPACS) (e.g. mandated reporting, registry logs, 72 CA034 EEG file etc ) 73 CA035 Review home care instructions, coordinate visits/prescriptions 74 CA036 Discharge day management 6 75 Other activity: please include short clinical description here and type new 78 in column A 81 End: Patient leaves office/facility 82 POST-SERVICE PERIOD 83 Start: Patient leaves office/facility 84 CA037 Conduct patient communications 85 CA038 Coordinate post-procedure services 86 Office visits: List Number and Level of Office Visits # visits 87 99211 16 minutes 88 99212 27 minutes 1 89 99213 36 minutes 1 90 99214 53 minutes 91 99215 63 minutes 92 CA039 Post-operative visits (total time) 63.0 93 Other activity: please include short clinical description here and type new 96 in column A 99 End: with last office visit before end of global period A B AD 1 RUC Practice Expense Spreadsheet MENDED 2 de 69727 3 RUC Collaboration Website oval, ated implant, Meeting Date: January 2021 magnetic Clinical Revision Date (if applicable): taneous Activity Code Tab: 18 t to external processor Specialty: AAO-HNS 4 5 LOCATION Facility 6 GLOBAL PERIOD 090 TOTAL COST OF CLINICAL ACTIVITY TIME, SUPPLIES AND $ 100.24 7 EQUIPMENT TIME 8 TOTAL CLINICAL STAFF TIME 149.0 9 TOTAL PRE-SERVICE CLINICAL STAFF TIME 60.0 10 TOTAL SERVICE PERIOD CLINICAL STAFF TIME 26.0 11 TOTAL POST-SERVICE CLINICAL STAFF TIME 63.0 100 Supply Code MEDICAL SUPPLIES 101 TOTAL COST OF SUPPLY QUANTITY x PRICE $ 40.97 102 SA043 pack, cleaning, surgical instruments 2 103 SA048 pack, minimum multi-specialty visit 2 104 SA053 pack, post-op incision care (suture & staple) 0 105 SA054 pack, post-op incision care (suture) 1 106 SB012 drape, sterile, for Mayo stand 107 SB024 gloves, sterile 108 SB026 gown, patient 109 SB027 gown, staff, impervious 110 SB034 mask, surgical, with face shield 111 SB044 underpad 2ft x 3ft (Chux) 112 SD009 canister, suction 1 113 SD132 tubing, suction, non-latex (6ft uou) 2 114 SG006 adhesive remover, pad (acetone) 115 SG016 bandage, Kerlix, sterile 4.5in 116 SG020 bandage, Kling, sterile 4in 117 SG031 cottonoid 118 SG042 dressing, ear (Glasscock) 119 SG055 gauze, sterile 4in x 4in 2 120 SG079 tape, surgical paper 1in (Micropore) 121 SG081 applicator, cotton-tipped, sterile, 6in 1 122 SG082 cotton balls, sterile 123 SH024 Cipro HC otic soln 124 SJ007 bacitracin oint (0.9gm uou) 1 125 SJ010 basin, emesis 126 SJ028 hydrogen peroxide 127 SJ046 silver nitrate applicator 128 SJ060 tincture of benzoin, swab 129 SM001 atomizer tip shield (RhinoGuard) 130 Other supply item: to add a new supply item please include the name of the item consistent with the paid invoice here, type NEW in column A and enter the type of unit in column E (oz, ml, unit). Please note that you must include a price estimate consistent with the paid invoice in column D. 131 Equipment EQUIPMENT 133 Code 134 TOTAL COST OF EQUIPMENT TIME x COST PER MINUTE $ 4.14 135 EQ234 suction and pressure cabinet, ENT (SMR) 63.0 136 EQ183 microscope, operating 63.0 137 EQ170 light, fiberoptic headlight w-source 63.0 138 EF008 chair with headrest, exam, reclining 63.0 EQ137 instrument pack, basic ($500-$1499) 20.0 139 146 Other equipment item: to add a new equipment item please include the name of the item consistent with the paid invoice here, type NEW in column A and please note that you must include a purchase price estimate consistent with the paid invoice in column D. 147 AMA/Specialty Society RVS Update Committee Summary of Recommendations *Screen: High Volume Growth*

April 2021

Cardiac Ablation – Tab 7

The RUC identified CPT code 93656 with Medicare utilization over 10,000 that have increased by at least 100% from 2014 through 2019e. In January 2020, the RUC recommended to refer this issue to the CPT Editorial Panel in May 2020 for revision and bundling. Technology and clinical practice have changed since these codes were developed in 2011. Based on the billed together data for these and related codes, the specialty societies recommended referral to CPT to update code descriptors and likely bundle services now commonly performed together, such as 3D mapping. In October 2020, the CPT Editorial Panel revised one code (93653) to bundle with 3D mapping and to include “induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus,” and another (93656) to add 3D mapping and “left atrial pacing and recording from coronary sinus or left atrium” and “intracardiac echocardiography including imaging supervision and interpretation” to their descriptors.

The surveying specialties had submitted a letter to the CPT Editorial Panel in December 2020 requesting that the coding changes for these services to be rescinded for CPT 2022 due to the specialty’s concern that the RUC survey respondents may have been confused about the coding changes. In February 2021, the CPT Editorial Panel Executive Committee did not rescind their changes, which were among the coding changes for CPT 2022. Since the request to rescind the changes was not considered by CPT until after the January 2021 RUC meeting and January 2021 was the last RUC meeting of the CPT 2022 cycle, the RUC had recommended for these services to be valued as interim for CPT 2022 and that the codes would be resurveyed and reviewed at the April 2021 RUC meeting.

93653 Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry The RUC reviewed the survey results from 62 cardiac electrophysiologists and recommends the survey 25th percentile work RVU of 15.00 for CPT code 93653. The RUC recommends 31 minutes of pre-service evaluation, 3 minutes of pre-service positioning, 15 minutes of pre-service scrub/dress/wait time, 120 minutes of intra-service time and 30 minutes of immediate post-service time. The RUC noted that CPT code 93653 was revised to now bundle the physician work of CPT codes 93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) and 93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure), which previously were separately reported add-on services.

contacted well enough to be delivering energy, which resulted in the physician delivering repeated ablation on the same spots many times, to produce an effect. The physician now knows exactly how well the catheter is contacting the tissue and is also examining the different impedance and various electrical measurements during the ablation delivery. Due to these recent improvements in technology, the lesions are now much more efficient and effective, but also because of that, the risk of causing collateral injury during the ablation delivery is much higher with each lesion delivery. For instance, the ablation treatment is much more intense in terms of risk of heart block and esophageal injury. Furthermore, while the physician is obtaining many more data points to create the 3-dimensional map, the physician still needs to make sure every one of those points are accurate as review of points is not automated.

The specialties noted that 93653 is typically the most intense service to perform among the three base codes in this family (93653, 93654 and 93656). CPT code 93653 is typically performed on a young patient who does not have other conditions and the ablation site occurs very close to the patient’s innate conduction system. There is an approximately 0.5 percent to 1 percent risk of causing heart block requiring a permanent pacemaker. The time when the physician is applying radiofrequency energy is extraordinarily intense as opposed to the other two ablation services, 93654 and 93656, which are longer procedures on generally sicker patients and the intensity is more spread out over time.

To justify a value of 15.00, the RUC compared the survey code to top key reference code 93580 Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant (work RVU= 17.97, intra-service time of 120 minutes, total time of 210 minutes) and noted that both services involve an identical amount of intra-service time and that 80 percent of the survey respondents who selected the top key reference code also indicated that the survey code is a more intense and complex procedure to perform. However, the reference code involves more total time. The RUC also compared the survey code to 2nd key reference code 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation (work RVU= 14.00, intra- service time of 90 minutes, total time of 183 minutes) and noted that the survey code involves much more intra-service time and somewhat more total time. 75 percent of the survey respondents who selected this reference code indicated the survey code was more intense and complex, however, the RUC recommendation of 15.00 has a lower intensity than the reference code. The specialty noted and the RUC concurred that there are very few major surgical procedures that comprise 000-day or XXX global periods to use as reference codes to compare to the survey code. The RUC concluded that CPT code 93653 should be valued at the 25th percentile work RVU as supported by the resurvey. The RUC recommends a work RVU of 15.00 for CPT code 93653.

93654 Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed The RUC reviewed the survey results from 63 cardiac electrophysiologists and recommends the survey 25th percentile work RVU of 18.10 for CPT code 93654. The RUC recommends 40 minutes of pre-service evaluation, 3 minutes of pre-service positioning, 15 minutes of pre-service scrub/dress/wait time, 200 minutes of intra-service time and 33 minutes of immediate post-service time. The RUC noted that, unlike codes 93653 and 93655, the work of intracardiac electrophysiologic 3D mapping was already bundled into this service prior to the CPT revisions.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

The specialties noted that the actual ablation portion of the procedure is more intense relative to when this procedure was last valued, since the cardiac electrophysiologist is now receiving much more feedback from the catheter that is touching the heart and now knows exactly how many grams of force are being applied. When the base procedure was last reviewed, the physician would not have been certain that the tissue was contacted well enough to be delivering energy, which resulted in the physician delivering repeated ablation on the same spots many times, to produce an effect. The physician now knows exactly how well the catheter is contacting the tissue and is also examining the different impedance and various electrical measurements during the ablation delivery. Due to these recent improvements in technology, the lesions are now much more efficient and effective, but also because of that, the risk of causing collateral injury during the ablation delivery is much higher with each lesion delivery. The ablation treatment is much more intense in terms of risk of heart block and esophageal injury. Furthermore, while the physician is obtaining many more points to create the 3-dimensional map, they still need to make sure every one of those points are accurate as review of points is not automated.

In addition, the specialties noted that ventricular tachycardia patients are the most complicated, often with recurrent heart failure admissions and these patients typically have with an implantable defibrillator. The defibrillator must be turned off prior to the procedure and the patient requires more pre-service evaluation time to make sure that they are hemodynamically stable prior to and throughout the procedure.

To justify a work value of 18.10, the RUC compared the survey code to CPT code 93581 Percutaneous transcatheter closure of a congenital ventricular septal defect with implant (work RVU= 24.39, intra-service time of 180 minutes, total time of 270 minutes) and noted that the survey code involves 20 more minutes of intra-service time and 21 more minutes of total time. The RUC also compared the survey code to CPT code 33978 Removal of ventricular assist device; extracorporeal, biventricular (work RVU= 25.00, intra-service time of 200 minutes, total time of 355 minutes) and noted that although both services involve an identical amount of intra-service time, it would be appropriate to value the survey code somewhat lower due to the disparity in total time. The specialty noted and the RUC concurred that there are very few major surgical procedures that comprise 000-day or XXX global periods to use as reference codes to compare to the survey code. The RUC concluded that CPT code 93654 should be valued at the 25th percentile work RVU as supported by the resurvey. The RUC recommends a work RVU of 18.10 for CPT code 93654.

93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 63 cardiac electrophysiologists and recommends the survey 25th percentile work RVU of 7.00 for CPT code 93655. The RUC recommends 60 minutes of intra-service time for this add-on service.

To support a work value of 7.00, the RUC compared the survey code to CPT code 93592 Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure) (work RVU= 8.00, intra-service and total time of 60 minutes) and noted that both add-on codes have identical times, whereas the reference code involves somewhat more intense physician work. The RUC also compared the survey code to CPT code 34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) (work RVU= 7.00, intra-service and total time of 60 minutes) and noted that both services have identical times. The RUC concluded that CPT code 93655 should be valued at the 25th percentile work RVU as supported by the resurvey. The RUC recommends a work RVU of 7.00 for CPT code 93655.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

93656 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3- dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and His bundle recording, when performed The RUC reviewed the survey results from 61 cardiac electrophysiologists and recommends the survey 25th percentile work RVU of 17.00 for CPT code 93656. The RUC recommends 35 minutes of pre-service evaluation, 3 minutes of pre-service positioning, 15 minutes of pre-service scrub/dress/wait time, 180 minutes of intra-service time and 30 minutes of immediate post-service time. The RUC noted that CPT code 93656 was revised to now bundle the physician work of CPT codes 93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) and 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure), which previously were separately reported add-on services.

To justify a value of 17.00, the RUC compared the survey code to CPT code 93581 Percutaneous transcatheter closure of a congenital ventricular septal defect with implant (work RVU= 24.39, intra-service time of 180 minutes, total time of 270 minutes) and noted that both services involve an identical amount of intra-service time, whereas the reference code involves slightly more total time and is also slightly more intense to perform. The RUC also compared the survey code to CPT code 33978 Removal of ventricular assist device; extracorporeal, biventricular (work RVU= 25.00, intra-service time of 200, total time of 355) and noted that the reference code involves 20 more minutes of intra-service time and 92 more minutes of total time, justifying a lower valuation for the survey code. The specialty noted and the RUC concurred that there are very few major surgical procedures that comprise 000-day or XXX global periods to use as reference codes to compare to this survey code. The RUC concluded that CPT code 93656 should be valued at the 25th percentile work RVU as supported by the resurvey. The RUC recommends a work RVU of 17.00 for CPT code 93656.

93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 61 cardiac electrophysiologists and recommends the survey 25th percentile work RVU of 7.00 for CPT code 93657. The RUC recommends 60 minutes of intra-service time for this add-on service.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

To support a work value of 7.00, the RUC compared the survey code to CPT code 93592 Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure) (work RVU= 8.00, intra-service and total time of 60 minutes) and noted that both add-on codes have identical times, whereas the reference code involves somewhat more intense physician work. The RUC also compared the survey code to CPT code 34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) (work RVU= 7.00, intra-service and total time of 60 minutes) and noted that both services have identical times. The RUC concluded that CPT code 93657 should be valued at the 25th percentile work RVU as supported by the resurvey. The RUC recommends a work RVU of 7.00 for CPT code 93657.

Affirmation of RUC Recommendations The RUC reviewed the specialty societies’ request to affirm the recent RUC valuations for CPT codes 93613, 93621 and 93662. The RUC noted that for 93613, this is also the code’s current 2021 CMS value. For code 93621, this service was surveyed for the October 2020 RUC meeting for CY 2022 and represents a reduction compared to the current 2021 CMS value.

For code 93662, the RUC recommendation would represent an increase compared to the current 2021 CMS value. In the CY 2021 Medicare Physician Payment Schedule Final Rule, CMS’ rationale for not accepting the RUC recommendation and instead implementing a lower value for 93662 was the 45 percent decrease in total time from when the service was previously surveyed in 2000. The Agency’s 1.44 work value was derived from using a work value crosswalk to code 92979 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure). Unfortunately, the coronary IVUS crosswalk code (92979) that CMS had used to determine an alternate valuation was flawed because the nature of the services performed, intensity and work involved are different, with intracardiac echocardiography (ICE) and intravascular ultrasound (IVUS) performed in different parts of the heart for different reasons. Coronary IVUS is performed inside the coronary arteries to guide diagnostic catheterization and/or percutaneous coronary interventions. ICE is used to provide high-resolution real-time visualization of cardiac structures, continuous monitoring of a catheter location within the heart. It commonly guides trans-septal puncture where the operator creates a hole in the septum of the heart to gain access to the other cardiac chambers on the other side of the heart and is useful for early recognition of procedural complications, such as pericardial effusion or thrombus formation. ICE remains highly technical in nature and requires the patient to be anesthetized, which is not required in IVUS use. ICE is most used with atrial fibrillation ablations, a highly technical and challenging service, this reinforces the intensity of ICE.

The RUC recommendation for CPT code 93662 was based on the survey 25th percentile work RVU from robust survey results of 42 cardiologists as well as a favorable comparison to code 34713 Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure) (work RVU = 2.50 and intra-service time of 20 minutes) and MPC code 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (work RVU = 2.65 and intra-service time of 30 minutes). Both reference services bracket code 93662 in both physician work and time.

The RUC recommends affirming the recent RUC-recommended work RVU of 5.23 for CPT code 93613, 1.75 for CPT code 93621 and 2.53 for CPT code 93662. CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Practice Expense No direct practice expense inputs are recommended for CPT codes 93653-93657 as they are facility-only services.

Work Neutrality The RUC’s recommendation for this family of codes will result in an overall work savings that should be redistributed back to the Medicare conversion factor.

CPT Tracking Global Work RVU Code Number CPT Descriptor Period Recommendation

Medicine Cardiovasular Intracardiac Electrophysiological Procedures/Studies

Y1 ZZZ 5.23 ✚93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately (No Change) in addition to code for primary procedure) (Affirmed February 2017 RUC recommendation)

(Use 93613 in conjunction with 93620, 93653, 93656)

(Do not report 93613 in conjunction with 93609, 93654) Y2 ZZZ 1.75 ✚93621 Comprehensive electrophysiologic evaluation including insertion and

repositioning of multiple electrode catheters with induction or (Affirmed October 2020 RUC attempted induction of arrhythmia; with left atrial pacing and recording recommendation) from coronary sinus or left atrium (List separately in addition to code

for primary procedure)

(Use 93621 in conjunction with 93620, 93653, 93654) (Do not report 93621 in conjunction with 93656)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

93653 Y3 000 15.00 Comprehensive electrophysiologic evaluation including with insertion

and repositioning of multiple electrode catheters, induction or

attempted induction of an arrhythmia with right atrial pacing and

recording, and catheter ablation of arrhythmogenic focus, including with intracardiac electrophysiologic 3-dimensional mapping, induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, (when necessary), left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed (when necessary),with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo- tricuspid isthmus or other single atrial focus or source of atrial re-entry (Do not report 93653 in conjunction with 93600, 93602, 93603, 93610, 93612, 93613, 93618, 93619, 93620, 93621, 93642, 93654, 93656) 93654 Y4 000 18.10 with treatment of ventricular tachycardia or focus of

ventricular ectopy including intracardiac

electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed (Do not report 93654 in conjunction with 93279-93284, 93286- 93289, 93600-93603, 93609, 93610, 93612, 93613, 93618-93620, 93622, 93642, 93653, 93656) (f)93655 Y5 ZZZ 7.00 Intracardiac catheter ablation of a discrete mechanism of arrhythmia

which is distinct from the primary ablated mechanism, including repeat

diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) (Use 93655 in conjunction with 93653, 93654, 93656)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

93656 Y6 000 17.00 Comprehensive electrophysiologic evaluation including transseptal

catheterizations, insertion and repositioning of multiple electrode

catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3- dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, when necessary, right ventricular pacing/recording, when necessary, and His bundle recording, when performed necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation (Do not report 93656 in conjunction with 93279, 93280, 93281, 93282, 93283, 93284, 93286, 93287, 93288, 93289, 93462, 93600, 93602, 93603, 93610, 93612, 93613, 93618, 93619, 93620, 93621, 93653, 93654, 93662) (f)93657 Y7 Additional linear or focal intracardiac catheter ablation of the left or ZZZ 7.00 right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) (Use 93657 in conjunction with 93656) Y8 Intracardiac echocardiography during therapeutic/diagnostic ZZZ 2.53 ✚93662 intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) (Affirmed May 2019 RUC recommendation)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Elements of Cardiac Ablation Codes 93653 SVT Ablation 93654 VT Ablation 93656 AF Ablation Procedure/Services included Inherent Bundled Not Inherent Bundled Not Inherent Bundled Not with Ablations Bundled, Bundled, Bundled, Sometimes Sometimes Sometimes Performed Performed Performed Insert/reposition multiple X X X catheters Transseptal catheterization(s) X (93462) Induction or attempted X X X induction of arrhythmia with Right Atrial pacing and recording Intracardiac ablation of X X X arrhythmia SVT Ablation X VT Ablation X AF ablation X Intracardiac 3d mapping X X X (93613) Right Ventricular pacing and X X X recording Left Atrial pacing and X X X recording from coronary sinus or Left Atrium (93612) His Bundle recording X X X Left Ventricular pacing and X recording Intracardiac X X X Echocardiography (93662)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 93653 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93653 Tracking Number Y1 Original Specialty Recommended RVU: 15.00 Presented Recommended RVU: 15.00 Global Period: 000 Current Work RVU: 14.75 RUC Recommended RVU: 15.00

CPT Descriptor: Comprehensive electrophysiologic evaluation including with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and his bundle recording, when performed treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry (Do not report 93653 in conjunction with 93600, 93602, 93603, 93610, 93612, 93613, 93618, 93619, 93620, 93621, 93642, 93654, 93656)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 64-year-old female has recurrent palpitations. an event monitor has documented supraventricular tachycardia (svt). a comprehensive electrophysiologic evaluation with catheter ablation is ordered.

Percentage of Survey Respondents who found Vignette to be Typical: 100%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: The procedure and the risks, benefits, and alternatives associated with electrophysiology testing and supraventricular tachycardia ablation are explained to the patient. Management of antiarrhythmic medications is communicated to the patient. Arrangements are made for the X-ray technician, electrophysiology laboratory technician, and nurse. Informed consent is obtained. The patient is evaluated on the day of the procedure with a history and physical examination. Preprocedure laboratory testing is reviewed as well as current medications and changes in health status.

Description of Intra-Service Work: Local analgesia is administered along with anesthesia appropriate to the patient including moderate sedation. Venous access is obtained. Arterial access to monitor blood pressure and to facilitate retrograde aortic access to the left ventricle may be obtained. Multi-electrode catheters are advanced from the access sheaths and into the respective cardiac chambers where they will be used to pace and record. Pacing and sensing is performed in the right atrium, left atrium, and right ventricle. His bundle recording is obtained. Refractory periods are measured. Attempts at arrhythmia induction are performed via maneuvers that include burst pacing and premature pacing using programmed electrical stimulation at multiple drive cycle lengths from multiple atrial and ventricular sites.

Once the SVT is induced, pacing maneuvers are performed to elucidate the mechanism of the tachycardia. A combination of diagnostic maneuvers is performed and a high definition anatomical map of the chamber(s) of interest is generated. Voltage and electrical activation in the arrhythmia and/or in sinus rhythm is performed to identify normal activation, location of scar, and mechanism of the arrhythmia. 3-dimensional mapping activation and voltage mapping may be performed to assist in identifying the arrhythmia mechanism, substrate, cardiac anatomy, and to guide catheter ablation. Catheter ablation may then be performed. An ablation catheter is maneuvered from the sites of vascular access to the appropriate cardiac location to facilitate delivery of ablative energy. Multiple lesions are delivered to ensure eradication of the arrhythmia focus and to provide consolidation lesions in the surrounding tissue.

CPT Code: 93653 During the course of an electrophysiology procedure, an arrhythmia is induced that requires use of advanced 3D computer mapping system to assist in identifying the arrhythmia circuit, localizing the origin (for focal arrhythmias) or the critical isthmus (reentrant arrhythmias). The 3D mapping system is calibrated, and recordings are made during sinus rhythm (to identify normal activation and location of scar) and during each distinct arrhythmia. The physician then analyzes the computer-generated map, ensuring that electrograms are annotated correctly and that the display parameters are correct for the specific arrhythmia being mapped. Based upon the data from the 3D mapping system, endocardial electrograms, surface ECG and the response of the SVT to pacing maneuvers, the ablation catheter is advanced to the point of earliest activation, localized by the mapping system, to identify a mid-diastolic potential, Kent potential, and/or similar paced maps. When a reentrant circuit is identified, entrainment mapping studies are performed and evaluated to confirm the catheter location is within the reentrant circuit. Radiofrequency (or cryo) ablation is then performed. If initial mapping in one chamber does not lead to complete identification of the essential arrhythmia circuit (either based on analysis of the map or based on incomplete ablation result, then the mapping catheter(s) is/are moved into another cardiac chamber and an additional 3D map is generated to aid in diagnosis; this is repeated until the arrhythmia mechanism is fully characterized and ablation is deemed completely successful. A final report that includes the mapping procedure and findings is prepared.

To record left atrial activity, femoral venous access site is already prepared for related procedure. Achieve central venous access, place a sheath in the femoral vein using standard percutaneous techniques, changing to subclavian or jugular access if that fails. Introduce the catheter into the sheath and advance into the right atrium where the ostium of the coronary sinus is engaged. Advance the catheter into the coronary sinus. Use the multielectrode catheter to record electrical activity from the left atrium and, at times, pace the left atrium to attempt arrhythmia induction. Reposition the catheter as necessary throughout the course of the cardiac electrophysiology procedure to optimize recordings and pacing thresholds. At the conclusion of the procedure, remove the catheter. Include a description of this additional work and catheter use and associated findings in the procedure report.

Throughout the ablation the patient is monitored for hemodynamic compromise due to cardiac perforation, - or tachyarrhythmias, embolic phenomena, or damage to cardiac or vascular structures. Following the ablation portion of the procedure, repeat electrophysiologic testing is performed to assess the outcome of ablation using decremental, burst, and premature pacing maneuvers. These are again repeated following a 30-minute waiting period following the conclusion of the final ablation lesion. If the tachycardia demonstrates recovery or incomplete suppression, then repeat mapping and ablation are performed as described above. These steps are repeated until the tachycardia is rendered durably suppressed. Sheaths are removed, appropriate hemostasis is achieved, and follow-up assessment of the patient for any complications is performed.

Description of Post-Service Work: The patient is monitored in the recovery unit for delayed complications. Results of the procedure are discussed with the patient and the patient's family, and postprocedure assessments are performed. CPT Code: 93653 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Richard Wright, MD; Thad Waites, MD; Edward Tuohy, MD; Mark Schoenfeld, MD; Presenter(s): David Slotwiner, MD; Christopher Liu, MD Specialty American College of Cardiology & Heart Rhythm Society Society(ies): CPT Code: 93653

Sample Size: 1036 Resp N: 62 Description of randomly selected electrophysiologists from the two societies Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 25.00 40.00 50.00 200.00 Survey RVW: 7.25 15.00 18.00 23.25 37.00 Pre-Service Evaluation Time: 31.00 Pre-Service Positioning Time: 15.00 Pre-Service Scrub, Dress, Wait Time: 15.00 Intra-Service Time: 3.00 120.00 120.00 150.00 360.00 Immediate Post Service-Time: 30.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 4-FAC Difficult Patient/Difficult Procedure

CPT Code: 93653 Recommended Physician Work RVU: 15.00 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 31.00 40.00 -9.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 15.00 20.00 -5.00 Intra-Service Time: 120.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9B General Anes or Complex Regional Blk/Cmplx Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 30.00 33.00 -3.00

CPT Code: 93653

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93580 000 17.97 RUC Time

CPT Descriptor Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 33340 000 14.00 RUC Time

CPT Descriptor Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 37244 000 13.75 RUC Time 12,731 CPT Descriptor 1 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 93653 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 20 % of respondents: 32.2 %

Number of respondents who choose 2nd Key Reference Code: 16 % of respondents: 25.8 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93653 93580 33340

Median Pre-Service Time 58.00 30.00 40.00

Median Intra-Service Time 125.00 120.00 90.00

Median Immediate Post-service Time 30.00 60.00 30.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 213.00 210.00 160.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 20% 45% 35%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 25% 75% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 5% 10% 85%

Physical effort required 0% 40% 60% CPT Code: 93653

Psychological Stress Less Identical More

• The risk of significant complications, 0% 35% 65% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 6% 19% 50% 25%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 40% 60% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 47% 53%

Physical effort required 13% 34% 53%

Psychological Stress Less Identical More

• The risk of significant complications, 13% 62% 25% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

History Background

When the Relativity Assessment Workgroup identified CPT code 93656 (atrial fibrillation ablation) due to its rapid increase in growth, the ACC and HRS reviewed the code and determined that certain work should be bundled into the existing code due to their being billed together more than 75% of the time. With continued review of 93656 and the related the volume data, the societies also identified that CPT 93653 (SVT ablation) should have services bundled into it before the codes are CPT Code: 93653 re-surveyed for upcoming RUC valuation. As a result, in October 2020, the ACC and HRS presented a code change application to the CPT Editorial Panel on codes: 93653, 93654, 93655, 93656, 93657. As indicated in the summary spreadsheet, revised 93653 is now a more comprehensive, bundled service that includes the work of 3D mapping (93613) and left atrial pacing/recording (93621). The societies surveyed members late 2020 and presented data in January 2021. Due to inconsistencies in the survey data and in order to better convey the bundled services to respondents, the ACC and HRS resurveyed members March 2021.

The ACC and HRS randomly surveyed cardiac electrophysiologists, as designated by membership rolls, on the newly created codes and entire family. The 000- and ZZZ-global day survey was completed by physicians who have experience with the service. To remedy the above-described shortcomings, the societies work with the Research Subcommittee to deploy several tactics to obtain more consistent survey results. First, fake/dummy codes were used in the survey so that respondents would not presume to know the code descriptors. Second, additional language noting the bundling was included in the survey invitation. Third, respondents were required to attest they had read and understood the new language before completing the survey.

The key reference code is 93580 for percutaneous transcatheter closure of a congenital interatrial communication. It was selected by approximately 32% of respondents. 80% of the respondents indicated that 93653 was more complex. The second reference code was 33340 for percutaneous transcatheter closure of left atrial appendage with endocardial implant. It was selected by over 25% of respondents. About 75% of the respondents indicated that 93653 was more intense/complex overall.

Rationale

In reviewing the survey data to develop work recommendations, the expert panel believes the data accurate reflects the newly bundled services, 93653 and 93656. The societies believe the technological advances made in patient care indicate survey respondents understood that 3D mapping and left atrial pacing were now inherent to 93653. After nearly a decade and many changes in technology and broader service dispersion have clearly altered the way this service is provided. Over time, the mapping systems have improved, now providing much more detailed and accurate anatomical and electrical activation mapping, often removing the need for fluoroscopy completely. Catheter technology has advanced, providing real-time assessment of the quality of contact between the catheter tip and the endocardial tissue. Last, the 3D mapping systems in conjunction with new catheter technology are now able to provide real-time assessment of the quality of radiofrequency ablation lesion formation. This feature has allowed operators to significantly shorten the duration of each radiofrequency application while also improving the quality of the lesions delivered. The results indicate survey respondents understood that 3D mapping and left atrial pacing were now inherent to 93653. After nearly a decade and many changes in technology and broader service dispersion, a reduction in intraservice times is logical for performing this procedure. The societies support the resurvey data and stand behind the 25th survey value.

While we recognize that in some ways the resurvey may be viewed as a failure, we believe the general consistency with the initial survey—demonstrating reductions in intraservice time—provides insights and a foundation to develop final recommendations for this family. First, with the additional information and tactics taken in the resurvey, we have no reason to believe respondents failed to understand the bundling that has occurred. Rather, we now have confidence that in the survey and the survey-based recommendations we make. Second, in digesting the data from the two surveys, we believe the reductions in time can, in fact, be explained by evolutions in technology and service dispersion, as discussed above. We can speak to this in more detail if helpful. Finally, the resurvey does provide a viable path forward for valuation, as the survey 25th-percentile work RVUs proceed in a reasonable progression that align with other services in the fee schedule. We recognize these recommendations produce an increase in intensity as the drop in time is not 1:1 proportionate with the drop in RVU. We believe that increase is best explained by the fact that several separately reported services are now bundled together, with work being done more quickly and several services being combined in a way that makes meaningful comparison to the prior intensity unhelpful.

Recommendation

During the January meeting, several RUC members questioned whether codes 93613, 93621 and 93662 should also be addressed in the recommendations for cardiac ablation services. These codes are bundled into CPT codes 93653 and/or 93656. Each was recently surveyed by the specialties and the RUC in 2017, 2020, 2019, respectively. As such, the societies recommend affirming the recent times and RVUs of these recently valued codes, as they remain separate in CPT for use in concert with other CPT codes.

CPT Code: 93653 Therefore, for code 93653 the societies recommend, the survey 25th of RVW of 15.00 with 49 minutes preservice time from package 4 with 14 minutes removed, 120 minutes intraservice time from the survey median, and 30 minutes postservice time with 3 minutes removed from package 9B. This logically aligns with the KRS 93580 in terms of IWPUT, total time, and intraservice time. Survey respondents felt 93580 was less complex and had a shorter preservice time than 93653. This recommendation also produces a work RVU savings from the current, component-coded services. The survey 25th percentile recommendation is further supported, as results from the original RUC survey and comparison to other codes (37227, 33340) from the fee schedule, as shown in the summary spreadsheet.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93653, 93613, 93621

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Cardiac Electrophysiology How often? Commonly

Specialty Cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 63642 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure is about twicethe Medicare-based claims volume.

Specialty Cardiac electrophysiology Frequency 50022 Percentage 78.59 %

Specialty Cardiology Frequency 11902 Percentage 18.70 %

Specialty Frequency 0 Percentage 0.00 %

CPT Code: 93653 Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 31,821 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure reflects 2019e Medicare-based claims.

Specialty Cardiac electrophysiology Frequency 25009 Percentage 78.59 %

Specialty Cardiology Frequency 5951 Percentage 18.70 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93653

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 93654 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93654 Tracking Number Y2 Original Specialty Recommended RVU: 18.10 Presented Recommended RVU: 18.10 Global Period: 000 Current Work RVU: 19.75 RUC Recommended RVU: 18.10

CPT Descriptor: Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording,left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed (Do not report 93654 in conjunction with 93279-93284, 93286-93289, 93600-93603, 93609, 93610, 93612, 93613, 93618- 93620, 93622, 93642, 93653, 93656)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 73-year-old male with a history of New York Heart Association Class III heart failure due to ischemic dilated cardiomyopathy (ef 25%) and prior myocardial infarction presents with recurrent implantable cardioverter- defibrillator (icd) therapies for drug-refractory ventricular tachycardia.

Percentage of Survey Respondents who found Vignette to be Typical: 94%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: The procedure and the risks, benefits, and alternatives associated with electrophysiology testing and ventricular tachycardia ablation are explained to the patient and the patient's family. Arrangements are made for the X-ray technician, electrophysiology laboratory technician, and nurse. The patient is evaluated on the day of the procedure with a history and physical examination and pre-procedure laboratory testing, medications, and changes in heath are reviewed. Informed consent is obtained. Direct current cardioversion/defibrillation, electrophysiology (EP), and ablation equipment is confirmed to be present and in proper working order. Fluoroscopic equipment that will be used to visualize catheter movements and location is tested. Three-dimensional mapping equipment is tested and confirmed to be functioning normally.

Description of Intra-Service Work: Local analgesia is administered. Patients with implantable cardioverter-defibrillators will have their devices reprogrammed and/or transiently deactivated at the start of the case so as to minimize adverse consequences resulting from electromagnetic interference from radiofrequency current application.

Venous access is obtained. Arterial access to monitor blood pressure and to facilitate retrograde aortic access to the left ventricle is obtained. Multi-electrode catheters are advanced from the access sheaths and into the respective cardiac chambers where they will be used to pace and record. Papillary muscles are also recorded in the three-dimensional anatomical ultrasound map. Pacing and sensing is performed in the right atrium and right ventricle. His bundle recording is obtained. Refractory periods are measured. Attempts at ventricular tachycardia induction are performed via burst pacing, decremental pacing, and premature pacing using programmed electrical stimulation at multiple drive cycle lengths from multiple ventricular sites. To record left atrial activity, femoral venous access site is already prepared for related procedure. Achieve central venous access, place a sheath in the femoral vein using standard percutaneous techniques, changing to subclavian or jugular access CPT Code: 93654 if that fails. Introduce the catheter into the sheath and advance into the right atrium where the ostium of the coronary sinus is engaged. Advance the catheter into the coronary sinus. Use the multielectrode catheter to record electrical activity from the left atrium and, at times, pace the left atrium to attempt arrhythmia induction. Reposition the catheter as necessary throughout the course of the cardiac electrophysiology procedure to optimize recordings and pacing thresholds. At the conclusion of the procedure, remove the catheter. Include a description of this additional work and catheter use and associated findings in the procedure report.

Once an arrhythmia is induced, pacing maneuvers are performed to elucidate the mechanism of the ventricular tachycardia. During the course of an electrophysiology procedure, an arrhythmia is induced that requires use of advanced 3D computer mapping system to assist in identifying the arrhythmia circuit, localizing the origin (for focal arrhythmias) or the critical isthmus (reentrant arrhythmias). The 3D mapping system is calibrated, and recordings are made during sinus rhythm (to identify normal activation and location of scar) and during each distinct arrhythmia. The physician then analyzes the computer-generated map, ensuring that electrograms are annotated correctly and that the display parameters are correct for the specific arrhythmia being mapped. Based upon the data from the 3D mapping system, endocardial electrograms, surface ECG and the response of the SVT to pacing maneuvers, the ablation catheter is advanced to the point of earliest activation, localized by the mapping system, to identify a mid-diastolic potential, Kent potential, and/or similar paced maps. When a reentrant circuit is identified, entrainment mapping studies are performed and evaluated to confirm the catheter location is within the reentrant circuit. Radiofrequency (or cryo) ablation is then performed. If initial mapping in one chamber does not lead to complete identification of the essential arrhythmia circuit (either based on analysis of the map or based on incomplete ablation result, then the mapping catheter(s) is/are moved into another cardiac chamber and an additional 3D map is generated to aid in diagnosis; this is repeated until the arrhythmia mechanism is fully characterized and ablation is deemed completely successful. Occasionally mapping of the epicardial surface of the heart is necessary. A final report that includes the mapping procedure and findings is prepared.

The electrical activation sequence is mapped with the three-dimensional electroanatomical mapping system and activation timing is superimposed upon the three-dimensional image previously obtained. Anticoagulation is administered once catheters have been placed on the left side of the heart. Once the ventricular tachycardia circuit is localized, a catheter is moved to the appropriate location or region of abnormal myocardium to deliver ablative energy. Multiple lesions are delivered to ensure eradication of the arrhythmia focus and to provide consolidation lesions in the surrounding tissue. Throughout the ablation the patient is monitored for hemodynamic compromise due to cardiac perforation, - or tachyarrhythmias, embolic phenomena, or damage to cardiac or vascular structures.

Following the ablation portion of the procedure, repeat electrophysiologic testing is performed to assess the outcome of ablation using decremental, burst, and premature pacing maneuvers. These are again repeated following a 30-minute waiting period following the conclusion of the final ablation lesion. If the tachycardia demonstrates recovery or incomplete suppression, then repeat mapping and ablation are performed as described above. These steps are repeated until the tachycardia is rendered durably suppressed. Following the ablation portion of the procedure, further electrophysiologic testing is performed to assess the outcome of ablation using decremental, burst, and premature pacing maneuvers. These are repeated following a 30-minute period following the conclusion of the final ablation lesion. Anticoagulation is reversed. Sheaths are removed, appropriate hemostasis is achieved, and follow-up assessment of the patient for any complications is performed. Patients with implantable cardioverter-defibrillators will have their devices reprogrammed to an active configuration with rates reprogrammed as necessary to treat any remaining arrhythmias.

Description of Post-Service Work: The patient is monitored in the recovery unit and then overnight in a telemetry unit for delayed complications. Results of the procedure are discussed with the patient and the patient's family, and postprocedure assessments are performed. CPT Code: 93654 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Richard Wright, MD; Thad Waites, MD; Edward Tuohy, MD; Mark Schoenfeld, MD; Presenter(s): David Slotwiner, MD; Christopher Liu, MD Specialty American College of Cardiology & Heart Rhythm Society Society(ies): CPT Code: 93654

Sample Size: 1036 Resp N: 63 Description of randomly selected electrophysiologists from the two societies Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 10.00 20.00 36.00 140.00 Survey RVW: 9.50 18.10 24.38 29.71 46.00 Pre-Service Evaluation Time: 40.00 Pre-Service Positioning Time: 15.00 Pre-Service Scrub, Dress, Wait Time: 15.00 Intra-Service Time: 5.00 170.00 200.00 240.00 515.00 Immediate Post Service-Time: 35.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 4-FAC Difficult Patient/Difficult Procedure

CPT Code: 93654 Recommended Physician Work RVU: 18.10 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 40.00 40.00 0.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 15.00 20.00 -5.00 Intra-Service Time: 200.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9B General Anes or Complex Regional Blk/Cmplx Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 33.00 33.00 0.00

CPT Code: 93654

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93580 000 17.97 RUC Time

CPT Descriptor Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93590 000 21.70 RUC Time

CPT Descriptor Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 37244 000 13.75 RUC Time 12,731 CPT Descriptor 1 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

Number of respondents who choose Top Key Reference Code: 21 % of respondents: 33.3 %

Number of respondents who choose 2nd Key Reference Code: 20 % of respondents: 31.7 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93654 93580 93590

Median Pre-Service Time 58.00 30.00 58.00

Median Intra-Service Time 200.00 120.00 135.00

Median Immediate Post-service Time 33.00 60.00 30.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 291.00 210.00 223.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 5% 24% 71%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 5% 95% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 5% 95%

Physical effort required 5% 24% 71% CPT Code: 93654

Psychological Stress Less Identical More

• The risk of significant complications, 0% 10% 90% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 15% 10% 75%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 10% 90% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 18% 85%

Physical effort required 0% 25% 75%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 15% 85% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

History Background

When the Relativity Assessment Workgroup identified CPT code 93656 (atrial fibrillation ablation) due to its rapid increase in growth, the ACC and HRS reviewed the code and determined that certain work should be bundled into the existing code due to their being billed together more than 75% of the time. With continued review of 93656 and the related the volume data, the societies also identified that CPT 93653 (SVT ablation) should have services bundled into it before the codes are CPT Code: 93654 re-surveyed for upcoming RUC valuation. As a result, in October 2020, the ACC and HRS presented a code change application to the CPT Editorial Panel on codes: 93653 and 93656, and were tasked in surveying the other codes in the family: 93654, 93655, and 93657. The societies surveyed members late 2020 and presented data in January 2021. Due to inconsistencies in the survey data and in order to better convey the bundled services to respondents, the ACC and HRS resurveyed members March 2021.

The key reference code is 93580 for percutaneous transcatheter closure of a congenital interatrial communication. It was selected by approximately 33% of respondents. Approximately 95% of the respondents indicated that 93654 was more complex. The second reference code was 93590 for percutaneous transcatheter closure of paravalvular leak. It was selected by approximately 32% of respondents. About 85% of the respondents indicated that 93654 was more intense/complex overall.

Rationale

In reviewing the resurvey data to develop work recommendations, the expert panel believes the data does accurately reflect the newly bundled services, 93653 and 93656. The societies believe the technological advances made in patient care indicate survey respondents understood that 3D mapping and left atrial pacing were now inherent to 93653. After nearly a decade and many changes in technology and broader service dispersion have clearly altered the way this service is provided. Over time, the mapping systems have improved, now providing much more detailed and accurate anatomical and electrical activation mapping, often removing the need for fluoroscopy completely. Catheter technology has advanced, providing real-time assessment of the quality of contact between the catheter tip and the endocardial tissue. Last, the 3D mapping systems in conjunction with new catheter technology are now able to provide real-time assessment of the quality of radiofrequency ablation lesion formation. This feature has allowed operators to significantly shorten the duration of each radiofrequency application while also improving the quality of the lesions delivered. The results indicate survey respondents understood that 3D mapping and left atrial pacing were now inherent to 93653. After nearly a decade and many changes in technology and broader service dispersion, a reduction in intraservice times is logical for performing this procedure. The societies support the resurvey data and stand behind the 25th survey value.

Recommendation

Therefore, for code 93654 the societies recommend the survey 25th RVU of 18.10 with 58 minutes preservice time from package 4 with five minutes removed, 200 minutes intraservice time from the survey median, and 33 minutes postservice time from Post Service Package 9B. This value builds some increment from 93653 that accounts for longer time. The survey 25th percentile recommendation is further supported by results from the original RUC survey and comparison codes as shown in the summary spreadsheet.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93654

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Cardiac Electrophysiology How often? Commonly

Specialty Cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 15500 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure is about twice as likely as Medicare based claims.

Specialty Cardiac electrophysiology Frequency 11935 Percentage 77.00 %

Specialty Cardiology Frequency 3147 Percentage 20.30 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 7,750 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure reflects 2019 eMedicare based claims. CPT Code: 93654

Specialty Cardiac electrophysiology Frequency 5968 Percentage 77.00 %

Specialty Cardiology Frequency 1573 Percentage 20.29 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93654

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 93655 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93655 Tracking Number Y3 Original Specialty Recommended RVU: 7.00 Presented Recommended RVU: 7.00 Global Period: ZZZ Current Work RVU: 7.50 RUC Recommended RVU: 7.00

CPT Descriptor: Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) (Use 93655 in conjunction with 93653, 93654, 93656)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 64-year-old female has undergone successful ablation of her atrial supraventricular tachycardia (SVT) focus (reported separately). Attempts to re-induce that arrhythmia reveal an additional atrial focus (also reported separately). A decision is made to ablate this additional focus following its discovery.

Percentage of Survey Respondents who found Vignette to be Typical: 100%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work:

Description of Intra-Service Work: A full electrophysiologic study and ablation procedure has been performed. Diagnostic and ablative electrophysiology (EP) catheters are in cardiac chambers. During the course of the post-ablation electrophysiologic evaluation, a second (or greater) arrhythmia is identified. For example, if the primary tachycardia ablated was atrioventricular (AV) nodal reentrant tachycardia and during post ablation testing, an atrial tachycardia, atrial flutter, or accessory pathway with orthotropic reentry tachycardia is identified, this would be considered a separate mechanism of tachycardia. Pacing maneuvers are performed to define the mechanism(s) of the new tachycardia(s). Mapping is performed to define the optimal ablation site or sites that are distinct from the initial ablation site(s). Catheter ablation of this distinct mechanism of tachycardia is performed at its origin. Multiple lesions are delivered to ensure eradication of the arrhythmia focus and to provide consolidation lesions in the surrounding tissue.

During the course of an electrophysiology procedure, an arrhythmia is induced that requires use of advanced 3D computer- assisted mapping system to localize the arrhythmia origin. The mapping system is placed in the cardiac chamber of interest using standard percutaneous techniques. The system is calibrated, and recordings are made during sinus rhythm to identify normal activation and location of scar during each distinct tachycardia. The computer-generated map is displayed, modifications are made in the computer parameters and display, and the tachycardia origin is identified. The ablation catheter is moved to the point of early activation, localized by the mapping system, to identify a mid-diastolic potential, Kent potential, and/or similar paced maps. When a reentrant circuit is identified, entrainment mapping studies are performed and evaluated to confirm the catheter location is within the reentrant circuit. Additional mappings are made to confirm arrhythmia origin and to study additional arrhythmias at the conclusion of the procedure. A final report that includes the mapping procedure and findings is prepared.

To record left atrial activity, femoral venous access site is already prepared for related procedure. Achieve central venous access, place a sheath in the femoral vein using standard percutaneous techniques, changing to subclavian or jugular access if that fails. Introduce the catheter into the sheath and advance into the right atrium where the ostium of the coronary sinus is CPT Code: 93655 engaged. Advance the catheter into the coronary sinus. Use the multielectrode catheter to record electrical activity from the left atrium and, at times, pace the left atrium to attempt arrhythmia induction. Reposition the catheter as necessary throughout the course of the cardiac electrophysiology procedure to optimize recordings and pacing thresholds. At the conclusion of the procedure, remove the catheter. Include a description of this additional work and catheter use and associated findings in the procedure report.

Description of Post-Service Work: CPT Code: 93655 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Richard Wright, MD; Thad Waites, MD; Edward Tuohy, MD; Mark Schoenfeld, MD; Presenter(s): David Slotwiner, MD; Christopher Liu, MD Specialty American College of Cardiology & Heart Rhythm Society Society(ies): CPT Code: 93655

Sample Size: 1036 Resp N: 63 Description of randomly selected electrophysiologists from the two societies Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 11.00 25.00 50.00 120.00 Survey RVW: 3.28 7.00 8.00 10.00 20.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 14.00 45.00 60.00 69.00 120.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 93655 Recommended Physician Work RVU: 7.00 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 60.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 93655

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 35306 ZZZ 9.25 RUC Time

CPT Descriptor Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 37237 ZZZ 4.25 RUC Time

CPT Descriptor Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 93592 ZZZ 8.00 RUC Time

CPT Descriptor Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure)

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 93655 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 15 % of respondents: 23.8 %

Number of respondents who choose 2nd Key Reference Code: 13 % of respondents: 20.6 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93655 35306 37237

Median Pre-Service Time 0.00 0.00 1.00

Median Intra-Service Time 60.00 90.00 45.00

Median Immediate Post-service Time 0.00 0.00 1.00 Median Critical Care Time 0.0 0.00 0.00 Median Other Hospital Visit Time 0.0 0.00 0.00 Median Discharge Day Management Time 0.0 0.00 0.00 Median Office Visit Time 0.0 0.00 0.00 Prolonged Services Time 0.0 0.00 0.00 Median Subsequent Observation Care Time 0.0 0.00 0.00 Median Total Time 60.00 90.00 47.00 Other time if appropriate

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 40% 53% 7%

Mental Effort and Judgment Less Identical More

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 33% 67%

Physical effort required 0% 71% 29% CPT Code: 93655

Psychological Stress Less Identical More

• The risk of significant complications, 0% 33% 67% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 54% 31% 15%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 50% 50% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 50% 50%

Physical effort required 0% 67% 33%

Psychological Stress Less Identical More

• The risk of significant complications, 16% 31% 53% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

History Background

When the Relativity Assessment Workgroup identified CPT code 93656 (atrial fibrillation ablation) due to its rapid increase in growth, the ACC and HRS reviewed the code and determined that certain work should be bundled into the existing code due to their being billed together more than 75% of the time. With continued review of 93656 and the related the volume data, the societies also identified that CPT 93653 (SVT ablation) should have services bundled into it before the codes are CPT Code: 93655 re-surveyed for upcoming RUC valuation. As a result, in October 2020, the ACC and HRS presented a code change application to the CPT Editorial Panel on codes: 93653 and 93656, and were tasked in surveying the other codes in the family: 93654, 93655, and 93657. The societies surveyed members late 2020 and presented data in January 2021. Due to inconsistencies in the survey data and in order to better convey the bundled services to respondents, the ACC and HRS resurveyed members March 2021.

The key reference code is 35306 for thromboendarterectomy. It was selected by approximately 24% of respondents. 60% of the respondents indicated that 93655 was more complex. The second reference code was 32737 for Transcatheter placement of an intravascular stent(s). It was selected by approximately 20% of respondents. About 46% of the respondents indicated that 93655 was more intense/complex overall.

Rationale

Recommendation

While this code descriptor did not change, its use as an additional ablation with a new base code that includes 3D mapping and left-atrial pacing, changing the service. The same 3D mapping and left-atrial pacing elements that were bundled into 93653 should now typically be considered to be included into this service, since those elements occur throughout the additional ablation. Therefore, for code 93655 the societies recommend, the 25th survey value of 7.00 RVW with 60 minutes intraservice time. This is sensibly below the KRS. This value also brings the IWPUT for 93655 in nearly identical alignment with that of 93653. This recommended value can also be supported by comparison to the percutaneous transcatheter closure of paravalvular leak, 93592; open iliac artery exposure, 34820; and transcatheter intracardiac shunt creation, 33746, as seen in the summary spreadsheet.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93655

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Cardiac Electrophysiology How often? Commonly

Specialty Cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 62294 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure is about twice as likely as Medicare based claims.

Specialty Cardiac electrophysiology Frequency 50085 Percentage 80.40 %

Specialty Cardiology Frequency 10715 Percentage 17.20 %

Specialty Frequency 0 Percentage 0.00 %

CPT Code: 93655 Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 31,821 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure reflects Medicare based claims.

Specialty Cardiac electrophysiology Frequency 25042 Percentage 78.69 %

Specialty Cardiology Frequency 5474 Percentage 17.20 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93655

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 93656 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93656 Tracking Number Y4 Original Specialty Recommended RVU: 17.00 Presented Recommended RVU: 17.00 Global Period: 000 Current Work RVU: 19.77 RUC Recommended RVU: 17.00

CPT Descriptor: Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and his bundle recording, when performed (Do not report 93656 in conjunction with 93279, 93280, 93281, 93282, 93283, 93284, 93286, 93287, 93288, 93289, 93462, 93600, 93602, 93603, 93610, 93612, 93613, 93618, 93619, 93620, 93621, 93653, 93654, 93662)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 62-year-old male with a history of hypertension has recurrent atrial fibrillation. despite rate and rhythm control with antiarrhythmic drugs, he remains symptomatic. a comprehensive electrophysiologic evaluation with transeptal catheterization and catheter ablation by pulmonary vein isolation for atrial fibrillation is ordered.

Percentage of Survey Respondents who found Vignette to be Typical: 95%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: A three-dimensional imaging study such as cardiac magnetic resonance imaging (MRI) or computed tomography (CT) scanning may be obtained prior to the procedure to assess atrial size and for pulmonary vein anatomic variants. The procedure and the risks, benefits, and alternatives associated with electrophysiology testing and atrial fibrillation ablation are explained to the patient and the patient's family. Management of antiarrhythmic medications is communicated to the patient. Arrangements are made for the X-ray technician, electrophysiology laboratory technician, and nurse. The patient is evaluated on the day of the procedure with a history and physical examination and pre-procedure laboratory, medications, and change in health status are reviewed with careful attention to the degree of anticoagulation. Informed consent is obtained. Direct current cardioversion/defibrillation, electrophysiology (EP), and ablative equipment is confirmed to be present and in proper working order. Fluoroscopic equipment that will be used to visualize catheter movements and location is tested.

Description of Intra-Service Work: Local analgesia is administered. Venous access is obtained. Arterial access to monitor blood pressure and to retrograde aortic access to the left ventricle may be obtained. By means of the venous access sites, multi-electrode catheters are positioned in specific cardiac chambers. An intracardiac echocardiographic probe is advanced into the heart and imaging of the heart and pericardium is performed: specific structures visualized include: right atrium, tricuspid valve, right ventricle, left atrium, aortic valve, left ventricle, pulmonary veins (left upper, left lower, right upper, right lower), pericardium, superior vena cava, coronary sinus. Intracardiac echocardiography may be used to guide catheter manipulation, guide transseptal puncture, provide visualization of catheter contact during mapping and ablation, and observe for complications throughout the procedure. The intracardiac echo catheter may be placed into the left atrium or right ventricle for additional imaging planes. One or two transseptal catheterizations are performed to achieve access and facilitate placement of both a circular mapping catheter and an ablation catheter in the left atrium.

CPT Code: 93656 Additional anticoagulation is administered. Level of anticoagulation is monitored throughout the procedure and additional anticoagulation is administered as needed. Conduction intervals and refractory periods are measured and arrhythmia induction attempted. His bundle recording and ventricular pacing and sensing are performed. A mapping catheter is passed into the left atrium and pulmonary vein conduction is assessed and recorded. Selective venography of the pulmonary veins may be performed to define anatomy. A high definition 3D anatomical map of the chamber(s) of interest is generated. Voltage and relative electrical activation in the arrhythmia and/or sinus may be performed to identify normal activation, location of scar, and mechanism of arrhythmia. Importation, segmentation, and/or registration to the three dimensional map of a MRI/CT scan may be performed. High output pacing is performed to prevent and/or monitor for phrenic nerve damage during ablation. Catheter ablation is then performed to achieve pulmonary vein isolation. Point lesions or balloon administered lesions encircling the pulmonary vein region are created that guided by anatomical mapping and electrical signals provided by a circular mapping catheter. Pulmonary vein isolation, as measured by the circular mapping catheter as well as loss of tissue voltage and tissue pacing capture are the measured endpoints.

Throughout the ablation the patient is monitored hemodynamic compromise due to cardiac perforation, - or tachyarrhythmias, embolic phenomena, thrombus formation, or damage to cardiac or vascular structures, including meticulous monitoring for lesion delivery within the pulmonary vein or close to the esophagus. Following the ablation portion of the procedure, further electrophysiologic testing is performed to assess the outcome of ablation. These are again repeated following a 30-minute waiting period following the conclusion of the final ablation lesion. If the pulmonary veins demonstrate recovery of conduction, then repeat mapping and ablation are performed as described above. These steps are repeated until the pulmonary veins are rendered durably isolated. Once electrophysiology testing and ablation are completed, anticoagulation is reversed. Post procedure, sheaths are removed, appropriate hemostasis is achieved, and follow-up assessment of the patient for any complications is performed.

Description of Post-Service Work: The patient is monitored in the recovery unit and then overnight in a telemetry unit for delayed complications. Results of the procedure are discussed with the patient and the patient's family and a postprocedure assessment is performed. CPT Code: 93656 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Richard Wright, MD; Thad Waites, MD; Edward Tuohy, MD; Mark Schoenfeld, MD; Presenter(s): David Slotwiner, MD; Christopher Liu, MD Specialty American College of Cardiology & Heart Rhythm Society Society(ies): CPT Code: 93656

Sample Size: 1036 Resp N: 61 Description of randomly selected electrophysiologists from the two societies Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 30.00 60.00 100.00 214.00 Survey RVW: 8.85 17.00 21.50 28.48 46.00 Pre-Service Evaluation Time: 35.00 Pre-Service Positioning Time: 15.00 Pre-Service Scrub, Dress, Wait Time: 15.00 Intra-Service Time: 4.00 150.00 180.00 210.00 380.00 Immediate Post Service-Time: 30.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) 4-FAC Difficult Patient/Difficult Procedure

CPT Code: 93656 Recommended Physician Work RVU: 17.00 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 35.00 40.00 -5.00 Pre-Service Positioning Time: 3.00 3.00 0.00 Pre-Service Scrub, Dress, Wait Time: 15.00 20.00 -5.00 Intra-Service Time: 180.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) 9B General Anes or Complex Regional Blk/Cmplx Proc

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 30.00 33.00 -3.00

CPT Code: 93656

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93580 000 17.97 RUC Time

CPT Descriptor Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93590 000 21.70 RUC Time

CPT Descriptor Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 37244 000 13.75 RUC Time 12,731 CPT Descriptor 1 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 0.00

CPT Descriptor

Number of respondents who choose Top Key Reference Code: 23 % of respondents: 37.7 %

Number of respondents who choose 2nd Key Reference Code: 17 % of respondents: 27.8 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93656 93580 93590

Median Pre-Service Time 63.00 30.00 58.00

Median Intra-Service Time 210.00 120.00 135.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 17% 35% 48%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 27% 73% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 5% 95%

Physical effort required 10% 29% 59% CPT Code: 93656

Psychological Stress Less Identical More

• The risk of significant complications, 4% 26% 70% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 12% 23% 65%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 18% 82% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 18% 82%

Physical effort required 0% 29% 71%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 18% 82% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

History Background

When the Relativity Assessment Workgroup identified CPT code 93656 (atrial fibrillation ablation) due to its rapid increase in growth, the ACC and HRS reviewed the code and determined that certain work should be bundled into the existing code due to their being billed together more than 75% of the time. With continued review of 93656 and the related the volume data, the societies also identified that CPT 93653 (SVT ablation) should have services bundled into it before the CPT Code: 93656 codes are re-surveyed for upcoming RUC valuation. As a result, in October 2020, the ACC and HRS presented a code change application to the CPT Editorial Panel on codes: 93653, 93654, 93655, 93656, 93657. As indicated in the summary spreadsheet, revised 93653 is now a more comprehensive, bundled service that includes the work of 3D mapping (93613) and left atrial pacing/recording (93621). The societies surveyed members late 2020 and presented data in January 2021. Due to inconsistencies in the survey data and in order to better convey the bundled services to respondents, the ACC and HRS resurveyed members March 2021.

The key reference code is 93580 for percutaneous transcatheter closure of a congenital interatrial communication. It was selected by approximately 38% of respondents. 83% of the respondents indicated that 93656 was more complex. The second reference code was 93590 percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve. It was selected by approximately 27% of respondents. About 88% of the respondents indicated that 93656 was more intense/complex overall.

Rationale

Recommendation

CPT Code: 93656

Therefore, for code 93656 the societies recommend, survey 25th percentile of 17.00 RVW with 53 minutes preservice time from package 4 with 10 minutes removed, 180 minutes intraservice time from the survey median, and 30 minutes postservice time from package 9B with 3 minutes removed. This recommendation produces a work RVU savings from the current, component-coded services. The survey 25th percentile recommendation is further supported summary spreadsheet and results from the original RUC survey support similar values.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: No

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93656

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Cardiac Electrophysiology How often? Commonly

Specialty Cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 106654 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure is about twice as likely as Medicare based claims.

Specialty Cardiac electrophysiology Frequency 92256 Percentage 86.50 %

Specialty Cardiology Frequency 13972 Percentage 13.10 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 53,327 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure reflects Medicare based claims. CPT Code: 93656

Specialty Cardiac electrophysiology Frequency 46128 Percentage 86.50 %

Specialty Cardiology Frequency 6986 Percentage 13.10 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93656

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 93657 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93657 Tracking Number Y5 Original Specialty Recommended RVU: 7.00 Presented Recommended RVU: 7.00 Global Period: ZZZ Current Work RVU: 7.50 RUC Recommended RVU: 7.00

CPT Descriptor: Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) (Use 93657 in conjunction with 93656)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 72-year-old male has symptomatic atrial fibrillation refractory to medical therapy. An electrophysiology (EP) study and ablation are performed to achieve pulmonary vein isolation (reported separately). Despite demonstration of electrical isolation of the pulmonary veins, atrial fibrillation continues.

Percentage of Survey Respondents who found Vignette to be Typical: 95%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work:

Description of Intra-Service Work: A full electrophysiologic study and ablation procedure has been performed for atrial fibrillation. Diagnostic and ablation catheters are present in cardiac chambers. Pulmonary vein isolation has been accomplished. An intracardiac echocardiographic probe has been advanced into the heart and imaging of the heart and pericardium is performed. Intracardiac echocardiography may be used to guide catheter manipulation, guide transseptal puncture, guide catheter manipulation and observe for complications throughout the procedure. Due to the presence of non- pulmonary vein sources of atrial fibrillation, additional non-pulmonary vein ablation lesions are created. These additional ablation lesions may contain any or all of the following: 1) Regions of fractionated potentials are mapped and ablated outside the pulmonary vein area. 2) linear lesions are created along the roof, mitral isthmus, or septal aspect of the left atrium. 3) Non-pulmonary vein focal sources of atrial fibrillation induction are induced, localized, and ablated. These locations may include areas of the left atrium, right atrium, superior vena cava, or coronary sinus. During the delivery of ablation energy, continuous monitoring for hemodynamic instability, arrhythmias, embolic events, and injury to the esophagus is performed.

During the course of these additional ablation lesions, an advanced 3D computer-assisted mapping system is used to facilitate identification of sites to target for catheter ablation as well as to record sites of lesions to allow the operator to create linear lesions. The mapping system is placed in the cardiac chamber of interest using standard percutaneous techniques. The system is calibrated, and recordings are made during sinus rhythm to identify normal activation and location of scar during each distinct tachycardia. The computer-generated map is displayed, modifications are made in the computer parameters and display, and the tachycardia origin is identified. The ablation catheter is moved to the point of early activation, localized by the mapping system, to identify a mid-diastolic potential, Kent potential, and/or similar paced maps. When a reentrant circuit is identified, entrainment mapping studies are performed and evaluated to confirm the catheter location is within the reentrant circuit. Additional mappings are made to confirm arrhythmia origin and to study additional arrhythmias at the conclusion of the procedure. A final report that includes the mapping procedure and findings is prepared.

CPT Code: 93657 Appropriate post ablation attempts at reeducation and observation for 30-minutes are performed. Following restoration of sinus rhythm, conduction intervals are measured and arrhythmia induction is re-attempted over a 30-minute period following the last ablation lesion. If the target site demonstrates recovery or incomplete suppression, then repeat mapping and ablation are performed as described above. These steps are repeated until the target site is rendered durably suppressed or the line demonstrates durable conduction block.

Description of Post-Service Work: CPT Code: 93657 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2021 Richard Wright, MD; Thad Waites, MD; Edward Tuohy, MD; Mark Schoenfeld, MD; Presenter(s): David Slotwiner, MD; Christopher Liu, MD Specialty American College of Cardiology & Heart Rhythm Society Society(ies): CPT Code: 93657

Sample Size: 1036 Resp N: 61 Description of electrophysiologists Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 10.00 25.00 45.00 120.00 Survey RVW: 3.00 7.00 8.25 10.00 26.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 7.00 45.00 60.00 84.00 150.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 93657 Recommended Physician Work RVU: 7.00 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 60.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 93657

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 35306 ZZZ 9.25 RUC Time

CPT Descriptor Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 37237 ZZZ 4.24 RUC Time

CPT Descriptor Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coaronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 34812 ZZZ 4.13 RUC Time 9,013 CPT Descriptor 1 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 0.00

CPT Descriptor 2

Other Reference CPT Code Global Work RVU Time Source 93592 ZZZ 8.00 RUC Time

CPT Descriptor Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure)

RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: CPT Code: 93657 Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by percent distribution) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 23 % of respondents: 37.7 %

Number of respondents who choose 2nd Key Reference Code: 17 % of respondents: 27.8 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93657 35306 37237

Median Pre-Service Time 0.00 0.00 1.00

Median Intra-Service Time 60.00 90.00 45.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 17% 35% 48%

Mental Effort and Judgment Less Identical More

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 5% 95%

Physical effort required 10% 39% 61% CPT Code: 93657

Psychological Stress Less Identical More

• The risk of significant complications, 4% 26% 70% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 12% 24% 64%

Mental Effort and Judgment Less Identical More

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 18% 82%

Physical effort required 0% 30% 70%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 18% 82% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

History Background

When the Relativity Assessment Workgroup identified CPT code 93656 (atrial fibrillation ablation) due to its rapid increase in growth, the ACC and HRS reviewed the code and determined that certain work should be bundled into the existing code due to their being billed together more than 75% of the time. With continued review of 93656 and the related the volume data, the societies also identified that CPT 93653 (SVT ablation) should have services bundled into it before the codes are CPT Code: 93657 re-surveyed for upcoming RUC valuation. As a result, in October 2020, the ACC and HRS presented a code change application to the CPT Editorial Panel on codes: 93653, 93654, 93655, 93656, 93657. The societies surveyed members late 2020 and presented data in January 2021. Due to inconsistencies in the survey data and in order to better convey the bundled services to respondents, the ACC and HRS resurveyed members March 2021.

The key reference code is 35306 for thromboendarterectomy. It was selected by approximately 30% of respondents. About 66% of the respondents indicated that 93657 was more complex. The second reference code was 32737 for Transcatheter placement of an intravascular stent(s). It was selected by approximately 21% of respondents. About 53% of the respondents indicated that 93657 was more intense/complex overall.

Rationale

Recommendation During the January meeting, several RUC members questioned whether codes 93613, 93621 and 93662 should also be addressed in the recommendations for cardiac ablation services. These codes are bundled into CPT codes 93653 and/or 93656. Each was recently surveyed by the specialties and the RUC in 2017, 2020, 2019, respectively. As such, the societies recommend affirming the recent times and RVUs of these recently valued codes, as they remain separate in CPT for use in concert with other CPT codes.

While this code descriptor did not change, its use as an additional ablation with a new base code that includes 3D mapping and intracardiac echo, changing the service. The same 3D mapping and intracardiac echo elements that were bundled into 93656 should now typically be considered to be included into this service, since those elements occur throughout the CPT Code: 93657 additional ablation. Therefore, for code 93657 the societies recommend the survey 25th percentile of 7.00 RVU with 60 minutes intraservice time. This value fits well with comparators noted in the summary spreadsheet.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93657, 93613, 93662

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty Cardiac Electrophysiology How often? Commonly

Specialty Cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 43919 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure is twice much as Medicare based claims.

Specialty Cardiac electrophysiology Frequency 36000 Percentage 81.96 %

Specialty Cardiology Frequency 8000 Percentage 18.21 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 21,959 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Figure reflects 2019e Medicare based claims.

Specialty Cardiac electrophysiology Frequency 18000 Percentage 81.97 %

Specialty Cardiology Frequency 4000 Percentage 18.21 %

CPT Code: 93657 Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93657

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

SS Rec Summary

A B C D E F G H I J K L M N O P Q R S T U V W AR AS AT AU AV 13 ISSUE: Cardiac Ablation Services Bundling 14 TAB: 7 15 RUC Review RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE DESC Year Work Per 16 Source CPT Global Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Percutaneous transcatheter 17 1st REF 93580 000 2002 20 0.133 0.086 17.97 210 30 120 60 closure of congenital Percutaneous transcatheter 18 2nd REF 33340 000 2016 16 0.136 0.077 14.00 183 40 3 20 90 30 closure of the left atrial CURRENT 93653 000 Comprehensive 2012 0.075 0.062 14.75 239 23 1 5 180 30 19 electrophysiologic evaluation CURRENT 93613 ZZZ Intracardiac electrophysiologic 2017 0.058 0.058 5.23 90 90 20 3 dimensional mapping (List Comprehensive 2001 (2020 for CURRENT 93621 ZZZ 0.070 0.070 2.10 30 30 21 electrophysiologic evaluation CPT 2022)) Comprehensive 22 OLD SVY 93653 000 74 0.130 0.079 8.00 15.00 18.49 22.76 30.00 235 50 15 15 60 120 125 180 240 30 0 27 40 60 110 electrophysiologic evaluation Interim Rec Comprehensive 93653 000 0.134 0.087 18.49 213 40 3 15 125 30 23 from Feb21 electrophysiologic evaluation RESURVEY Comprehensive with Proxy 936X1 000 electrophysiologic evaluation 62 0.135 0.085 7.25 15.00 18.00 23.25 37.00 211 31 15 15 3 120 120 150 360 30 0 25 40 50 200 24 Code # including with insertion and Comprehensive REC 93653 000 electrophysiologic evaluation 0.112 0.075 15.00 199 31 3 15 120 30 including with insertion and 25 repositioning of multiple 26 27 28 RUC Review RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE DESC Year Work Per 29 Source CPT Global Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Percutaneous transcatheter 30 1st REF 93580 000 2002 21 0.133 0.086 17.97 210 30 120 60 closure of congenital Percutaneous transcatheter 31 2nd REF 93590 000 2016 20 0.148 0.097 21.70 223 40 3 15 135 30 closure of paravalvular leak; Comprehensive 32 CURRENT 93654 000 2012 0.076 0.064 19.75 309 23 1 5 240 40 electrophysiologic evaluation Comprehensive 33 OLD SVY 93654 000 73 0.092 0.065 10.00 20.00 25.00 30.00 50.00 387 62 20 20 60 180 240 282 480 45 0 10 20 30 200 electrophysiologic evaluation Interim Rec Comprehensive 93654 000 0.075 0.059 19.75 336 40 3 20 240 33 34 from Feb21 electrophysiologic evaluation RESURVEY Comprehensive with Proxy 936X2 000 electrophysiologic evaluation 63 0.111 0.080 9.50 18.10 24.38 29.71 46.00 305 40 15 15 5 170 200 240 515 35 0 10 20 36 140 with insertion and 35 Code # iti i f lti l Comprehensive REC 93654 000 electrophysiologic evaluation 0.081 0.062 18.10 291 40 3 15 200 33 36 with insertion and 37 38 RUC Review RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE DESC Year Work Per 39 Source CPT Global Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Thromboendarterectomy, 40 1st REF 35306 ZZZ 2006 15 0.103 0.103 9.25 90 0 90 0 including patch graft if Transcatheter placement of an 41 2nd REF 37237 ZZZ 2013 13 0.093 0.090 4.25 47 1 45 1 intravascular stent(s) (except Intracardiac catheter ablation 42 CURRENT 93655 ZZZ 2012 0.083 0.083 7.50 90 90 of a discrete mechanism of Intracardiac catheter ablation 43 OLD SVY 93655 ZZZ 74 0.167 0.167 4.00 8.00 10.00 10.89 20.00 60 16 45 60 90 240 0 10 28 50 300 of a discrete mechanism of Interim Rec Intracardiac catheter ablation 93655 ZZZ 0.108 0.108 6.50 60 60 44 from Feb21 of a discrete mechanism of RESURVEY Intracardiac catheter ablation with Proxy 936X3 ZZZ of a discrete mechanism of 63 0.133 0.133 3.28 7.00 8.00 10.00 20.00 60 14 45 60 69 120 0 0 11 25 50 120 45 Code # arrhythmia which is distinct Intracardiac catheter ablation REC 93655 ZZZ of a discrete mechanism of 0.117 0.117 7.00 60 60 arrhythmia which is distinct 46 f th i bl t d 47 48 RUC Review RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE DESC Year Work Per 49 Source CPT Global Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Percutaneous transcatheter 50 1st REF 93580 000 2002 23 0.133 0.086 17.97 210 30 120 60 closure of congenital Percutaneous transcatheter 51 2nd REF 93590 000 2016 17 0.148 0.097 21.70 223 40 3 15 135 30 closure of paravalvular leak; CURRENT 93656 000 Comprehensive 2012 0.076 0.064 19.77 309 23 1 5 240 40 52 electrophysiologic evaluation CURRENT 93613 ZZZ Intracardiac electrophysiologic 2017 0.058 0.058 5.23 90 90 53 3 dimensional mapping (List Intracardiac echocardiography 54 CURRENT 93662 ZZZ 2019 0.058 0.058 1.44 25 25 during therapeutic/diagnostic Comprehensive 55 OLD SVY 93656 000 74 0.103 0.071 10.00 20.00 24.20 27.92 43.00 342 50 19 20 60 180 210 240 360 43 0 38 75 108 300 electrophysiologic evaluation Interim Rec Comprehensive 56 93656 000 0.086 0.065 20.00 306 40 3 20 210 33 from Feb21 electrophysiologic evaluation RESURVEY Comprehensive with Proxy 936X4 000 electrophysiologic evaluation 61 0.109 0.078 8.85 17.00 21.50 28.48 46.00 275 35 15 15 4 150 180 210 380 30 0 30 60 100 214 57 Code # including transseptal Comprehensive electrophysiologic evaluation REC 93656 000 0.085 0.065 17.00 263 35 3 15 180 30 including transseptal 58 catheterizations, insertion and 59 60 61 62 63 RUC Review RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE DESC Year Work Per 64 Source CPT Global Resp IWPUT Unit Time MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Thromboendarterectomy, 65 1st REF 35306 ZZZ 2006 18 0.103 0.103 9.25 90 90 including patch graft if Transcatheter placement of an 66 2nd REF 37237 ZZZ 2013 13 0.093 0.090 4.25 47 1 45 1 intravascular stent(s) (except Additional linear or focal 67 CURRENT 93657 ZZZ 2012 0.083 0.083 7.50 90 90 intracardiac catheter ablation Additional linear or focal 68 OLD SVY 93657 ZZZ 74 0.151 0.151 4.00 8.00 9.05 10.21 22.00 60 20 50 60 90 240 0 10 28 50 300 intracardiac catheter ablation Interim Rec Additional linear or focal 69 93657 ZZZ 0.108 0.108 6.50 60 60 from Feb21 intracardiac catheter ablation RESURVEY Additional linear or focal with Proxy 93657 ZZZ intracardiac catheter ablation 61 0.138 0.138 3.00 7.00 8.25 10.00 26.00 60 7 45 60 84 150 0 0 10 25 45 120 70 Code # of the left or right atrium for Additional linear or focal intracardiac catheter ablation REC 93657 ZZZ 0.117 0.117 7.00 60 0 60 0 of the left or right atrium for 71 treatment of atrial fibrillation 72 73 Intracardiac electrophysiologic 3-dimensional mapping (List CURRENT & separately in addition to code Jan 2017 RUC 93613 ZZZ 0.058 0.058 5.23 90 90 for primary procedure) Rec 74 75 Affirm previous January 2017 RUC recommendations 76 Comprehensive CURRENT 93621 ZZZ 0.070 0.070 2.10 30 30 77 electrophysiologic evaluation Comprehensive electrophysiologic evaluation Oct 2020 RUC including insertion and Recommendai 93621 ZZZ repositioning of multiple 0.088 0.088 1.75 20 20 ton electrode catheters with induction or attempted 78 induction of arrhythmia; with 79 Affirm previous October 2020 RUC recommendations 80 Intracardiac echocardiography CURRENT 93662 ZZZ during therapeutic/diagnostic 0.058 0.058 1.44 25 25 81 intervention including Intracardiac echocardiography May 2019 during therapeutic/diagnostic RUC 93662 ZZZ intervention, including 0.101 0.101 2.53 25 25 Recommenda imaging supervision and tion 82 interpretation (List separately 83 Affirm previous April 2019 RUC recommendations

Scott Manaker, MD AMA/RVS Update PE Subcommittee American Medical Association 330 N. Wabash Ave. Chicago, IL 60611

RE: Tab 7 Practice Expense

Dear Dr. Manaker:

Tab 7 on the April 2021 RUC agenda addresses five codes, SVT ablation, atrial fibrillation ablation, and the entire family of codes (93653-93657). Additionally, the Tab also includes three add-on codes 93613, 93621, and 93662. These services are provided exclusively in the facility setting. As such, we recommend no direct practice expense inputs for Tab 7.

Thank you for your consideration of this information as you prepare for the meeting. Please contact Claudia Vasquez at [email protected] if you have any questions.

Sincerely, Richard Wright, MD ACC RUC Advisor Mark Schoenfeld, MD HRS RUC Advisor AMA/Specialty Society RVS Update Committee Summary of Recommendations *CMS High Expenditure Procedures*

January 2017

Intracardiac 3D Mapping Add-On

In the NPRM for 2016 CMS re-ran the high expenditure services across specialties with Medicare allowed charges of $10 million or more. CMS identified the top 20 codes by specialty in terms of allowed charges, excluding 010 and 090-day global services, anesthesia and Evaluation and Management services and services reviewed since CY 2010. In the comment letter the RUC noted that it was scheduled to review the utilization and collect data under new bundled codes in October 2016. However, in the Final Rule for 2016 CMS indicated that the work and practice expense for this service should be reviewed.

93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 47 cardiologists and determined that the survey 25th percentile work RVU of 5.23 appropriately accounts for the work required to perform this service. The RUC recommends 90 minutes intra-service time. The RUC determined that the decrease in the recommended work RVU appropriately corresponds to the decrease in intra-service work. The RUC edited the description of work to delete “remove the catheter and obtaining hemostasis” as this is associated with the primary procedure. The RUC compared the surveyed code to the top key reference service 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) (PC work RVU = 4.99 and 90 minutes intra-service time) and determined that this service was slightly more intense and complex on all measures examined. The RUC also compared the surveyed code to the second top key reference code 93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) (work RVU = 7.50 and 90 minutes intra-service time) and determined that code 93655 is more intense than the surveyed code because it entails the initiation and prolonged observation (to allow for mapping, the surveyed code) of arrhythmias that are potentially dangerous and/or hemodynamically unstable with increased risk to the patient and thereafter requires ablation which in and of itself carries precision and risk- it requires greater intensity to perform the complex initiation of arrhythmias and to manage such patients while these arrhythmias are being mapped in order to allow for the subsequent ablation. In addition, any patient who has more than one arrhythmia focus becomes exponentially complex. The diagnostic maneuvers, mapping and ablation skills needed to successfully treat a second focus are significant. Not all arrhythmia foci are created equally. Patients who have more than one focus tend to have significant scar tissue. Mapping the circuit of the arrhythmia is particularly challenging because distinguishing between partly viable tissue and complete scare requires a very dense map (meaning many data points must be acquired and correctly interpreted and annotated on the map).

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

For additional support the RUC referenced MPC code 57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) (work RVU = 4.88 and 45 minutes intra-service time) and noted that the MPC code is much more intense and requires half the intra-service time. The RUC recommends a work RVU of 5.23 for CPT code 93613.

Practice Expense There are no direct practice expense inputs for this service.

Work Neutrality The RUC’s recommendation for these codes will result in an overall work savings that should be redistributed back to the Medicare conversion factor.

CPT Code CPT Descriptor Global Work RVU Period Recommendation

93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition ZZZ 5.23 to code for primary procedure)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 93613 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93613 Tracking Number Original Specialty Recommended RVU: 5.23 Presented Recommended RVU: 5.23 Global Period: ZZZ RUC Recommended RVU: 5.23

CPT Descriptor: Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: A 71-year-old female is undergoing radiofrequency ablation (reported separately) to treat atrial tachycardia. Atrial tachycardia is induced, with a morphology similar to the tachycardia that had been documented clinically. 3D mapping is indicated.

Percentage of Survey Respondents who found Vignette to be Typical: 96%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: n/a

Description of Intra-Service Work: During the course of an electrophysiology procedure, induce an arrhythmia that requires use of an advanced three-dimensional (3D) computer-assisted mapping system to localize the arrhythmia origin. Place the mapping system in the cardiac chamber of interest using standard percutaneous techniques. Calibrate the system and make recordings during sinus rhythm to identify normal activation and location of scar during each distinct tachycardia. Display the computer-generated map, make modifications in the computer parameters and display, and identify the tachycardia origin. Move the ablation catheter to the point of early activation localized by the mapping system to identify a mid-diastolic potential, Kent potential, and/or similar paced maps. When a re-entrant circuit is identified, perform entrainment mapping studies and evaluated them to confirm the catheter location is within the re-entrant circuit. Make additional mappings to confirm arrhythmia origin and study additional arrhythmias at the conclusion of the procedure. Prepare a final report and include the mapping procedure and findings.

Description of Post-Service Work: n/a CPT Code: 93613 SURVEY DATA RUC Meeting Date (mm/yyyy) 01/2017 Presenter(s): Richard Wright, MD; Mark Schoenfeld, MD; Thad Waites, MD; David Slotwiner, MD Specialty(s): ACC, HRS CPT Code: 93613 Resp N: Sample Size: 500 47 Response: 9.4 %

Description of random Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 12.00 50.00 100.00 128.00 250.00 Survey RVW: 2.25 5.23 7.00 8.00 15.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 30.00 48.00 90.00 120.00 400.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 93613 Recommended Physician Work RVU: 5.23 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 90.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 93613 Post-Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.0 99239x 0.0 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93609 ZZZ 4.99 RUC Time

CPT Descriptor Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93655 ZZZ 7.50 RUC Time

CPT Descriptor Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 57267 ZZZ 4.88 RUC Time 6,947 CPT Descriptor 1 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 63048 ZZZ 3.47 RUC Time 134,208

CPT Descriptor 2 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

Other Reference CPT Code Global Work RVU Time Source 22851 ZZZ 6.70 RUC Time

CPT Descriptor Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

CPT Code: 93613 RELATIONSHIP OF CODE BEING REVIEWED TO TOP TWO KEY REFERENCE SERVICES: Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by the mean) of the service you are rating to the top two chosen key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below.

Number of respondents who choose Top Key Reference Code: 26 % of respondents: 55.3 %

Number of respondents who choose 2nd Key Reference Code: 13 % of respondents: 27.6 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93613 93609 93655

Median Pre-Service Time 0.00 0.00 0.00

Median Intra-Service Time 90.00 90.00 90.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Intensity & Complexity Rating Scale: (much less= -2.00, somewhat less= -1.00, identical= 0.00, somewhat more= 1.00, much more= 2.00)

Top Key 2nd Key Ref Code Ref Code

Mental Effort and Judgment (Mean) The number of possible diagnosis and/or the number of 0.88 0.62 management options that must be considered

The amount and/or complexity of medical records, diagnostic tests, 0.62 0.69 and/or other information that must be reviewed and analyzed

Urgency of medical decision making 0.42 0.15

Technical Skill/Physical Effort (Mean) Technical skill required 0.96 0.54 CPT Code: 93613 Physical effort required 0.62 0.23 Psychological Stress (Mean) The risk of significant complications, morbidity and/or mortality 0.19 0.00

Outcome depends on the skill and judgment of physician 0.69 0.62

Estimated risk of malpractice suit with poor outcome 0.27 0.15

INTENSITY/COMPLEXITY MEASURES Top Key 2nd Key Ref Code Ref Code Time Segment (Mean) Overall intensity/complexity 0.96 0.77

Additional Rationale and Comments

93613 is an add-on code used with several cardiac electrophysiology evaluation and/or ablation services. It describes the work of placing the mapping system inside the heart and creating a map of the chamber to aid performance of the underlying service.

CMS identified 93613 in CY 2016 rulemaking as potentially misvalued through its high-expenditure screen. A random survey of 500 ACC and HRS members was executed with 47 completed surveys. The information obtained is used to develop the survey results in the SOR and the summary spreadsheet.

The key reference service was selected by 26 respondents. Respondents who selected atrial tachycardia mapping code 93609 as the key reference code found 93613 to be more intense/complex in every factor, as shown in the above table and the attached addendum. This comparison is reasonable, since the median survey time of 90 minutes equals the 90-minute survey time for 93609, yet respondents estimated 93613 to be more work.

At this RVU level, no comparable ZZZ MPC codes exist. The two highest MPC ZZZ codes—57267 for insertion of vaginal mesh or prosthesis for repair of pelvic floor defect and 63048 for vertebra laminectomy—are included on the SOR and summary spreadsheet. We note that both of those half as much intraservice time (45 minutes). We searched the RUC database for additional comparators and found only nine other RUC-reviewed ZZZ code with a time of 90 minutes. The lowest valued of those, 22851, describes application of intervertebral biomechanical devices and has a work RVU of 6.70.

Reflecting a robust survey, and given the reduction in intraservice time for 93613, we recommend the survey 25th- percentile work RVU of 5.23 with times of 0 minutes preservice, 90 minutes intraservice, and 0 minutes postservice. This value is 25% lower than the current value proportionately captures the 25% reduction in time, as demonstrated by the constant IWPUT.

SERVICES REPORTED WITH MULTIPLE CPT CODES

CPT Code: 93613 1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93613

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty cardiac electrophysiology How often? Commonly

Specialty cardiology How often? Sometimes

Specialty How often?

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 50,654 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. 2015 FFS utilization form RUC database.

Specialty cardiac electrophysiology Frequency 33654 Percentage 66.43 %

Specialty cardiology Frequency 15500 Percentage 30.59 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

CPT Code: 93613 Berenson-Eggers Type of Service (BETOS) Assignment Please pick the appropriate BETOS classification that best corresponds to the clinical nature of this CPT code. Please select the main BETOS classification and sub-classification to the greatest level of specificity possible.

Main BETOS Classification: Imaging

BETOS Sub-classification: Imaging/procedure

BETOS Sub-classification Level II: Heart inc. Cardiac Catheter

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93613

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

CPT Code: 93613 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SURVEY INTENSITY & COMPLEXITY ADDENDUM TABLE

Survey Code: 93613 # of Respondents: 47 Survey Code Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary Descriptor: procedure)

Top Ref Code: 93609 # of Respondents: 26 % of Respondents: 55% Top Ref Code Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation Descriptor: to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure)

Survey Code Compared to Top Ref Code Survey Code is: Much Somewhat Somewhat Much Identical Overall Intensity and Complexity: Less Less More More 0% 0% 23% 54% 23%

The number of possible diagnosis Less Identical More and/or number of management options

0% 23% 77% that must be considered

The amount and/or complexity of Mental Effort and medical records, diagnostic tests, Less Identical More Judgment:

and/or other information that must be 12% 31% 43% reviewed and analyzed Less Identical More Urgency of medical decision making

4% 65% 31%

Less Identical More Technical Skill:

0% 23% 77%

Less Identical More Physical Effort:

11% 35% 54%

The risk of significant complications, Less Identical More

morbidity and/or mortality 15% 58% 27% Outcome depends on the skill and Less Identical More Psychological Stress:

judgment of physician 0% 38% 62%

Estimated risk of malpractice suite Less Identical More

with poor outcome 12% 65% 23%

SS Rec Summary B C D E F G H I J K L M N O P Q R S T U

13 ISSUE: EP 3D Mapping add-on 14 TAB: 24 15 RVW Total PRE-TIME INTRA-TIME IMMD

16 Source CPT DESC Resp IWPUT MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST

17 1st REF 93609 Intraventricular and/or intra-atria 26 0.055 4.99 90 90

18 2nd REF 93655 Intracardiac catheter ablation of 13 0.083 7.50 90 90

19 CURRENT 93613 Intracardiac electrophysiologic 3 0.058 6.99 120 120

20 SVY 93613 47 0.078 2.25 5.23 7.00 8.00 15.00 90 30 48 90 120 400

21 REC 93613 0.058 5.23 90 90

22 MPC 57267 Insertion of mesh or other prost 0.108 4.88 45 45

23 MPC 63048 Laminectomy, facetectomy and 0.077 3.47 45 45

24 COMP 22851 Application of intervertebral bio 0.074 6.70 90 90 25 24_ Tab Number

Intracardiac 3D Mapping Issue

93613 Code Range

Attestation Statement

This form needs to be completed by any RUC Advisor whose specialty society is developing a recommendation to be reviewed by the RUC.

As a RUC Advisor, I attest that the integrity of the RUC survey, summary of recommendation forms and practice expense recommendations are based on accurate and complete data to the best of my knowledge. As a RUC advisor, I acknowledge that violations would be addressed by the executive committee (i.e., RUC Chair , AMA Representative and Alternate AMA Representative.)

_ Signature

_Mark Schoenfeld, MD, FHRS Printed Signature

_Heart Rhythm Society Specialty Society

_12/13/2016 Date _11, 19, 23, 24___ Tab Number

_Incompetent Vein, INR Monitoring, EP Device Monitoring, 3D Mapping____ Issue

___36470-71, 36475, 364X3-X6; 993X1-X2; 93293-95, 93297-98; 93613___ Code Range

Attestation Statement

This form needs to be completed by any RUC Advisor whose specialty society is developing a recommendation to be reviewed by the RUC.

______Signature

_Richard Wright, MD______Printed Signature

___ACC______Specialty Society

___12/12/16______Date

CPT Code:__93613_ Specialty Society(‘s)__ACC, HRS__

AMA/Specialty Society Update Process Practice Expense Summary of Recommendation Facility Direct Inputs

CPT Long Descriptor: Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)

Global Period:_ZZZ__ Meeting Date:_January 2017______

1. Please provide a brief description of the process used to develop your recommendation and the composition of your Specialty Society Practice Expense Committee: The reviewer panel utilized a consensus panel process to develop recommended inputs. No clinical staff time, supplies, or equipment are recommended for this facility-based ZZZ code.

2. You must provide reference code(s) for comparison on your spreadsheet. If the code you are making recommendations on is a revised code you must use the current PE direct inputs for the code as your comparison. You must provide an explanation for the selection of reference codes. Reference Code Rationale: Existing 93613.

3. If you are recommending more minutes than the PE Subcommittee standards you must provide evidence to justify the time: n/a

4. If you are requesting an increase over the current inputs in clinical staff time, supplies or equipment you must provide compelling evidence: n/a

5. Please describe in detail the clinical activities of your staff: n/a

Pre-Service Clinical Labor Activities:

Intra-Service Clinical Labor Activities:

Post-Service Clinical Labor Activities:

1 AMA Specialty Society Recommendation A B C D E F G 1 REFERENCE CODE *Please note: If a supply has a purchase price of $100 or more please bold the item name and CMS code. 2 93613 93613 Intracardiac Intracardiac Meeting Date: January 2017 electrophysiologic 3- electrophysiologic 3- Tab: 24 dimensional mapping dimensional mapping CMS Specialty: ACC, HRS (List separately in (List separately in 3 Code Staff Type addition to code for addition to code for i d) i d) 4 LOCATION Facility Non Fac Facility Non Fac Facility 5 GLOBAL PERIOD ZZZ 6 TOTAL CLINICAL LABOR TIME 0.0 0.0 0.0 0.0

7 TOTAL PRE-SERV CLINICAL LABOR TIME 0.0 0.0 0.0 0.0 8 TOTAL SERVICE PERIOD CLINICAL LABOR TIME 0.0 0.0 0.0 0.0 9 TOTAL POST-SERV CLINICAL LABOR TIME 0.0 0.0 0.0 0.0 10 PRE-SERVICE 11 Start: Following visit when decision for surgery or procedure made 12 Complete pre-service diagnostic & referral forms 13 Coordinate pre-surgery services 14 Schedule space and equipment in facility 15 Provide pre-service education/obtain consent 16 Follow-up phone calls & prescriptions 17 Other Clinical Activity - specify: 18 End: When patient enters office/facility for surgery/procedure 19 SERVICE PERIOD 20 Start: When patient enters office/facility for surgery/procedure: Greet patient, provide gowning, ensure appropriate medical records 21 are available 22 Obtain vital signs 23 Provide pre-service education/obtain consent 24 Prepare room, equipment, supplies 25 Setup scope (non facility setting only) 26 Prepare and position patient/ monitor patient/ set up IV 27 Sedate/apply anesthesia 28 Other Clinical Activity - specify: 29 Intra-service 30 Assist physician in performing procedure 31 Post-Service Monitor pt. following procedure/check tubes, monitors, drains, 32 multitasking 1:4 Monitor pt. following procedure/check tubes, monitors, drains, no 33 multitasking 1:1 34 Clean room/equipment by physician staff 35 Clean Scope 36 Clean Surgical Instrument Package 37 Complete diagnostic forms, lab & X-ray requisitions 38 Review/read X-ray, lab, and pathology reports Check dressings & wound/ home care instructions /coordinate office 39 visits /prescriptions 40 Other Clinical Activity - specify: 41 Dischrg mgmt same day (0.5 x 99238) (enter 6 min) n/a n/a 42 Dischrg mgmt (1.0 x 99238) (enter 12 min) n/a n/a 43 Dischrg mgmt (1.0 x 99239) (enter 15 min) n/a n/a 44 End: Patient leaves office

AMA Specialty Society Recommendation Page 1 AMA Specialty Society Recommendation A B C D E F G 1 REFERENCE CODE *Please note: If a supply has a purchase price of $100 or more please bold the item name and CMS code. 2 93613 93613 Intracardiac Intracardiac Meeting Date: January 2017 electrophysiologic 3- electrophysiologic 3- Tab: 24 dimensional mapping dimensional mapping CMS Specialty: ACC, HRS (List separately in (List separately in 3 Code Staff Type addition to code for addition to code for i d) i d) 4 LOCATION Facility Non Fac Facility Non Fac Facility 5 GLOBAL PERIOD ZZZ 45 POST-SERVICE Period 46 Start: Patient leaves office/facility 47 Conduct phone calls/call in prescriptions 48 Office visits: List Number and Level of Office Visits # visits # visits # visits # visits 49 99211 16 minutes 16 50 99212 27 minutes 27 51 99213 36 minutes 36 52 99214 53 minutes 53 53 99215 63 minutes 63 54 Total Office Visit Time 0.0 0.0 0.0 0.0 55 Other Clinical Activity - specify:

56 End: with last office visit before end of global period 57 MEDICAL SUPPLIES* CODE UNIT 58 pack, minimum multi-specialty visit SA048 pack 59 EQUIPMENT CODE

AMA Specialty Society Recommendation Page 2 AMA/Specialty Society RVS Update Committee Summary of Recommendations *High Volume Growth*

April 2019

Intracardiac Echocardiography

In January 2019, the Relativity Assessment Workgroup (RAW) reviewed services with 2017e Medicare utilization of 10,000 or more that has increased by at least 100% from 2012 through 2017. CPT code 93662 was identified and the RUC recommended this service be surveyed for April 2019.

93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 42 cardiologists and agreed on the following physician time component: 25 minutes of intra-service time.

The RUC reviewed the recommended survey 25th percentile work RVU of 2.53 and agreed that this value appropriately captures the amount of physician work involved. The recommended work value and time for this service reflects the change in technology from when it was last valued in 2000. Intracardiac echocardiography has become an essential tool for complex catheter ablation of many types of arrhythmias and it has also enabled operators to significantly reduce the use of fluoroscopy. Since this service was last valued, arrhythmia mapping systems have developed the ability to incorporate intracardiac echo images into 3-dimensional electroanatomical maps. This has improved the accuracy, safety and effectiveness of catheter ablation for a wide range of arrhythmias, most notably atrial fibrillation. To justify a work RVU of 2.53, the RUC compared the survey code to CPT code 34713 Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure) (work RVU = 2.50 and intra-service time of 20 minutes) and determined that the recommended work value for the survey code is supported by CPT code 34713 which has similar physician work and time. The RUC also compared the survey code to MPC code 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (work RVU = 2.65 and intra-service time of 30 minutes) and determined that the recommended work value is supported by MPC code 36476. The RUC agreed that both reference services bracket the survey code in both physician work and time, supporting the recommended work value for the survey code.

Additionally, survey respondents who selected coronary intravascular ultrasound (IVUS) code 92978 as the top key reference service (KRS), found the survey code to be more intense/complex overall. The RUC agreed that this comparison is reasonable, since the median survey time of 25 minutes for the survey code equals the 25-minute intra-service time for KRS code 92978, yet survey respondents estimated the survey code to be more work

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

and takes significantly more mental effort and judgment than KRS code 92978, further supporting the recommended survey 25th percentile work RVU of 2.53 for the survey code. The RUC recommends a work RVU of 2.53 for CPT code 93662.

Practice Expense These services are facility-only and have no direct practice inputs.

Work Neutrality The RUC’s recommendation for this code will result in an overall work savings that should be redistributed back to the Medicare conversion factor.

CPT Global Work RVU Code CPT Descriptor Period Recommendation 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, ZZZ 2.53 including imaging supervision and interpretation (List separately in addition to code for primary procedure)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 93662 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93662 Tracking Number Original Specialty Recommended RVU: 2.53 Presented Recommended RVU: 2.53 Global Period: ZZZ Current Work RVU: 2.80 RUC Recommended RVU: 2.53

CPT Descriptor: Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: During the catheter ablation of a 57 year-old man with symptomatic paroxysmal atrial fibrillation, intracardiac ultrasound is used to guide the trans-septal puncture, evaluate left atrial and pulmonary vein anatomy, and monitor for intra-procedural complications.

Percentage of Survey Respondents who found Vignette to be Typical: 98%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work:

Description of Intra-Service Work: Femoral venous access is obtained using fluoroscopic and or ultrasound guidance, avoiding the femoral artery. A 9 French or 10 French sheath is inserted into the vein. The intracardiac echo probe is advanced through the sheath, up the inferior vena cava to the right atrium again using fluoroscopic and intracardiac echo guidance, avoiding the venous branches and Eustachian ridge. The following structures are imaged for baseline anatomy: The fossa ovalis, aortic root, left atrium including the left atrial appendage, pulmonary veins, esophagus and the pericardial space to evaluate for document if a baseline effusion is present. Next, preparations for transseptal puncture are made by rotating and flexing the intracardiac echo catheter in 3 dimensions to identify the ideal location of the atrial septum for puncture. Under intracardiac echo guidance the transseptal needle is positioned in the appropriate portion of the septum. Intracardiac echo is used to confirm tenting of the septum by the needle at the desired location, and the puncture is then performed. Saline is flushed through the transseptal needle and intracardiac echo is used to confirm that the needle tip is in the left atrium by visualizing bubbles on intracardiac echo within the left atrium. A sheath is then advanced over the transseptal needle into the left atrium and the needle is withdrawn from the body. Throughout the remainder of the procedure intracardiac echo is used to confirm the position of the ablation catheter in the left atrium and it is used to monitor for complications including pericardial effusion and intracardiac thrombus. At the end of the procedure the catheter and sheaths are removed and hemostasis achieved using either manual pressure, vascular closure device or superficial stitches. Details of the procedure and then documented.

Description of Post-Service Work: CPT Code: 93662 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2019 Mark Schoenfeld, MD; Richard Wright, MD; David Slotwiner, MD; Thad Waites, MD; Presenter(s): Edward Tuohy, MD Specialty HRS, ACC Society(ies): CPT Code: 93662 Resp N: Sample Size: 1000 42 Response: 4.2 %

Description of 500 random HRS members; 500 random ACC members who designate EP in Sample: membership Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 43.00 100.00 120.00 250.00 Survey RVW: 1.80 2.53 3.80 5.15 8.25 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 7.00 20.00 25.00 35.00 120.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 93662 Recommended Physician Work RVU: 2.53 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 25.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 93662

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? Yes

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 92978 ZZZ 1.80 RUC Time

CPT Descriptor Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure)

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93613 ZZZ 5.23 RUC Time

CPT Descriptor Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 36227 ZZZ 2.09 RUC Time 11,934 CPT Descriptor 1 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 36476 ZZZ 2.65 RUC Time 9,561

CPT Descriptor 2 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

Other Reference CPT Code Global Work RVU Time Source 34713 ZZZ 2.50 RUC Time

CPT Code: 93662 CPT Descriptor Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)

Number of respondents who choose Top Key Reference Code: 12 % of respondents: 28.5 %

Number of respondents who choose 2nd Key Reference Code: 10 % of respondents: 23.8 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93662 92978 93613

Median Pre-Service Time 0.00 0.00 0.00

Median Intra-Service Time 25.00 25.00 90.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes)

Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 17% 58% 25%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 0% 0% 100% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making CPT Code: 93662

Technical Skill/Physical Effort Less Identical More Technical skill required 8% 25% 67%

Physical effort required 0% 58% 42%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 50% 50% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 50% 50% 0%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 30% 50% 20% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 50% 50%

Physical effort required 0% 60% 40%

Psychological Stress Less Identical More

• The risk of significant complications, 10% 50% 40% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

93662 is an add-on code used with several cardiac electrophysiology evaluation and/or ablation services. It can also be used with certain transcatheter structural valve procedures.

The RAW identified 93662 through its high-growth screen. A random survey of 1000 ACC and HRS members was executed with 42 completed surveys. The information obtained is used to develop the survey results in the SOR and the summary spreadsheet.

While we are not making a compelling evidence argument because we are recommending a reduction, we do wish to explain the ways this service is different from when it was valued in 2000. Intracardiac echo has become unessential to tool for complex catheter ablation of many types of arrhythmias. It has also enabled operators to significantly reduce the use of fluoroscopy. Over the past 15 years, arrhythmia mapping systems have developed the ability to incorporate intracardiac echo images into 3-dimensional electroanatomical maps. This has improved the accuracy, safety and effectiveness of catheter ablation for a wide range of arrhythmias, most notably atrial fibrillation.

The key reference service was selected by 12 respondents. Respondents who selected coronary intravascular ultrasound (IVUS) code 92978 as the key reference code found 93662 to be more intense/complex overall. This comparison is reasonable, since the median survey time of 25 minutes equals the 25-minute intraservice time for 92978, yet respondents estimated 93662 to be more work.

The second key reference service was selected by 10 respondents. Respondents who selected intracardiac 3D mapping code 93613 as the key reference code found 93662 to be identical or somewhat more intense/complex overall. However, comparison between 93662 and 93613 is challenging, as the latter has a much longer service time and higher work RVU than under discussion here.

Reflecting a valid survey, and given the reduction in intraservice time for 93662, we recommend the survey 25th- percentile work RVU of 2.53 work RVUs with times of 0 minutes preservice, 25 minutes intraservice, and 0 minutes postservice. This somewhat higher value reflects the higher intensity/complexity estimated by respondents who selected the KRS.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

2. Please provide a table listing the typical scenario where this code is reported with multiple codes. Include the CPT codes, global period, work RVUs, pre, intra, and post-time for each, summing all of these data and accounting for relevant multiple procedure reduction policies. If more than one physician is involved in the provision of the total service, please indicate which physician is performing and reporting each CPT code in your scenario. 93662 may be billed with 92987, 93453, 93460-96462, 93532, 93580, 93581, 93620, 93621, 93622, 93653, 93654, or 93656.

FREQUENCY INFORMATION

CPT Code: 93662 How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93622

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty cardiac electrophysiology How often? Commonly

Specialty cardiology How often? Sometimes

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 130000 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Twice the utilization estimated below for Medicare

Specialty cardiac electrophysiology Frequency 71000 Percentage 54.61 %

Specialty cardiology Frequency 59000 Percentage 45.38 %

Specialty Frequency Percentage %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 65,000 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. A continuation of recent growth trends of about 6,300 a year from 2015-2017 would lead to utilization of roughly 65,000 services in 2020.

Specialty cardiac electrophysiology Frequency 35500 Percentage 54.61 %

Specialty cardiology Frequency 29500 Percentage 45.38 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93662

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix. CPT Code: 93662

SS Rec Summary A B C D E F G H I J K L M N O P Q R S T AO AP AQ AR AS 3 INSTRUCTIONS 4 Insert information and data into all applicable cells except IWPUT and TOTAL TIME. These cells will automatically calculate. 5 Hide columns and rows that do not contain data. 6 1st REF = Top Key Reference code data 7 2st REF = Second Highest Key Reference code data 8 CURRENT = Current data (Harvard or RUC) for code being surveyed. If this is a new code, this row will be blank. 9 SVY = Survey data - as it appears on the Summary of Recommendation form. 10 REC = Specialty Society recommended data as it appears on the Summary of Recommendation form. 11 12

13 ISSUE: Intracardiac Echocardiography (ICE) 14 TAB: 23 15 RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE

16 Source CPT DESC Resp IWPUT MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX

17 1st REF 92978 Endoluminal imaging of coronar 12 0.072 1.80 25 25

18 2nd REF 93613 Intracardiac electrophysiologic 10 0.058 5.23 90 90

19 CURRENT 93662 Intracardiac echocardiography d 0.045 2.80 70 5 55 10

20 SVY 93662 Intracardiac echocardiography d42 0.152 1.80 2.53 3.80 5.15 8.25 25 7 20 25 35 120 0 43 100 120 250

21 REC 93662 Intracardiac echocardiography d 0.101 2.53 25 25

22 MPC 36227 Selective catheter placement, ex 0.139 2.09 15 15

23 MPC 36476 Endovenous ablation therapy of 0.088 2.65 30 30

24 COMP 34713 Percutaneous access and closu 0.125 2.50 20 20 April 2, 2019

Scott Manaker, MD AMA/RVS Update PE Subcommittee American Medical Association 330 N. Wabash Ave. Chicago, IL 60611

RE: Tab 23 Practice Expense

Dear Dr. Manaker:

Tab 23 on the April 2019 RUC agenda addresses one add-on code for intracardiac echocardiography performed during other catheter procedures. This add-on service is provided exclusively in the facility setting. As such, we recommend no direct practice expense inputs for Tab 23.

Thank you for your consideration of this information as you prepare for the meeting. Please contact James Vavricek at [email protected] if you have any questions.

Sincerely,

Richard Wright, MD ACC RUC Advisor

Mark Schoenfeld, MD HRS RUC Advisor AMA/Specialty Society RVS Update Committee Summary of Recommendations *High Volume Growth*

October 2020

Electrophysiologic Evaluation - REVISED

In October 2019, the RUC identified this service via the high-volume growth screen for services with Medicare utilization of 10,000 or more and have increased by at least 100% from 2013 through 2018. In January 2020, the RUC recommended this service be surveyed for April 2020. The code was surveyed individually, as it is not part of a specific family, because it is an add-on service that can be used with several different procedures - base codes or other add-on codes, diagnostic as well as therapeutic.

93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) The RUC reviewed the survey results from 53 cardiologists and cardiac electrophysiologists and determined that a direct work RVU crosswalk to CPT code 36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (work RVU = 1.75, 20 minutes intra- service and total time) would appropriately account for the physician work required to perform this service and falls below the survey 25th percentile.

The RUC discussed the decrease in intra-service time from 30 to 20 minutes and the accordant increase in intensity. Because the recommended work RVU is not an increase, a compelling evidence argument is not necessary. However, because of the change in calculated intensity that results from a decrease in intra-service time without an entirely commensurate decrease in work RVU, the specialty societies provided compelling evidence that there has been a change in technique that has changed physician work.

Since 2001, when this code was last surveyed, there have been several changes in technique that have contributed to an increase in the intensity and decrease in the total time of the procedure. In particular, the typical access technique has evolved to the femoral vein to insert the catheter, as opposed to the jugular or subclavian vein. Previously, a superior vena cava (SVC) approach via internal jugular (IJ) or subclavian vein access was the preferred route to access the coronary sinus. Anatomically, this provides an ideal angle from which to cannulate the coronary sinus which sits at the inferior posteroseptal region of the right atrium, just above the tricuspid valve. This angle makes it possible to use a simple fixed curve catheter and ensures that the catheter position will remain stable throughout the procedure. The downside of the superior approach is that it requires an additional access site (the internal jugular or subclavian vein) that would otherwise not be needed. This carries a small but real risk of pneumothorax and the IJ /

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

subclavian access site can be uncomfortable for patients during and after the procedure. For these reasons, most electrophysiologists have evolved their practice and now use a femoral vein approach to deploy the coronary sinus catheter.

The femoral approach avoids the need to prep and drape an additional access site since the other sheaths and catheters for EP studies are also placed from a femoral approach. However, a separate and additional sheath needs to be inserted into the femoral vein for placement of the coronary sinus catheter. Due to the need for multiple sheaths in the same femoral vein access region, care must be taken during venous access to space the access sites sufficiently to avoid interference between the catheters. In addition, a femoral venous approach introduces anatomical challenges for cannulating the coronary sinus and does not provide the natural stability of the catheter achieved from a subclavian approach. The primary anatomical obstacles are the height of the eustachian ridge/inferior vena cava junction and the abrupt reverse angle (usually greater than 135 degrees) that the catheter must traverse once it passes above the eustachian ridge in order to enter to coronary sinus ostium. With the advent of manually deflectable catheters, electrophysiologists are usually (but not always) able to cannulate the coronary sinus from a femoral approach despite the anatomical challenges. However, because the anatomy (eustachian ridge/IVC junction) intrinsically puts pressure on the catheter in a direction that pulls it away from the coronary sinus, the catheter is much less stable than it would be from a superior approach. As a result, it is typical for the coronary sinus catheter to become dislodged multiple times in a single case requiring the operator to reposition the catheter each time.

The RUC agreed that the minutes reduced from the change in access site are at the lower end of the intensity spectrum for the service, which naturally leads to an increase in calculated intensity that is compounded by the increased intensity of making the turn at the IVC/eustachian ridge and multiple re-positionings of the catheter.

Another difference from 2001 is that this service is typically added on to EP-studies performed in concert with ablation therapies, rather than with diagnostic-only EP studies as was predominant in 2001. Medicare reported together data show that these services are now typically performed as a combination of therapeutic and diagnostic interventions (e.g., EP ablation), as opposed to simply diagnostic procedures. The survey add-on code is most often reported with ablation code 93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo- tricuspid isthmus or other single atrial focus or source of atrial re-entry (work RVU = 14.75, 180 minutes intra-service time) and diagnostic code 93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) (work RVU = 5.23, 90 minutes intra-service time). Specifically, the data shows that approximately 80% of 93621 is reported with CPT code 93653. The placement of a catheter for pacing/recording in the left atrium and coronary sinus is more complex/intense in an ablation versus a diagnostic procedure. Patients who proceed to ablative therapies are more complex than those only receiving diagnostic catheterization.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Moreover, the RUC notes that while it is uncommon for an add-on code to be more intense than the underlying service, it does occur, and it is common in the electrophysiology space. A relevant example is trans-septal puncture CPT code 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) (work RVU = 3.73, 40 minutes intra-service and total time) that may be performed with SVT ablation CPT code 93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry (work RVU = 14.75, 180 minutes intra-service and 239 minutes total time). The ablation procedure intensity is 0.075 while the puncture is more intense at 0.093. An intensity of 0.088 from the RVU recommendation for CPT code 93621 fits this model and is a reasonable intensity rank order.

The RUC compared CPT code 93621 to the second highest key reference service and MPC code 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) (work RVU = 2.25, 30 minutes intra-service and total time) and noted the intra-service time is 10 minutes less for the survey code and all the survey respondents that selected the second key reference code rated the survey code as more intense and complex overall relative to the reference code.

The RUC also identified CPT code 37252 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure) (work RVU = 1.80, 20 minutes intra-service time and 22 minutes total time) for comparison purposes and noted that the comparator code has the same amount of intra-service time and intensity as the survey code.

For additional support, the RUC referenced key MPC codes 37253 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) (work RVU = 1.44, 20 minutes intra-service time and 1 minute immediate post-service time) and 36227 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) (work RVU = 2.09, 15 minutes intra- service and total time) and noted that the multi-specialty points of comparison codes appropriately bracket the survey code. The RUC further noted that there are 12 RUC reviewed ZZZ codes with 20 minutes intra-service time and work values between 1.40 and 2.00.

The RUC concluded that, given changes in intensity and total time for the procedure, CPT code 93621 should be valued based on a direct work RVU crosswalk to CPT code 36483 with 20 minutes intra-service time as supported by the survey. The RUC recommends a work RVU of 1.75 for CPT code 93621.

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

Practice Expense CPT code 93621 is provided exclusively in the facility setting; thus, no direct practice expense inputs are recommended.

Work Neutrality The RUC’s recommendation for this code will result in an overall work savings that should be redistributed back to the Medicare conversion factor.

CPT Global Work RVU Code CPT Descriptor Period Recommendation 93621 Comprehensive electrophysiologic evaluation including insertion and repositioning ZZZ 1.75 of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

CPT Code: 93621 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION

CPT Code:93621 Tracking Number Original Specialty Recommended RVU: 2.10 Presented Recommended RVU: 1.75 Global Period: ZZZ Current Work RVU: 2.10 RUC Recommended RVU: 1.75

CPT Descriptor: Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)

CLINICAL DESCRIPTION OF SERVICE:

Vignette Used in Survey: During a separately reported cardiac electrophysiology procedure, a 37 year-old man with recurrent palpitations is indicated, for diagnostic purposes, for the recording of electrical activity from the left atrium and ventricle and to pace the left atrium.

[Note: This is an add-on code. Only consider the additional work for left atrial pacing and recording from coronary sinus or left atrium. Do not include any work that is included in base codes 93620, 93653 or 93654.]

Percentage of Survey Respondents who found Vignette to be Typical: 88%

Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0%

Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0%

Description of Pre-Service Work: N/A

Description of Intra-Service Work: The patient is undergoing a separately reported cardiac electrophysiology procedure, and it is necessary to place a catheter in the coronary sinus to record left atrial activity. Femoral venous access site is already prepared for related procedure. Achieve central venous access, place a sheath in the femoral vein using standard percutaneous techniques, changing to subclavian or jugular access if that fails. Introduce the catheter into the sheath and advance into the right atrium where the ostium of the coronary sinus is engaged. Advance the catheter into the coronary sinus. Use the multielectrode catheter to record electrical activity from the left atrium and, at times, pace the left atrium to attempt arrhythmia induction. Reposition the catheter as necessary throughout the course of the cardiac electrophysiology procedure to optimize recordings and pacing thresholds. At the conclusion of the procedure, remove the catheter. Include a description of this additional work and catheter use and associated findings in the procedure report

Description of Post-Service Work: N/A CPT Code: 93621 SURVEY DATA RUC Meeting Date (mm/yyyy) 04/2020 Richard Wright, MD, Thad Waites, MD and Christpher Liu, MD, David Slotwiner, MD, Presenter(s): Mark Schoenfeld, MD Specialty American College of Cardiology; Heart & Rhythm Society Society(ies): CPT Code: 93621

Sample Size: 1188 Resp N: 53 Description of random ACC electrophysiologist members and random HRS members Sample: Low 25th pctl Median* 75th pctl High Service Performance Rate 0.00 40.00 75.00 120.00 250.00 Survey RVW: 1.45 2.50 3.20 5.00 20.00 Pre-Service Evaluation Time: 0.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 5.00 12.00 20.00 35.00 200.00 Immediate Post Service-Time: 0.00 Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 99217x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Sub Obs Care: 0.00 99224x 0.00 99225x 0.00 99226x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99217 (38); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99224 (20); 99225 (40); 99226 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process. (Note: your recommended pre time should not exceed your survey median time for any category) ZZZ Global Code

CPT Code: 93621 Recommended Physician Work RVU: 1.75 Specialty Specialty Adjustments/Recommended Recommended Pre- Recommended Pre-Service Time Service Time Pre Time Package Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 20.00 Please, pick the post-service time package that best corresponds to the data which was collected in the survey process: (Note: your recommended post time should not exceed your survey median time) ZZZ Global Code

Specialty Specialty Adjustments/Recommended Recommended Recommended Post-Service Time Post-Service Time Post Time Package Immediate Post Service-Time: 0.00 0.00 0.00

CPT Code: 93621

Modifier -51 Exempt Status Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No

New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No

TOP KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 93609 ZZZ 4.99 RUC Time

SECOND HIGHEST KEY REFERENCE SERVICE:

Key CPT Code Global Work RVU Time Source 99292 ZZZ 2.25 RUC Time

CPT Descriptor Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)

KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 36227 ZZZ 2.09 RUC Time 12,831 CPT Descriptor 1 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 37253 ZZZ 1.44 RUC Time 65,235

CPT Descriptor 2 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)

Other Reference CPT Code Global Work RVU Time Source 36483 ZZZ 1.75 RUC Time

CPT Code: 93621 CPT Descriptor Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

Number of respondents who choose Top Key Reference Code: 18 % of respondents: 33.9 %

Number of respondents who choose 2nd Key Reference Code: 6 % of respondents: 11.3 %

TIME ESTIMATES (Median) Top Key 2nd Key Reference Reference CPT Code: CPT Code: CPT Code: 93621 93609 99292

Median Pre-Service Time 0.00 0.00 0.00

Median Intra-Service Time 20.00 90.00 30.00

INTENSITY/COMPLEXITY MEASURES (of those that selected Key Reference codes) Survey respondents are rating the survey code relative to the key reference code.

Top Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 28% 28% 22% 22%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 22% 28% 50% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed CPT Code: 93621 • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 11% 50% 39%

Physical effort required 22% 44% 34%

Psychological Stress Less Identical More

• The risk of significant complications, 28% 39% 33% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

2nd Key Reference Code Much Somewhat Identical Somewhat Much Less Less More More

Overall intensity/complexity 0% 0% 0% 83% 17%

Mental Effort and Judgment Less Identical More

• The number of possible diagnosis 17% 50% 33% and/or the number of management options that must be considered • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed • Urgency of medical decision making

Technical Skill/Physical Effort Less Identical More Technical skill required 0% 17% 83%

Physical effort required 0% 17% 83%

Psychological Stress Less Identical More

• The risk of significant complications, 0% 50% 50% morbidity and/or mortality • Outcome depends on the skill and judgment of physician • Estimated risk of malpractice suit with poor outcome

Additional Rationale and Comments

CPT Code: 93621 The additional rationale below is the original rationale submitted by the specialty society(ies) prior to the RUC meeting and does not necessarily represent the rationale for the RUC recommendation. To view the RUC’s rationale, please review the separate RUC recommendation document.

History and Background

At the April 2020 virtual RUC meeting, the RUC recommended a value of 1.44, a crosswalk to CPT code 37253. The societies appealed that outcome after feeling limited by the virtual format, unable to adequately consult with one another or facilitate in the typical manner. That appeal was granted, and this SOR is a re-presentation of data from the April survey with reconfigured and enhanced recommendations the societies believe provide a satisfactory path forward.

In October 2019, the Relativity Assessment Workgroup identified services with Medicare utilization of 10,000 or more that have increased by at least 100% from 2013 through 2018, including CPT 93621 electrophysiologic evaluation.

For the April 2020 meeting, HRS and ACC randomly surveyed electrophysiologists, as designated by membership rolls. The survey was completed by physicians who have experience with the service. The key reference code is 93609 for intraventricular and/or intra-atrial mapping of tachycardia with catheter manipulation. It was selected by 33.9% of respondents. Nearly a third of these respondents indicate 93621 was virtually identical. The second reference code was 99292 for critical care evaluation. It was selected by 11.3% of respondents. All of these respondents indicated that 93621 was more intense/complex overall.

Since 2001, when this code was last surveyed, there have been a number of changes in technique that have contributed to change in intensity and total time of the procedure. In particular the typical access technique has evolved to the femoral vein to insert the catheter (as included in the updated description of service above), as opposed to the jugular or subclavian vein (as currently presented from the 2001 survey in the RUC database).

Compelling Evidence-Type Explanation for RVU Recommendation

Because the recommended work RVU is not an increase, a compelling evidence argument is not necessary. However, because of the change in calculated intensity that results from a decrease in intraservice time without an entirely commensurate decrease in work RVU, the societies make a compelling evidence-type presentation here. Specifically, there has been a change in technique that has changed physician work.

The technique used for coronary sinus catheter placement has evolved. Previously, a superior vena cava (SVC) approach via internal jugular (IJ) or subclavian vein access was the preferred route to access the coronary sinus. Anatomically, this provides an ideal angle from which to cannulate the coronary sinus which sits at the inferior posteroseptal region of the right atrium, just above the tricuspid valve. This angle makes it possible to use a simple fixed curve catheter and ensures that the catheter position will remain stable throughout the procedure. The downside of the superior approach is that it requires an additional access site (the internal jugular or subclavian vein) that would otherwise not be needed. This carries a small but real risk of pneumothorax and the IJ / subclavian access site can be uncomfortable for patients during and after the procedure. For these reasons, most electrophysiologists have evolved their practice and now use a femoral vein approach to deploy the coronary sinus catheter.

The femoral approach avoids the need to prep and drape an additional access site since the other sheaths and catheters for EP studies are also placed from a femoral approach. However, a separate and additional sheath does need to be inserted into the femoral vein for placement of the coronary sinus catheter. Due to the need for multiple sheaths in the same femoral vein access region, care must be taken during venous access to space the access sites sufficiently to avoid interference between the catheters. In addition, a femoral venous approach introduces anatomical challenges for cannulating the coronary sinus and does not provide the natural stability of the catheter achieved from a subclavian approach. The primary anatomical obstacles are the height of the eustachian ridge/inferior vena cava junction and the abrupt reverse angle (usually greater than 135 degrees) that the catheter must traverse once it passes above the eustachian ridge in order to enter to coronary sinus ostium. With the advent of manually deflectable catheters, electrophysiologists are usually (but not always) able to cannulate the coronary sinus from a femoral approach despite the anatomical challenges. However, because the anatomy (eustachian ridge/IVC junction) intrinsically puts pressure on the catheter in a direction that pulls it away from the coronary sinus, the catheter is much less stable than it would be from a superior approach. As a result, it is typical for the coronary sinus catheter to become dislodged multiple times in a single case requiring the operator to reposition the catheter each time.

CPT Code: 93621 We believe the minutes reduced from the change in access site are at the lower end of the intensity spectrum for the service, which naturally leads to an increase in calculated intensity that is compounded by the increased intensity of making the turn at the IVC/eustachian ridge and multiple re-positionings of the catheter.

Another difference from 2001 to now is that this service is typically added on to EP-studies performed in concert with ablation therapies, rather than with diagnostic-only EP studies as was predominant in 2001. Billed together data show that these services are now typically performed as a combination of therapeutic and diagnostic interventions (e.g., EP ablation), as opposed to simply diagnostic procedures, specifically the data shows that roughly 78% of 93621 is billed with 93653. This is another difference from the 2001 valuation. Patients who proceed to ablative therapies are more complex than those only receiving diagnostic catheterization.

For comparison purposes, the societies identified RVW comparator code 37252 for intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention. This code has the same amount of intraservice time, 20 minutes and, correctly, a slightly lower IWPUT of 0.088 than results from our recommendation. The societies also identified two other comparator codes that bracket the recommendation: 36483 for endovenous ablation therapy at 1.75 RVW with a slightly higher intensity than the recommendation at 0.088. This code reflects a mostly ‘technical’ procedure. The second code, 36227 for selective catheter placement has an RVW of 2.09 and a higher intensity of 0.1393 IWPUT.

Finally, revisiting a topic that arose during the first presentation of this code, while it is uncommon for an add-on code to be more intense than the underlying service, it does occur and it is common in the electrophysiology space. A relevant example is trans-septal puncture (93462) that may be performed with SVT ablation (93653). The ablation procedure IWPUT is 0.075 while the puncture is more intense at 0.093. An IWPUT of 0.088 from the RVU recommended below fits this model, and is a reasonable IWPUT rank order to the expert panel.

Recommendation

Therefore, for code 93621 the societies recommend a crosswalk to the RVW of 1.75 from code 36483 with 0 minutes preservice time, 20 minutes intraservice time from the survey median, and 0 minutes postservice time.

SERVICES REPORTED WITH MULTIPLE CPT CODES

1. Is this code typically reported on the same date with other CPT codes? If yes, please respond to the following questions: Yes

Why is the procedure reported using multiple codes instead of just one code? (Check all that apply.)

FREQUENCY INFORMATION

How was this service previously reported? (if unlisted code, please ensure that the Medicare frequency for this unlisted code is reviewed) 93621 CPT Code: 93621

How often do physicians in your specialty perform this service? (ie. commonly, sometimes, rarely) If the recommendation is from multiple specialties, please provide information for each specialty.

Specialty ACC How often? Commonly

Specialty HRS How often? Commonly

Specialty How often?

Estimate the number of times this service might be provided nationally in a one-year period? 59784 If the recommendation is from multiple specialties, please provide the frequency and percentage for each specialty. Please explain the rationale for this estimate. Based on double the Medicare data estimation reported in 2018.

Specialty Cardiac Electrophysiology Frequency 48000 Percentage 80.28 %

Specialty Cardiology Frequency 11794 Percentage 19.72 %

Specialty Frequency 0 Percentage 0.00 %

Estimate the number of times this service might be provided to Medicare patients nationally in a one-year period? 29,892 If this is a recommendation from multiple specialties please estimate frequency and percentage for each specialty. Please explain the rationale for this estimate. Fee for service utilization from RUC database from 2018 for 93621.

Specialty Cardiac Electrophysiology Frequency 24000 Percentage 80.28 %

Specialty Cardiology Frequency 5892 Percentage 19.71 %

Specialty Frequency 0 Percentage 0.00 %

Do many physicians perform this service across the United States? Yes

Main BETOS Classification: Procedures

BETOS Sub-classification: Major procedure

BETOS Sub-classification Level II: Cardiovascular-Other

Professional Liability Insurance Information (PLI)

If the surveyed code is an existing code and the specialty believes the specialty utilization mix will not change, enter the surveyed existing CPT code number 93621

If this code is a new/revised code or an existing code in which the specialty utilization mix will change, please select another crosswalk based on a similar specialty mix.

SS Rec Summary

ISSUE: Eletrophysiological services TAB: 21

RVW Total PRE-TIME INTRA-TIME IMMD SURVEY EXPERIENCE

Source CPT Global DESC Resp IWPUT MIN 25th MED 75th MAX Time EVAL POSIT SDW MIN 25th MED 75th MAX POST MIN 25th MED 75th MAX Intraventricular and/or intra- 1st REF 93609 ZZZ 18 0.055 4.99 90 0 0 0 90 0 atrial mapping of tachycardia Critical care, evaluation and 2nd REF 99292 ZZZ 6 0.075 2.25 30 0 0 0 30 0 management of the critically ill Comprehensive CURRENT 93621 ZZZ 0.070 2.10 30 30 0 electrophysiologic evaluation Comprehensive SVY 93621 ZZZ 53 0.160 1.45 2.50 3.20 5.00 20.00 20 0 0 0 5 12 20 35 200 0 0 40 75 120 250 electrophysiologic evaluation Comprehensive electrophysiologic evaluation REC 93621 ZZZ 0.088 1.75 20 0 0 0 20 0 including insertion and repositioning of multiple Intravascular ultrasound COMP 37252 ZZZ 0.088 1.80 22 1 0 0 20 1 (noncoronary vessel) during Allograft, structural, for spine COMP 20931 ZZZ 0.091 1.81 20 0 0 0 20 0 surgery only (List separately in Tissue cultured skin autograft, COMP 15151 ZZZ 0.100 2.00 20 0 0 0 20 0 trunk, arms, legs; additional 1 COMP Endovenous ablation therapy 36483 ZZZ 0.088 1.75 20 0 0 0 20 0 XWALK of incompetent vein, extremity, Intravascular ultrasound MPC 37253 ZZZ 0.071 1.44 21 0 0 0 20 1 (noncoronary vessel) during Selective catheter placement, MPC 36227 ZZZ 0.1393 2.09 15 0 0 0 15 0 external carotid artery, August 25, 2020

Scott Manaker, MD AMA/RVS Update PE Subcommittee American Medical Association 330 N. Wabash Ave. Chicago, IL 60611

RE: Tab 21 Practice Expense

Dear Dr. Manaker:

Tab 21 on the October 2020 RUC agenda addresses one add-on code for electrophysiologic services. This add-on service is provided exclusively in the facility setting. As such, we recommend no direct practice expense inputs for Tab 21.

Thank you for your consideration of this information as you prepare for the meeting. Please contact Claudia Vasquez at [email protected] if you have any questions.

Sincerely,

Richard Wright, MD ACC RUC Advisor

Mark Schoenfeld, MD HRS RUC Advisor