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Appendix IV.A 
IV.F 

Chapter 4.0 
Appendices 




Data Collection and 
Analysis for Generating 
Procedure-Specific Practice 
Expense Estimates (HCFA 
Contract No. 500-95-0009) 



April 30, 1997 



Prepared for 

Health Care Financing Administration 
Office of Research 
Mail Stop C-3- 1626 
7500 Security Boulevard 
Baltimore, MD 21244-1850 

Prepared by 
Abt Associates Inc. 
55 Wheeler Street 
Cambridge, MA 02138 



Abt 



Abt Associates Inc. 



55 Wheeler Street 
Cambridge, Massachusetts 
02138-1168 

617 492-7100 telephone 
617 492-5219 facsimile 



Hampden Square, Suite 500 
4800 Montgomery Lane 
Bethesda, Maryland 
20814-5341 

301 913-0500 telephone 
301 652-3618 facsimile 



101 North Wacker Drive 
Suite 400 
Chicago, Illinois 
60606-7301 

312 332-3300 telephone 
312 621-3 %W facsimile 



Appendix IV.A - 
IV.F 

Chapter 4.0 
Appendices 



Data Collection and 
Analysis for Generating 
Procedure-Specific Practice 
Expense Estimates (HCFA 
Contract No. 500-95-0009) 



April 30, 1997 



Prepared for 

Health Care Financing Administration 
Office of Research 
Mail Stop C-3- 1626 
7500 Security Boulevard 
Baltimore, MD 21244-1850 

Prepared by 
Abt Associates Inc. 
55 Wheeler Street 
Cambridge, MA 02138 



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List of CPEP Participants from Round II of CPEPs 



CPEP 1 Integumentary and Physical Medicine 



^rCr r alTICipdlll 


M r\ m inofinn 
IMUIIIIlldlHiy 


Name 


Society 


rJotten, Linda, U 1 K 


American Occupational Therapy Association 


Bozeman, MT 




Cohen, Jeffrey L., MD 


American College of Surgeons 


Hartford, CT 




Erwin, James H., MD 


American Academy of Physical Medicine & 


Wheaton, IL 


Rehabilitation 


Freedberg, Irwin M., MD 


American Academy of Dermatology 


New York, NY 


American Society for Dermatologic Surgery 


Keren, Lotchie M., DrM 


American Podiatric Medical Association 


Seattle, WA 




ivrrmes, vviinam J., uu 


American Academy of Osteopathy 


Manchester, NH 


American Osteopathic Association 


Resnick, Jeffrey I., MD 


American Society of Plastic & Reconstructive Surg 


Santa Monica, CA 




IvObb, L^Onaid L/., JJL 


American Chiropractic Association 


Huntsville, AL 




<st Win V^rnf»11 RA 

31. jonn, vemeii, d/\ 


American Academy of Dermatology 


Schaumburg, IL 


American Society for Dermatologic Surgery 


Taylor, Jessica A., FPSA 


American Academy of Facial Plastic & Reconst Surg 


Houston, TX 




Tetrault, Gerry, RN 


American Academy of Dermatology 


Coralville, IA 




Welker, Mary Jo, MD 


American Academy of Family Physicians 


Columbus, OH 





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List of CPEP Participants from Round II of CPEPs 
CPEP 2 Male Genital and Urinary 



CPEP Participant 
Name 



Nominating 
Society 



Card, Dennis, MD 
Concord, NH 

Heinemeier, Irene S. 
Reno, NV 

Lawrence, Maureen 
Concord, NH 

McGee, George E., MD, FACS 
Hattiesburg, MS 

Ratliff, Thelma J. 
Winchester, VA 



American Urological Association 



American Urological Association 



American Urological Association 



American Society of General Surgeons 



American College of Physicians 
American Society of Internal Medicine 



Senese, Victor, RN 
Oak Lawn, IL 



American Urological Association 



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List of CPEP Participants from Round II of CPEPs 
CPEP 3 Orthopaedics 



CPEP Participant 
Name 



Nominating 
Society 



Barrow, John P. 
Indianapolis, IN 

Bright, Robert, MD 
Baltimore, MD 



American Association of Neurological Surgeons 



American Academy of Pediatrics 



Coleman, William, MD, PhD 
Scottsboro, AL 



American Academy of Family Physicians 



Friedman, Mel, MD 
Owings Mills, MD 



American Academy of Orthopaedic Surgeons 



Ouzounian, Tye, MD 
Tarzana, CA 



American Orthopaedic Foot and Ankle Society 



Smith, David J., MD, FACS 
Ann Arbor, MI 



American Society of Plastic & Reconstructive Surg 



Smith, Linda, L. 
Columbus, OH 



American Podiatric Medical Association 



Smith, Lloyd S„ DPM 
Newton, MA 



American Podiatric Medical Association 



Taleisnik, Julio, MD 
Orange, CA 



American Society for Surgery of the Hand 



Tamler, Martin S., MD 
Royal Oak, MI 



American Academy of Physical Medicine & Rehab 
American Association of Electrodiagnostic Medicine 



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List of CPEP Participants from Round II of CPEPs 

CPEP 4 OB/GYN 



CPEP Participant 
Name 



Nominating 
Society 



Braun, Mary Ann, RNC, MSN, OGNP 
Washington, DC 

Harris, Daniel L., CMPE 
Phoenix, AZ 

Korb, Elizabeth G., CNM, MSN 
Asheville, NC 



American College of Obstetricians & Gynecologists 



American College of Obstetricians & Gynecologists 



American College of Obstetricians & Gynecologists 



Long, Doug, MD 
E. Boothbay, ME 

Molenaar, C. Richard 
Springfield, MA 

Moore, Glenn I., MD 
Lexington, KY 

Smith, Robert N, MD 
San Francisco, CA 

Tozzo, Pellegrino J., MD 
New Rochelle, NY 



American Academy of Family Physicians 



American College of Obstetricians & Gynecologists 



American College of Obstetricians & Gynecologists 



American College of Obstetricians & Gynecologists 



American Urological Association 



List of CPEP Participants from Round II of CPEPs 



CPEP 5 Ophthalmology 



CPEP Participant 


Nominating 


Name 


Society 


Ashnurn Frank" SI T\zfT) 


Ampnrfln ApaHpttw of Onhthfllmolnov 


Washington, DC 


American Society of Cataract and Refractive Surg 




American Society of Ophthalmic Registered Nurses 


Biglan, Albert W., MD 


American Academy of Ophthalmology 


Pittsburgh, PA 


American Society of Cataract and Refractive Surg 




American Society of Ophthalmic Registered Nurses 


Dobbs, Mary 


American Academy of Ophthalmology 


St. Louis, MO 


American Society of Cataract and Refractive Surg 




American Society of Ophthalmic Registered Nurses 


Dungan Applegeet, Carol, RN, MSN, CNOR, FAAN 


American Nurses Association 


Denver, CO 


Association of Operating Room Nurses 


Kontis, Theda, MD 


American Academy of Facial Plastic & Reconstructive 


Owings Mills, MD 


Surgery 


McPeak, Nancy, RN, BSN 


American Academy of Ophthalmology 


Glasgow, KY 


American Society of Cataract and Refractive Surgery 




American Society of Ophthalmic Registered Nurses 


Parrino, Jean P., COT 


American Academy of Ophthalmology 


New Albany, IN 


American Society of Cataract and Refractive Surgery 




American Society of Ophthalmic Registered Nurses 


Sharp, Robert H , OD 


American Optometric Association 


Atlantic, IA 




Tenney, Teresa, A. 


American Optometric Association 


Providence, RI 




Williams, George, MD 


American Academy of Ophthalmology 


Royal Oak, MI 





[ 
I 
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List of CPEP Participants from Round II of CPEPs 

CPEP 6 Radiology 



CPEP Participant 
Name 



Nominating 
Society 



Copeland, Lanny, MD 
Moultrie, GA 

Forsythe, John, RDMS, RDCS, RVT 
San Diego, CA 

Hauser, J. Bruce, MD 
Roanoke, VA 

Huurman, Walter W., MD 
Omaha, NE 



American Academy of Family Physicians 



American Institute of Ultrasound Medicine 



American College of Radiology 
Radiological Society of North America 

American Academy of Pediatrics 



Ibbott, Geoffrey S., PhD 
Lexington, KY 

Jacobson, Jeffrey M., MD 
Cleveland, OH 



American Association of Physicists in Medicine 



American Academy of Pediatrics 



Landau, Les M., DO 
Kirksville, MO 

McKusick, Kenneth, MD, FACR, FACNP 
Boston, MA 

Miale, Pat, MD, FACNP 
Ft. Lauderdale, FL 



American College of Osteopathic Surgeons 



American College of Nuclear Physicians 
American Society of Nuclear Medicme 

American Society of Nuclear Medicme 



Ring, Ernest J., MD 
San Francisco, CA 



Rose, Christopher, M., MD, FACR 
Burbank, CA 



Sawchuk, Peter L., MD, MBA 
Green Pond, NJ 

Tierney, James E. 
Minneapolis, MN 

Wexler, Lewis, MD 
Stanford, CA 



American College of Radiology 

Radiological Society of North America 

Society of Cardiovascular & Interventional Radiolo 

American Association of Physicists in Medicme 
American College of Radiology 
American Society for Therapeutic Radiology and One 
Radiological Society of North America 

American College of Emergency Physicians 



American College of Radiology 
Radiological Society of North America 

American Heart Association 



Wuerstle, Thomas J. 
Erie, PA 



Mobile X-Ray Providers of America 



List of CPEP Participants from Round II of CPEPs 
CPEP 7 Evaluation and Management 



CPEP Participant 
Name 



Nominating 
Society 



Backstrom, Ima Lou, CMA 
Fayetville, AR 

Bagley, Bruce, MD 
Latham, NY 

Bishop, Michael D., MD, FACEP 
Bloomington, IN 

Bower, Bruce F., MD 
Hartford, CT 

Busis, Neil A., MD 
Pittsburgh, PA 

Hetrick, Edward 
New City, NY 

Hill, Emily, PA-C 
Galax, VA 

Lareau, Suzanne, RN, MS, 
Loma Linda, CA 

Massey, Pamela Rand, PT, MSA 
Houston, TX 

McKibben, W. Jeanne, MD 
Oberlin, OH 

Murphy, Patricia A., PsyD. 
Terre Haute, IN 



American Association of Medical Assistants 



American Academy of Family Physicians 



American College of Emergency Physicians 



American Association of Clinical Endocrinologists 



American Academy of Neurology 

American Association of Electrodiagnostic Medicine 

American Society of Hematology 



American Academy of Family Physicians 
American Academy of Physician Assistants 

American Thoracic Society 



American College of Rheumatology 



American College of Physicians 
American Society of Internal Medicine 

American Psychological Association 



Sullivan, Michael 
Tacoma, WA 

Vanchiere, Charles, MD, CEO 
Lake Charles, LA 



Infectious Diseases Society of America 



American Academy of Pediatrics 



Woodcock, Elizabeth W., FACMPE 
Chartlottesville, VA 



American College of Physicians 
American Society of Internal Medicme 



List of CPEP Participants from Round II of CPEPs 
CPEP 8 General Surgery 



CPEP Participant 
Name 



Nominating 
Society 



Ascher, Nancy, MD, PhD 
San Francisco, CA 



American Society of Transplant Surgeons 



Bardon, Patricia, RN 
Grand Rapids, MI 

Dodd, Patricia, CST 
South Portland, ME 

Gage, John, MD, FACs 
Pensacola, FL 

Levine, Mark A., MD 
Englewood, CO 

Mabry, Charles, MD, FACS 
Pine Bluff, AR 

Opelka, Frank G., MD 
New Orleans, LA 

Rhodes, Nancy M., MPH 
Philadelphia, PA 

Rholl, Kenneth, MD 
Alexandria, VA 



American Society of Colon and Rectal Surgeons 



Association of Surgical Technologists 



American College of Surgeons 



American College of Physicians 
American Society of Internal Medicine 

American College of Surgeons 



American Society of Colon and Rectal Surgeons 



Society of Thoracic Surgeons 



American College of Radiology 



Senagore, Anthony, MD 
Grand Rapids, MI 

Wadle, Ronald W., DO, FACOS 
Livonia, MI 



American Society of Colon and Rectal Surgeons 



American College of Osteopathic Surgeons 



List of CPEP Participants from Round II of CPEPs 



CPEP 9 Otolaryngology 



CPEP Participant 
Name 


Nominating 
Society 


Anglin, Terry, MBA 
Oklahoma City, OK 


American Academy of Otolaryngology - HNS 


Bradley, Joel Jr., MD 
Clarksville, TN 


American Academy of Pediatrics 


Crotty, David W.,DO 
Santa Rosa, CA 


American Academy of Osteopathy 
American Osteopathic Association 


Ellison, Cynthia 
Nashville, TN 


American Speech, Language and Hearing Association 


Pollock, Kimberley J., RN, MBA 
Dallas, TX 


American Academy of Otolaryngology - HNS 


Rietz, Robert, MD, MBA 
Brookings, SD 


American Academy of Otolaryngology - HNS 
American Speech, Language and Hearing Association 


Taylor, Charles R..MS 
Springfield, MO 


American Academy of Otolaryngology - HNS 


Towne, Bradford, DMD 
Montpelier, VT 


American Association of Oral and Maxillofacial 
Surgeons 


Wilbers, James E., MBA 
Cincinnati, OH 


American Academy of Otolaryngology - HNS 



List of CPEP Participants from Round II of CPEPs 
CPEP 10 Miscellaneous Internal Medicine 



CPEP Participant 
Name 



Nominating 
Society 



Berendes, Jerry 
Marshfield, WI 



Blayney, Douglas W., MD, FACP 
Glendora, CA 

Fischer, Thomas J., MD 
Cincinnati, OH 



Fleming, David, MD 
Moberly, MO 

Gerald, Melvm, MD 
Washington, DC 

Green Lawrence, MD 
Chester, PA 



Kuchins, Anne, GNP 
Flushing, NY 

Lloyd, Robert, MD 
Chevy Chase, DC 

Paganini, Emil P., MD 
Cleveland, OH 

Ratkin, Gary A., MD 
St. Louis, MO 



American Academy of Neurology 
American Association of Electrodiagnostic Medicine 
American Electroencephalographic Society 
American Society of Electroneurodiagnosuc Technol 

American Society of Clinical Oncology 



American College of Allergy & Immunology 
International Association of Allergy & Clinical 
Immunology 

Joint Council of Allergy, Asthma & Immunology 

American College of Physicians 
American Society of Internal Medicine 

American Academy of Family Physicians 



American Academy of Neurology 

American Association of Electrodiagnostic Medicine 

American Electroencephalographic Society 

American Society of Electroneurodiagnostic Technology 

American Geriatrics Society 



American College of Rheumatology 



American Society of Nephrology 
Renal Physicians Association 

American Society of Hematology 



Wright, Jean A., MBA, MD 
Atlanta, GA 



American Academy of Pediatrics 



List of CPEP Participants from Round II of CPEPs 
CPEP 11 Gastroenterology 



CPEP Participant 
Name 



Nominating 
Society 



Bolan, Kevin C, RPA-C 
Newcomb, NY 

Chally, Cecil, MD 
Minneapolis, MN 

Chapman, Elaine M., RN 
Tempe, AZ 

Corley, Sarah T., MD 
Arlington, VA 

Fleming, Patricia R. 
Greensboro, NC 



American Academy of Physician Assistants 



American Gastroenterological Association 



Society of Gastroenterology Nurses & Associates 



American College of Physicians 
American Society of Internal Medicine 

American Association of Nurse Anesthetists 



Klish, William, MD 
Houston, TX 

Lockhart, Ann, RN, MN 
New Orleans, LA 

Smith, Melody, RN 
Decatur, IL 

Turner, Thomas C. 
New Orleans, LA 



American Academy of Pediatrics 



American Society of Colon and Rectal Surgeons 



American College of Physicians 
American Society of Internal Medicine 

American College of Gastroenterology 



Zeman, Robert K., MD 
Washington, DC 



American College of Radiology 



List of CPEP Participants from Round II of CPEPs 
CPEP 12 Cardiothoracic and Vascular 



CPEP Participant 
Name 



Nominating 
Society 



Anderson, Richard Powell, MD 
Seattle, WA 



Society of Thoracic Surgeons 



Applebaum, Harry, MD 
Los Angeles, CA 

Byrnes, John Francis, PA-C 
Maitland, FL 

Little, Alexander G., MD 
Las Vegas, NV 

Mayer, John E., MD 
Boston, MA 

Oblath, Robert, MD 
Encino, CA 

Tatken, Greta E., 
Annandale, VA 



American Pediatric Surgical Association 



Society of Thoracic Surgeons 



Society of Thoracic Surgeons 



Society of Thoracic Surgeons 



International Society for Cardiovascular Surgery 
Society for Vascular Surgery 

Society of Thoracic Surgeons 



List of CPEP Participants from Round II of CPEPs 
CPEP 13 Cardiology 



CPEP Participant 
Name 



Nominating 
Society 



Bateman, Timothy M., MD, FACC 
Kansas City, MO 

Gottdiener, John, MD 
Washington, DC 

Hamill, Stephen C, MD 
Rochester, MN 



American College of Cardiology 



American Society of Echocardiography 



North American Society of Pacing and Electrophysiology 



Laskey, Warren K., MD, FACC 
Baltimore, MD 



American College of Cardiology 



McKay, H. Brent, CPA, MBA 
Little Rock, AR 

Murphy, Mary 
Houston, TX 



American College of Physicians 
American Society of Internal Medicine 

American College of Cardiology 



Picard, Michael, MD 
Boston, MA 



American Society of Echocardiography 



Prystowsky, Eric, MD 
Indianapolis, IN 

Tidwell, Melissa 
Orlando, FL 



North American Society of Pacing and Electrophysio 



American College of Cardiology 



Williams, Anne Michelle, MD, FACS 
Glasgow, MT 



American College of Surgeons 



List of CPEP Participants from Round II of CPEPs 
CPEP 14 Anesthesiology/Pathology 



CPEP Participant 
Name 



Nominating 
Society 



Bauer, Stephen N., MD 
Carmichael, CA 

Beutler, Jeffrey M., CRNA 
Grand Rapids, MI 

Cohen, Neal H., MD, MPH 
San Francisco, CA 

Gamble, William G., MD, FACS 
Minneapolis, MN 

Johnstone, Robert E., MD 
Morgantown, WV 

Klein, Laurence, MD 
Washington, DC 

Larson, Sherry R., MHA, CEO 
Orlando, FL 

Martin, Scott A., MD 
St. Louis, MO 



College of American Pathologists 



American Association of Nurse Anesthetists 
American Society of Anesthesiologists 

American Society of Anesthesiologists 



American College of Surgeons 



American Society of Anesthesiologists 



American College of Physicians 
American Society of Internal Medicine 

College of American Pathologists 



College of American Pathologists 



Pomerantz, Anlouise, HT 
Orlando, FL 

Rowlingson, John, MD 
Charlottesville, VA 



College of American Pathologists 



American Society of Regional Anesthesia 



Venters, Lynda F., MBA, FACMPE 
Albuquerque, NM 



American Society of Anesthesiologists 



Wills, Randy F., MBA 
Cambridge, MA 



College of American Pathologists 



List of CPEP Participants from Round II of CPEPs 
CPEP 15 Neurosurgery 



CPEP Participant 


Nominating 


Mama 




Anderson, Kristen, MA 


American Academy of Neurology 


Houston, TX 


American Electroencephalographic Society 




American Society of Electroneurodi agnostic Technology 


Blaylock, Kevin, CPA 


American Association of Neurological Surgeons 


Oklahoma City, OK 




DeLano, Michael, CST/CFA 


Association of Surgical Technologists 


Hot Springs, SD 




Doll, Kay V. 


American Association of Neurological Surgeons 


Lexington, KY 




Florin, Robert, MD 


American Association of Neurological Surgeons 


Whittier, CA 




Kusske, John, MD 


American Association of Neurological Surgeons 


Laguna Hills, CA 




Marek, Richard, MD 


American Academy of Family Physicians 


Albuquerque, NM 





Roski, Richard, MD 
Davenport, IA 



American Association of Neurological Surgeons 



Subspecialty Representation at Round II CPEPs 





CPEP 


CPEP Participant 
Name 


Subspecialty Nominating 
Society 


CPEPl 


Integumentary and Physical 
Medicine 


John Zitelli, MD 


American College of Mohs 
Micrographic Surgery and Cutaneous 
Oncology 


CPEP4 


Obstetrics and Gynecology 


Kathryn Hone a, MD 


American Society of Reproductive 
Medicine 


PPPP4 




f^arnlvn Rnnowiry NAT") 


Sonptv of frvnprnlncHP OnrnlncJists 


CPEP4 


OHstptnps flnH frvnppnlncTv 
kj u o i^/ li i \*> o cuiu vj yiicuuiut y 




Motional Abortion Feneration 


CPEPS 


Onhthalmoloov 


Michael Hettmf?er MT) 


Eye Bank Association of America 


CPEP6 


Radiology 


Robert Zwolack, MD, 
PhD 


Society for Vascular Surgery 


CPEP8 


General Surgery 


Nelson Burton, MD 


Society of Thoracic Surgeons 


CPEP8 


General Surgery 


Latham Flanagan, MD 


American Society for Bariatric Surgery 


CPEP10 


Miscellaneous Internal 


R. Bart Sangal, MD 


American Sleep Disorders Association 



Medicine and Other 
Services 



Abt 



Abt Associates Inc. 

55 Wheeler Street ■ Cambridge MA 02138-1168 ■ (617) 492-7100 



Memo 



To: Clinical Practice Expert Panel Members 

From: Abt Principal Investigator 

Abt Project Director 
Date: May 20, 1996 

Subject: Briefing materials for upcoming CPEP meeting 

Your Clinical Practice Expert Panel (CPEP) will reconvene at the BW1 Marriott in Baltimore on Monday and 
Tuesday, June 3rd and 4th. Please review the enclosed documents as they will detail the content and structure 
of the meetings. This information includes: 

• Summary of Extrapolation Method - a description of the approach that will be used at 
the upcoming meeting to extrapolate from the reference service resource profiles to the rest 
of the services within the family. 

• Grouping of CPT Codes by Family - a listing of CPT codes and their descriptions, as they 
are grouped into clinically homogenous families. 

• Equipment and Supply Grids - for each family, a listing of the items used in the 
performance of the reference service, presented in a format suitable for extrapolation to the 
rest of the services within the family. If possible, please review these grids prior to arriving 
at the Baltimore meetings. Panel familiarity with the extrapolation material will help 
expedite the process considerably. 

• Ground Rules and Guidelines for Developing Service-Specific Profiles - This includes 
definitions of the roles of various attendees as well as guidelines for the panel process 

In addition, we want to thank those CPEP members who reviewed and submitted the reference service data 
from the first round of CPEP meetings. We carefully reviewed all CPEP member comments. Suggested 
changes to the reference service data were made only in cases where it was clear that the recording of 
information was in error. Suggested changes that require a consensus agreement (e.g., increasing/decreasing 
time estimates, reallocating time estimates among different staff types) were not incorporated, but can be raised 
for discussion at the CPEP meetings in June when we initiate extrapolation discussions for the service family in 
which the reference service resides. Should you have any questions about the meetings, please contact (Abt 
Contact) at (Abt Contact Phone Number). Thank you again for your continued participation on this project. 
We look forward to seeing you on June 3rd and 4th. 



OVERVIEW OF THE EXTRAPOLATION METHOD FOR ROUND 2 OF THE CPEPs 
Data Collection and Analysis for Generating Procedure-Specific 
Practice Expense Estimates 

Introduction 

Under contract to the Health Care Financing Administration, Abt Associates Inc. is developing 
resource-based practice expense values for the services in the Medicare Fee Schedule (MFS). As 
part of the project, the first round of Clinical Practice Expert Panels (CPEPs) were conducted in 
February, 1996, during which profiles of direct clinical and administrative resources were developed 
for a set of "reference services." Each of the 229 service families contained in the classification 
system of CPT-4 codes (developed in an earlier phase of the project) has a reference service 1 . In the 
second round of CPEP meetings to be held in June, 1996, the work of the panels will focus on 
extrapolation of the reference service resource profile to all CPT codes in the service family, for each 
family within each CPEP. The reference service data collected during round one will serve as the 
baseline profile for each family, and the panels will identify differences in resource requirements for 
the extrapolated codes at a level that is more aggregated than was used in the first round of CPEP 
meetings. This paper provides an overview of the methodology that will be employed during the 
June extrapolation meetings. Please take some time to familiarize yourself with the process. 
Successful implementation of this process will require that all participants have an understanding of 
the approach. 

Labor 

The labor extrapolation will be performed in two basic steps, with the first activity implemented prior 
to the CPEP and the remaining activities being performed during the two-day meetings. 

Step 1 : Review reference materials (enclosed in this mailing) prior to meeting 
Step 2: Identify and arrive at consensus on key drivers 

Each of these steps is described below. 

Step 1: Review reference materials and identify potential key "drivers" 

Definition: "Drivers" are characteristics that differentiate groups of CPT codes from the reference 
service within a family. For example, in a pilot test of the extrapolation process, physicians noted 
that for some surgical service families, the number of post-discharge office visits is the key driver of 
practice expense differences within the family. This observation allowed the participants to group 
the services in a family into sub-groups, each of which contained services with the same number of 



1 There are a small number of families which contain two reference services. 



Abt Associates Inc. 



1 



post-discharge office visits. The resource profile for each sub-group was defined to be that of the 
reference service, plus (or minus) the resources required to deliver the greater (lesser) number of 
office visits. In this example, post-discharge office visits was identified as the key driver. Similarly, 
the presence or absence of malignancy is another potential driver, as is the degree of pre-surgical 
authorization required. 

Please review the enclosed material, keeping in mind the task of identifying the key drivers or factors 
which determine practice expense differences: 

• A complete listing of the CPT-4 codes within your CPEP, arranged in family order 
and sorted by CPT code within each family and, 

• Information on each procedure that may assist you in identifying additional key 
drivers for each family (e.g., physician intra-service time, number of post-operative 
visits). 

Please bring the above documents with you for further discussion at the CPEP meeting along with 
recommendations for other key drivers for each family. 

Step 2: Identify and arrive at consensus on the key drivers of labor time for each family 

One of the initial tasks during the first day of the CPEP meeting will involve arriving at consensus 
among the CPEP members on the key drivers that distinguish sets of codes within a given family. 
Using the data provided in the briefing package, as well as discussing potential drivers that CPEP 
members may suggest, the panel will arrive at consensus on the critical factors, or drivers, that affect 
resource use. This will require that the panel address a number of questions for each family: 

■ Are the labor requirements for each code in this family the same as for the reference service? 

■ If the requirements are different from those of the reference service then the following questions 
will be addressed: 

► what is it about the codes with different requirements that determines the differences (e.g., 
cancer-related, number of post-discharge visits) 9 

- can you categorize the codes into sub-groups that are highly similar in these dimensions 9 

► can you provide increments (or decrements) to the labor time of the reference service for each 
of the sub-groups (by staff type and function) 9 ■ 

These questions will help us to identify and come to consensus on the key distinguishing features 
between sets of codes within a family, as well as provide the different time requirements by staff type 
for the extrapolated codes. See Attachment A for a sample worksheet of extrapolated staff times. 



Abt Associates Inc. 



2 



Equipment and Supplies 



Extrapolation of equipment and disposable supplies will be completed in "grids." The grids will be 
tables that contain supply (or equipment) items along the vertical axis and service periods along the 
horizontal axis (See Attachment B and C). All panelist will receive the grids prior to the meetings. 

Guidelines/Ground Rules for Extrapolation 

Moving Codes. If agreed upon by the CPEP, codes will be allowed to move from one family to 
another family within the CPEP. CPEPs must extrapolate all codes in their CPEP, regardless of their 
familiarity with the codes. 

Code-specific Extrapolation. It is important that to the extent possible the panel stay focused on 
groups, or sub-families, of codes, rather than individual codes. The level of detail and effort required 
when addressing specific individual codes is inefficient. The objective of the extrapolation is to focus 
on groups of codes that are similar in their resource use along one or more dimensions (e.g., number 
of post-operative visits, cancer-related codes, intra-service time, etc.) 

Sub-specialty Input . There are specific codes in each family that are performed by specialists other 
than the CPEP members (e.g., hand surgeons vs. general orthopaedic surgeons). We will be 
obtaining input from sub-specialists for the relevant codes by allowing participation at the CPEP 
meetings by sub-specialists for specific sub-sets of codes. 



Abt Associates Inc. 



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Glossary of Terms Used in Family Listing of CPT Codes 



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Instructions for Completing the Equipment and Supply Grids 



The enclosed grids will be used during the extrapolation process to record equipment and supply needs for 
the services in each family for your CPEP. To the extent feasible, please review and complete the grids 
prior to arriving at the Baltimore meetings. 

General Instructions: Whenever possible, services in a given family should be grouped into "like" 
procedures. The enclosed equipment and supply grids are designed to accommodate such sub-groupings 
but can. if necessary, be used to identify the resources for a single procedure. For each family there is a 
listing (printed on legal-size paper) of all items identified as necessary for the provision of the reference 
service. Enclosed with each packet are copies of blank grids printed on SV2 x 1 1 -sized paper with columns 
corresponding to general aspects of a medical procedure (e.g., pre-service. intra-service, and post-operative 
office visits). These are designed to be an overlay to the legal-sized equipment and supply grids (align the 
top right edges). Each 8V2 x 1 1 page is designed to capture the equipment or supply needs for a particular 
sub-group of services (as defined by the panelists) within the same family as the reference service. Copy 
as many of the blank grids as needed to accommodate the number of sub-groups within each family. 
The equipment and supply needs of these sub-groups should be compared to those of the reference service 
and usage of each item should be noted in the appropriate columns. 

Note that at the bottom of each list of equipment or supply items for a reference service there are lines 
labeled "Pack." When possible, we will identify during the meetings a list of items that are commonly used 
for a multitude of procedures and label them a "pack". For example, panelists may identify a list of 
supplies commonly used during excisions or the treatment of lacerations. If possible, please consider the 
potential composition of such packs. We will compile lists of items for each pack during the meetings and 
refer to them during the extrapolation process. Past pilot tests of the extrapolation process have shown that 
such an approach significantly simplifies and expedites the process. 

Supplies: CPEP members should complete the grids (including the addition of new supply types) by 
reporting quantities of supplies in the table cells for the pre-service visit, intra-service time, and all post- 
operative office visits. If it is more convenient to consider supplies required for the provision of all aspects 
of the service, panelists may instead indicate the total quantities for each supply in the "total" column. 
Please note that the supplies listed for the reference service correspond to the total quantities required for 
all aspects of the provision of that service (e.g.. all pre-service. intra-service. and post-operative needs). 

Equipment: For equipment, the cells should simply be checked when the listed piece of equipment is used 
for a specific service. If additional pieces of equipment not listed for the reference service are used for the 
extrapolated codes, then these should be added to the list and the appropriate columns should be checked. 
Again, panelists may find only the "total" column necessary for recording equipment usage for the various 
services within a family. Please do not feel obligated to complete the grid for every aspect of the provision 
of a service if this is not appropriate or convenient. 

Should you have any questions regarding the use of the equipment and supply grids, please contact (Abt 
( 'ontact and Phone Number). 



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GROUND RULES AND GUIDELINES 



Goal of the CPEP meeting: 

To provide HCFA with estimates of the resources needed to provide each service. We 
will arrive at consensus on extrapolated values, based on reference service values, for 
codes or groups of codes within each family. 

Substantive: 

1 . Focus on PRACTICE EXPENSES and not WORK (see Attachment A for 
inclusions/exclusions guidelines) : 

practice expenses are relevant only if they are incurred by the practice 

2. Moving Codes 

if agreed upon by the CPEP, codes will be allowed to move from one family to 
another family within the CPEP. CPEPs must extrapolate all codes in their CPEP, 
regardless of their familiarity with the codes. 

3. Code-specific Extrapolation 

it is important that to the extent possible the panel stay focused on groups, or sub- 
families, of codes, rather than individual codes. The level of detail and effort 
required when addressing specific individual codes is inefficient. The objective of 
the extrapolation is to focus on groups of codes that are similar in their resource 
use along one or more dimensions (e.g., number of post-operative visits, cancer- 
related codes, intra-service time, etc.) 

4. Changing Reference Service Values 

changes to the reference values will only be considered if the CPEP unanimously 
agrees. 

5. Role of CPEP members. 

each CPEP member is acting as an expert in his/her field 

CPEP members are not representing their medical societies, but are to present their 
judgement about practice expenses from the perspective of their own practices and 
their knowledge of typical practice 

the function of the CPEP members who are not the primary providers of the 
reference service is to act as independent assessors of the resource estimates 
suggested, to ask questions to ensure validity and reality, and to add their own 
clinical judgement 



6. Role of Sub-specialty Representatives: 

provide input on relevant codes that are performed by the sub-specialist. 

7. Role of Society Observers: 

explain data that may have been included 
serve as a resource to the entire CPEP process 

8. Role of Abt Moderator: 

keep the pace moving 

help group decide when they are stuck (using the process defined below) 

ensure that all panel members participate and have the opportunity to speak (do 
not let one member dominate) 

maintain a neutral role regarding content matters, but actively assist in managing 
group processes 

9. Role of Abt/HCF A Floater: 

serve as a resource for technical issues and questions across all CPEPs 
provide assistance in resolving particularly difficult consensus discussions 

10. Role of Recorders: 

check participants and observers in at the door 
enter consensus data into laptop/worksheet 

take notes about general discussion, particularly on disagreements and 
justifications for consensus values 

Process: 

1 . Start and end sessions on time 

2. Take breaks only at designated times (to avoid the 'busybody syndrome" - people coming 
and going during the course of the meeting to take phone calls, etc.); the group may 
decide when each break is warranted 

3. Respect all contributions and contributors - divergent views are encouraged 



4. 



Allow only one person to speak at a time 



5. In order to minimize interruptions during the CPEP meetings, communication among 
CPEP members and Society Observers during the sessions is limited to written notes and 
messages. Society Observers can communicate verbally to CPEP members only during 
the designated breaks. 

6. Disagreements should not become personal. 

7. Resolution of conflicts: in cases where consensus cannot be reached in a reasonable time 
frame, agree to disagree and move on. Before attempts to obtain consensus are 
abandoned, outlier opinions should be excluded if they keep the panel from reaching 
consensus. In situations where consensus is not achieved, the views of each CPEP member 
will be recorded and analyzed subsequent to the CPEP meeting. 



m 



Attachment A: 
Guidelines for Inclusion/Exclusion 



Resource Profiles 



SHOULD: 



SHOULD NOT: 



Include activities most commonly not performed by physicians 
as defined by Medicare (MDs, DOs, ODs, Psychologists, 
Chiropractors, Dentists, Podiatrists). 

Be based on recent, accepted clinical practice. 



Be based on the typical patient across all age groups. 



Reflect the practice's variable costs. Variable costs include 
costs of resources directly attributable to performing a 
particular service. 



Reflect time required to perform service-specific functions by 
support staff who are typically employed or contracted by a 
practice and who cannot bill separately. Examples of support 
staff include: 

•Registered nurses(RNs) 
•Licensed Practical Nurses (LPNs) 
•Medical Secretaries 
•Receptionists 
•Technicians 



Include medical equipment, with acquisition cost > $500, that 
is purchased or leased by practice and that is used in the direct 
provision of a given service. 

Include disposable medical supplies that are purchased by 
practice and that are used in direct provision of a given service. 



1 . Include activities most commonly performed by physicians as 
defined by Medicare. 



Be based on outmoded clinical practices or new practices that 
have yet to be adopted by most providers. 



Be based on an unusually easy or difficult case. Nor should 
resource estimates be based only on the Medicare population. 



4. 



7. 



Reflect the practice's overhead costs. Overhead costs include 
fixed expenses of the practice and are not directly related to a 
specific service. These costs are the focus of the Survey of 
Practices. Examples of resources that are part of overhead 
costs, but are often mistaken as part of variable costs include: 

Standby time 

Time to transport/courier patient test results/specimens 
Time to restock supplies 
Quality assurance activities 

Employee training 

nclude time spent performing service-specific functions by 
staff, who are employed and paid by a hospital, nor time spent 
by fellows or physicians. 

Reflect time spent on service-specific functions by staff who 
bill separately for their services through the physician work 
component. Since these staff bill through the work component 
of the fee schedule, they are not considered part of practice 
expenses. Staff who can bill separately include: 



•Certified Registered Nurse 

Anesthetists (CRNAs) 
•Clinical Social Workers(CSWs) 
•Chiropractors 
•Dentists 

•Doctors of Osteopathy 
•Nurse Midwives (NMs) 
•Nurse Practitioners (NPs)/ 

Clinical Nurse Specialists (CNSs) 



•Optometrists 
•Podiatrists 

•Physical/Occupational 
Therapists (PT/OTs) 
•Physician Assistants(PAs) 
•Physicians 

•Clinical Psychologists(CPs) 



Include any medical equipment owned or provided by a 
hospital, nor any non-medical capital items (e.g., office 
computers and software, photocopiers, or desks) . 

Include any medical supplies purchased or provided by a 
hospital. 



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Abt Associates Inc. 

55 Wheeler Street ■ Cambridge MA 02138-1168 ■ (617) 492-7100 



Memo 



To: New Clinical Practice Expert Panel Members 

From: Abt Principal Investigator 

Abt Project Director 
Date: May 20, 1 996 

Subject: Briefing materials for upcoming CPEP meeting 



Thank you for agreeing to participate in the second round of Clinical Practice Expert Panel (CPEP) meetings. 
Your CPEP will convene at the BWI Marriott in Baltimore on Monday and Tuesday, June 3rd and 4th. 
Enclosed you will find documents providing information for the upcoming CPEP meetings. This information 
includes: 

• Overview of the Clinical Practice Expert Panels - a thorough description of the CPEP process. 

• Overview of Practice Expense Project and Summary of Round I CPEP Process - a brief 

overview of the CPEP process and the Round I CPEP meetings. 

• Summary of Extrapolation Method - a description of the approach that will be used at the 
upcoming meeting to extrapolate from the reference service resource profiles to the rest of the 
services within the family. 

• Grouping of CPT Codes by Family - a listing of CPT codes and their descriptions, as they are 
grouped into clinically homogenous families. 

• Equipment and Supply Grids - for each family, a listing of the items used in the performance of 
the reference service, presented in a format suitable for extrapolation to the rest of the serv ices 
within the family. If possible, please review these grids prior to arriving at the Baltimore meetings. 
Panel familiarity with the extrapolation material will help expedite the process considerably. 

• Ground Rules and Guidelines for Developing Service-Specific Profiles - This includes 
definitions of the roles of various attendees as well as guidelines for the panel process. 

All new panelists should read the document titled "Overview of Practice Expense Project & Summary of 
Round I CPEP Process, May 7, 1996." Also, the summary of the Exfapolation Methodology contains valuable 
information for both new and continuing panelists. Please review these two documents and the equipment and 
supply grids before arriving at the meetings. The remaining materials are designed to be used as references. 
Please bring all enclosed documents with you to the meeting. 

Should you have any questions about the meetings, please contact {Abt Contact) at {Abt Contact Phone 
Number). Again, thank you for your participation on this project. We look forward to seeing you on June 3rd 
and 4th. 



1 
I 



Data Collection and Analysis for Generating Procedure-Specific 

Practice Expense Estimates 



HCFA Contract No. 500-95-0009 



Overview of Clinical Practice Expert Panels (CPEPs) 

December 15, 1995 



Abt 



Abt Associates Inc. 



I 

1 
i 



1.0 Introduction 

1.1 Background 

In response to the Omnibus Budget Reconciliation Act of 1989 (OBRA-89), in 1992 the 
Health Care Financing Administration (HCFA) began phasing in the Medicare Fee Schedule 
(MFS) . The MFS defines a predeteimined payment for physician services that is based on three 
components: physician work, practice expense, and malpractice insurance costs. A relative value 
unit (RVU) is assigned to each of these three components. To determine the Medicare payment 
for a service, these RVUs are summed and multiplied by a geographic adjustment factor (GAF) 
and by a conversion factor, which translates the total RVUs into a dollar amount. 

The physician work relative value units included in the MFS were developed using a 
resource-based approach that reflects the physician resources required to provide each service. 
However, under the original legislation enacting the Fee Schedule, the relative values for the 
practice expense and malpractice cost components were determined based on historical charge 
data predating the MFS. As a result, in the Social Security Act Amendments of 1994, Congress 
mandated that the Secretary of Health and Human Services "...develop a methodology for 
implementing in 1998 a resource-based system for determining practice expense relative value 
units for each physician service" covered by Medicare. In response to this legislation, HCFA 
issued a Request for Proposals and selected Abt Associates Inc. to conduct the study, "Data 
Collection and Analysis for Generating Procedure Specific Practice Expense Estimates." The 
objective of this project is to collect and analyze data on the practice resource requirements of 
providing MFS services. These data will be used to develop revised practice expense RVUs that 
represent the actual resources used to provide each service. 

Abt will provide HCFA with databases that include all information collected through this 
study. In 1996, HCFA intends to award multiple contracts to further analyze these data and 
enable other health services researchers to test alternative methods for estimating physician 
practice expense RVUs. Ultimately, the payment revisions will be determined by HCFA after 
soliciting public comment in a Notice of Proposed Rulemaking. These changes are mandated by 
law to take effect January 1, 1998. 



Prepared by Abt Associates Inc., December 15, 1995 



Page 2 Overview of Clinical Practice Expert Panels 

1.2 Overview of Approach 

Abt, in conjunction with HCFA, has developed a two-pronged approach to collect data on 
the costs that make up practice expenses: overhead and variable costs. 1 During the first half of 
1996, we will conduct a survey of 5,000 practices to collect data on aggregate practice expenses. 
These survey data will be used to help allocate the overhead costs to individual services. 
Information necessary for generating variable cost estimates for each service will be generated by 
the Clinical Practice Expert Panels (CPEPs) that are the subject of this overview. 

Each CPEP will meet twice. During their first meeting, they will develop resource 
profiles that specify the inputs, (e.g. medical supplies, clinical personnel) required to provide 
selected reference services. These reference services have been selected from 229 service 
families into which MFS services are grouped. During a second meeting, CPEP members will 
develop variable cost estimates for the remaining codes in each family by extrapolating from the 
reference service cost estimates. The resulting variable costs will be added to the service-specific 
overhead costs (derived from the survey results) to determine the total practice costs of each MFS 
service. The project's process for developing service-specific practice expense is depicted in 
Exhibit 1 . 

1.3 Input from the Medical Community 

Considerable effort has been devoted to secure participation from the medical community 
in designing this data collection approach. Abt has formed a Technical Expert Group (TEG), 
comprised of researchers and physicians, who have provided technical direction to the project. A 
Clinical Practice Expert Panel-Technical Expert Group (CPEP-TEG), composed of active 
clinicians and practice administrators, has also met to advise Abt and HCFA on all facets of the 
CPEP design and process. In addition, HCFA has organized two public meetings for medical 
societies, and throughout various stages of this project Abt has provided over 125 medical 
societies the opportunity to provide comments and recommendations on the following key aspects 
of the project: 



'Overhead costs include those fixed expenses that are incurred in the operation of the practice as a whole and are 
indirectly related to the provision of the service, such as rent and utilities. Variable costs include those expenses that 
are directly attributable to performing a particular service, such as nurse wages and medical supply costs. Thus, for a 
given service, the total practice expense equals the sum of the practice-wide overhead costs, allocated to the service- 
specific level, and the variable costs of providing that service. 

Prepared by Abt Associates Inc., December 15, 1995 



I 
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Page 3 



Overview of Clinical Practice Expert Panels 



• The practice expense survey; 

• The grouping of MFS services into service families; 

• The grouping of service families into CPEPs; 

• Selection of reference services; 

• Worksheets to collect variable practice expense data; and 

• Nominations for CPEP membership. 

The input obtained from all of these groups has been instrumental in devising the approach for the 
project. 

In the sections that follow, we describe the structure of the CPEPs and how the CPEPs 
will function to develop variable cost estimates. Section 2.0 describes the structure and 
composition of the CPEPs. The primary functions of the CPEPs and process for convening the 
first panel are explained in Section 3.0. 

2.0 Structure and Composition of the CPEPs 

The MFS contains over 6,000 services for which the CPEPs must develop variable cost 
estimates. To facilitate this task, Abt developed a classification system that organizes the MFS 
services into clinical and resource homogenous groups. These groups, referred to as service 
families, were, in turn, assigned to specific CPEPs. The classification system (described in detail in 
the Technical Appendix) resulted in 229 unique service families assigned across 1 5 CPEPs. 

Some families have been assigned to more than one CPEP to provide built-in validation of the 
resource and variable cost estimates that will be developed by these panels. Evaluation and 
Management (E&M) service families, which are common to the entire medical community, are both 
grouped in an E&M services CPEP and assigned across all CPEPs to obtain data from a broad 
representation of specialties. A complete listing of all CPEPs and their total service family 
assignments is presented in Exhibit 2. 

Clearly, detailed resource requirements cannot be completed for all services in the MFS. 
Therefore, a reference service from each service family was identified for which detailed resource 
profiles will be developed. In a second set of CPEP meetings, the practice expenses of the remaining 
codes in each family will be estimated by extrapolating from the reference services. 



Prepared by Abt Associates Inc. , December 15, 1995 



Page 4 Overview of Clinical Practice Expert Panels 

Reference services were selected using criteria determined after consultation with the CPEP- 

TEG: 



• Commonly performed (i.e high volume and high Medicare allowed charges relative to the 
other services in the family); 

• Mid-range level of resource usage relative to other services in the family; 

• Little or no change in definition or coding application over the last several years; and 

• Little variation across physicians in the way the services are performed. 

BMAD and other data were used to identify the specialties which provide the services in 
each CPEP, as well as to identify the percent of a specialty's services performed within each 
CPEP. Both of these factors were considered in determining the optimal composition of the 
CPEPs. In addition, several other factors were considered in formulating the CPEP composition. 
The CPEPs are structured such that no panel has a substantial majority of its representation from a 
single specialty. In addition, a primary care provider and a surgeon were assigned to each panel. We 
have also attempted to ensure that different types of practice staff (i.e. physicians, practice 
administrators, and other clinicians) are included on each CPEP. Similarly, we have attempted to 
achieve appropriate cross-specialty representation as well as geographic and practice type variation. 
Such broad representation will ensure that different practice characteristics are considered when 
defining the resource requirements for the reference services. 

3 . CPEP RESPONSIBILITIES 

In providing input to the variable cost estimation process, the CPEPs will be asked to 
perform three primary tasks: 

• Develop service-specific resource profiles for the reference services (Meeting 1); 

• Extrapolate reference service variable cost estimates to the remainder of the codes 
in each family (Meeting 2); and, 

• Validate the practice costs derived for all MFS services (mail review). 



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Page 5 Overview of Clinical Practice Expert Panels 

3 . 1 First CPEP Meeting to Develop Resource Profiles 

Abt has developed standardized worksheets to ensure that the various inputs are 
enumerated in the resource profiles. The worksheets are designed to collect data on the number 
of minutes spent on clinical and administrative functions by practice support staff. They also 
collect information on utilization of medical equipment and disposable medical supplies. In 
preparation for the first CPEP meeting, we are asking panel members to complete these 
worksheets for the reference services assigned to their CPEP. 

The panel discussions will be structured and moderated by senior Abt Associates staff to 
achieve consensus among participants regarding the resource profiles for each reference service. 
Discussions will be directed at understanding and resolving any initially divergent views in order 
to ensure the agreement of all panel members. CPEP members' prior exposure to the worksheets 
and the types of data needed to develop resource profiles for each service should facilitate the 
consensus-building process. Abt has also provided over 125 medical societies with the 
opportunity to complete the worksheets. 2 Abt will prepare summary tables depicting the results 
of the data collected from both the CPEP members and the medical societies. These summary 
data will help to promote initial discussions at the panel meetings. 

We expect that CPEP members will each enter the panel meetings with a perspective 
based on his/her own practice. The moderator will facilitate group discussions toward a consensus 
description of the "typical" resources required to render the service. In addition, panel members 
will be reminded to base their resource estimates on recent clinical practice. 

3.2 Additional Functions of the Cpeps 

Abt will collect standard prices (wages and supply prices) of the inputs specified in the 
resource profiles for each reference service. These prices will be applied to the data on resource 
profiles provided by the first CPEP meetings to compute variable cost estimates for all of the 
reference services. The extrapolation process conducted during the second CPEP panel meeting 



2 In HCFA's public meetings several medical societies raised concerns about the scope of representation on each 
CPEP, given that each of the 15 CPEPs can accommodate only 8-17 participants. In an effort to broaden the scope of 
data reviewed during each CPEP, Abt and HCFA decided to provide the societies with the opportunity to complete 
the worksheets and submit data on whichever reference services they deem relevant. The approach to collecting these 
data was left to the discretion of each society, allowing each organization to develop its data collection strategy based 
on both concerns of pragmatism and validity. 

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Page 6 Overview of Clinical Practice Expert Panels 

will require CPEP members to evaluate the variable costs of the remaining services within each 
group relative to the reference service for the family. 

Abt will subsequently combine the resulting variable cost estimates with the service- 
specific overhead cost estimates derived from the survey of medical practices to calculate the total 
practice costs of each MFS service. The CPEP members will be asked to complete the final task 
of reviewing the total practice expense determined for each service, focusing particularly on the 
cost relationships across services. 

3.3 S CHEDULE OF CPEP ACTIVITIES 

The schedule of the CPEP activities that were described in section 3.1 and 3.2 is listed 

below. 



CPEP Summary Schedule 



Panel 

First Series of CPEP Meetings 


Schedule 

1 February 1996 


Second Series of CPEP Meetings 


May 1996 


Validation Activities (completed via 
mail review) 


January 1997 



Prepared by Abt Associates Inc. , December 15, 1995 



Exhibit 2: 

Summary of Clinical Practice Expert Panels 



CPEP 



Description 



Unique # of 
Service 
Families 3 



Total U of 
Service 
Families 4 



Integumentary and Physical Medicine 



12 



17 



Male Genital and Urinary 



19 



23 



Orthopaedics 



24 



29 



Obstetrics and Gynecology 



18 



22 



Ophthalmology 



16 



19 



Radiology 



17 



19 



Evaluation and Management and Other Services 



15 



19 



General Surgery 



25 



36 



Otolaryngology 



16 



22 



Miscellaneous Internal Medicine and Other 
Services 



17 



22 



11 



Gastroenterology 



12 



12 



Cardiothoracic and Vascular Surgery 



16 



13 



Cardiology 



14 



19 



14 



Anesthesiology and Pathology 



10 



15 



Neurosurgery 



10 



14 



3 The classification of MFS services into service families and CPEPs resulted in the creation of 229 mutually 
exclusive and exhaustive clinical and resource homogenous service family groupings assigned across 15 CPEPs. 

"For validation purposes, certain service families have been assigned to multiple CPEPs resulting in 299 service 
family assignments allocated across the 15 CPEPs. 



TECHNICAL APPENDIX 



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A 1.0 BACKGROUND ON CPEP STRUCTURE AND COMPOSITION 

To formulate the Clinical Practice Expert Panels (CPEPs), Abt completed the following 

steps: 

• Identified all services in the MFS to be included in the analysis; 

• Grouped clinical- and resource-homogeneous services into service families; 

• Assigned related service families to appropriate Clinical Practice Expert Panels 
(CPEPs); 

• Selected a reference service from each family that would serve as the benchmark for 
estimating variable costs for the remaining codes in each family; and, 

• Identified individuals to serve as CPEP members. 

Each of these steps was performed with extensive input from HCFA medical staff, Abt's clinical 
consultants, the TEG and CPEP-TEG, as well as numerous medical societies. Below, we describe in 
greater detail how these steps were implemented in defining the CPEPs. 

Al.l IDENTIFYING SERVICES TO BE GROUPED 

To determine the specific set of service codes for which practice expenses will be measured, 
Abt consulted with staff in HCFA's Bureau of Policy Development. The HCPCS coding system has 
three levels, level 1 CPT-4 (numeric codes), level 2 (alphanumeric national codes), and level 3 
(alphanumeric local codes). All HCPCS level 1 and level 2 codes 5 are designated by HCFA with a 
status indicator, which shows whether the HCPCS code is in the fee schedule, and whether it is 
separately payable if the service is covered. Of the 8,538 services with status codes, the 
following codes are currently used: 

A= Active code (5,875 codes) 

B= Bundled into another service (41 codes) 

5 

Except for enteral and parental therapy, durable medical equipment, orthotics, and temporary codes for non- 
physician services or items. 

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Page A-2 Overview of Clinical Practice Expert Panels 

C= Carrier-priced (161 codes) 
D= Deleted codes (134 codes) 

E= Excluded from the fee schedule by regulation (437 codes) 

G= Not valid for Medicare (29 codes) 

H= Deleted modifier (1) 

N= Non-covered service (140 codes) 

P= Bundled or excluded codes (107 codes) 

R= Restricted coverage (482 codes) 

T= Injections (4 codes) 

X= Exclusion by Law (1,160 codes) 

HCFA concluded that the practice expenses for selected services with status indicators A 
(5,873), B (3), C (45), G (4), N (30), R (39), and T (4), as well as 253 anesthesia codes, which 
are paid under a separate fee schedule, were to be evaluated as part of this project. Therefore, in 
total, there are 6,251 codes that will be valued in this study. Approximately 850 of these codes 
have technical/professional component modifiers that will require analysis of their separate 
components. 



A1.2 Grouping Services into Service Families 

Abt, in conjunction with HCFA, has developed a method for categorizing these services 
into useful groups (called families) for analysis. The services have been grouped into service 
families based upon the following criteria: 



The codes in each family have relatively comparable variable costs; 

The codes within a family are clinically related, to the extent necessary and 
feasible (to ensure that panelists are familiar with all or most of the services in a 
family, such that constructive discussions will be possible); 



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Page A-3 



Overview of Clinical Practice Expert Panels 



• Assignment of services to families is based only on HCPCS/CPT-4 coding, rather 
than patient or physician-specific factors (so that unique HCPCS code payment 
rates are defined); and, 

• Each family has a reasonable/manageable number of services that will undergo 
extrapolation. 

In addition to these criteria, to the extent possible, codes assigned to a family are 
performed predominantly in the same setting (e.g., simple skin procedures all performed in 
ambulatory settings.) 

In order to properly implement the criteria, Abt initially combined and modified portions 
of two existing classification systems: the Ambulatory Patient Groups (APG) system developed 
by 3M and the Berenson-Eggers-Holohan (Urban Institute) system. 6 Abt applied the useful 
elements of these two systems, as well as the criteria listed above, to arrange the MFS services 
into appropriate service families. This initial classification system was reviewed by Abt staff to 
verify that all codes identified for inclusion in this study were accounted for and assigned into 
families. HCFA clinical staff, Abt's clinical consultants, as well as over 125 medical societies, 
also reviewed the initial classification system to determine the extent to which services had been 
grouped based on resource and clinical homogeneity. Many modifications were incorporated into 
the system based upon their feedback, including reassigning codes to families, merging families 
with similar codes, and dividing families that contained a wide range of services into smaller 
groups for analysis. 

A1.3 Assigning Service Families to CPEPs 

In order to organize the families defined by Abt's classification system into a format 

6 Each of these systems has advantages and disadvantages for the purposes of classifying services into families. 
The APG system, with nine major categories and 297 APGs, is useful to the extent that it groups procedures 
performed on an outpatient basis according to resource and clinical homogeneity. However, it does not take into 
account the practice resources of inpatient services and classifies evaluation and management (E&M) codes by 
diagnosis. Conversely, the BEH system, which collapses CPT codes into over 100 categories, assigns inpatient and 
E&M services into groups of services with similar clinical characteristics and resource requirements that could be 
incorporated in a meaningful classification scheme for estimating practice expenses. 

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Page A-4 Overview of Clinical Practice Expert Panels 

useful for analysis, related service families were assigned to CPEPs. The following guidelines 
were used to define the CPEPs and their service family assignments: 



• Ensure high-volume providers of a service are represented on a panel reviewing a 
service; 

• Allow for cross-specialty representation on a panel; 

• Maintain CPEP members familiarity with services in the family and CPEP; and, 

• Ensure that each panel has a reasonable number of services to evaluate (neither too 
many nor too few). 

Abt used the Part B Medicare Annual Data (BMAD) Procedure File to determine the total 
number of services performed by each specialty in each service family. Because some specialties 
(e.g. pediatrics, OB/GYN), are not well represented in the BMAD data, other sources such as 
MEDSTAT private payment data, were used as well. Top specialty providers in each service 
family were identified. Families with similar top specialty providers were then grouped into 
CPEPs. Organizing the families in this manner ensures that panel members, who have been 
selected based in part on the specialty composition of the CPEP, are familiar with most of the 
services in the families assigned to the CPEP. This will help to promote constructive dialogue 
during the panel meetings on the services in question. 

Some families have been assigned to more than one CPEP to provide built-in validation of 
the resource and variable cost estimates that will be developed by these panels. Abt's clinical 
consultants recommended many of these redundancy assignments. In addition to being assigned to 
CPEP # 7, service families consisting of evaluation and management services (E&M), which are 
common to the entire medical community, were assigned across all CPEPs to obtain data from a 
wide range of specialties. Assignments of E&M service families to CPEPs were identified by 
using BMAD data to determine the main E&M service families that are provided by the 
specialties comprising a CPEP. In establishing these validity assignments, Abt staff tried to 



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Page A-5 Overview of Clinical Practice Expert Panels 

maintain a manageable workload for each CPEP. 



3 



The initial assignment of service families to CPEPs was reviewed by Abt's clinical ? 

2 

consultants, HCFA clinical staff, the TEG, the CPEP-TEG, and the medical societies. Numerous | 

revisions to the classification system were made based on these comments. The resulting 

classification system contains 229 unique service families allocated across 15 CPEPs, with each 

CPEP having between 8 and 25 service families. Including the validity assignments, there are 

299 service families assigned across the 15 CPEPS with each CPEP having between 10 and 36 

service families. 



A1.4 Selecting Reference Services 

A reference service has been selected from each service family to serve as the benchmark 
for extrapolating the variable practice costs to the other codes in each family. (Several families 
have two reference services due to either the large size of the family or the nature of the services 
within the family that would make extrapolation from one reference service extremely difficult.) 
Reference services were chosen to be representative of all the codes within a particular family. 
To ensure that appropriate reference services were identified, the CPEP-TEG was convened to 
assist in developing guidelines for selecting these services. Abt, with the input of this panel, 
established the following criteria (listed in order of importance): 

• The service should be commonly-performed (i.e., high-volume and high Medicare 
allowed charges relative to the other services in the family); 

• The service should have a mid-range level of resource usage relative to the other 
codes in the family; 

• The service should be a code whose definition or coding application has not 
changed in the last several years; and 

• The variation across physicians in the way the service is performed should be 
minimal. 



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Page A-6 Overview of Clinical Practice Expert Panels 

A preliminary list of reference services was compiled based on recommendations submitted by 
numerous medical societies. Abt's clinical consultants and HCFA medical staff reviewed the 
candidate reference services suggested by these societies and made final selections based upon the 
above criteria. 

A1.5 Selecting CPEP Members 

In general, the number of representatives from a specialty that were selected to serve on a 
CPEP was determined from both the fraction of the CPEP's total volume and annual Medicare 
allowed charges accounted for by the specialty, and the percentage of the specialty's total volume 
and charges in that CPEP. The specialty categories were based on the AMA's detailed self- 
designated specialty categorization system, to which were added non-physician providers of 
services. The actual number of representatives from each specialty that were assigned to a CPEP 
was a function of the total number of specialties in a CPEP and the relative volumes of services 
performed by each specialty in a CPEP. In addition, a primary care provider and a surgeon were 
assigned to each CPEP. These assignments were carefully made to ensure that no panel had a 
substantial majority of its representation from a single specialty. A preliminary list of the 
specialty assignments for each CPEP was prepared by Abt and reviewed by Abt's clinical 
consultants and HCFA staff. 

To recruit potential CPEP members, Abt Associates has worked with over 125 medical 
societies to identify physicians, non-physician clinicians (e.g. nurses, technicians), and practice 
administrators to participate in the CPEPs. Panelists have been selected according to the 
following criteria: 

• Appropriate cross-specialty representation; 

• Sufficient geographic variation; 

• Mix of different practice types; and 

• Knowledge of costs associated with providing services. 



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Page A-7 Overview of Clinical Practice Expert Panels 

Selecting panel members in this manner addressed variation in practice styles across different 
specialties, geographic locations, and practice settings. 



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5 




Data Collection and Analysis for Generating Procedure-Specific 

Practice Expense Estimates 



HCFA Contract No. 500-95-0009 



Overview of Practice Expense Project & 
Summary of Round 1 CPEP Process 

May 20, 1996 



Abt 



Abt Associates Inc. 



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Overview of Practice Expense Project and Summary of Round l CPEP Process 



1.0 Project overview 

1.1 Background 

The Social Security Act Amendments of 1994 mandate that the Secretary of Health and 
Human Services "develop a methodology for implementing in 1998 a resource-based system for 
determining practice expense relative value units for each physician service" covered by the 
Medicare Fee Schedule (MFS). Under this Congressional mandate, the Health Care Financing 
Administration (HCFA) has engaged Abt Associates Inc. to collect and analyze data that are 
required to develop resource-based practice-expense relative values for over 6,000 codes 
contained in the MFS. Ultimately, the final determination of relative values for practice expenses 
will be made by HCFA after inviting public comment in a Notice of Proposed RuleMaking that is 
expected to be published in early 1997, with final values becoming effective January 1, 1998. 

1.2 Methodology 

Abt, in conjunction with HCFA, has developed a data collection strategy for capturing the 
two general cost categories that comprise practice expenses: overhead and variable costs. 
Overhead costs, which are the expenses incurred during the operation of a practice that are not 
easily attributable to the provision of a specific service (e.g. rent, utilities), will be collected via a 
self-administered mail survey of several thousand physician practices. Variable costs, which are 
expenses that are more easily attributable to a particular service (e.g. nurse time, medical supplies) 
are being collected through a consensus process via Clinical Practice Expert Panels (CPEPs) of 
physicians, other non-physician clinicians, and practice administrators. 

The MFS contains over 6,000 services that must have variable cost estimates developed 
by the CPEPs. To facilitate this task, Abt, in conjunction with HCFA medical staff, developed a 
classification system that organizes the MFS services into 229 clinical and resource homogenous 
groups referred to as service families, each of which is assigned to one of 15 CPEPs. Each CPEP 
contains between 15 and 36 service families. Since it is not feasible to develop detailed resource 
requirements for all services in the MFS, a reference service from each service family was selected 
for which a detailed resource profile was developed during the first round of CPEP meetings. 

The CPEP meetings are being conducted in two rounds, the first of which was completed 
in February. During the first round of CPEP meetings, resource profiles were developed which 
specified the inputs required to provide each reference service. During the second round of 
CPEPs, the resource profile generated for the reference service in each family will be extrapolated 
to the remainder of codes in the family. The resulting variable costs will be added to the service- 
specific overhead costs (allocated from the survey data) to determine the total practice costs of 
each MFS service. 



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2.0 Summary of Round l CPEPs 



2.1 CPEP Composition 

The membership of each CPEP responsible for developing the resource profiles was 
determined by using HCFA administrative claims data (i.e., BMAD) and other information to 
identify both the specialties which provide the services in each CPEP, as well as the percent of 
each specialty's services performed within each CPEP. In addition, in order to obtain as broad a 
representation as possible, a primary care provider and a general surgeon were assigned to each 
panel. To the extent possible, the membership of each CPEP represented different types of 
practice staff (i.e physicians, practice administrators, and other non-physician clinicians), relevant 
cross-specialty representation, as well as geographic and practice type variation. This broad 
representation ensures that different practice characteristics are considered when defining the 
resource requirements for the reference services and for extrapolating to the remainder of the 
services. 

2.2 Data Collection Prior to CPEPs 

The first round of CPEPs was devoted to developing consensus estimates of the resources 
(labor, equipment, and supplies) required to provide the reference services. To facilitate 
discussions of the resources, standardized data collection instruments, or "worksheets" 1 were 
distributed to panel members and medical societies prior to convening the meetings in order to 
collect the various inputs enumerated in the resource profiles. Panel members were asked to 
complete a worksheet for each of the reference services in their CPEP. The worksheets were 
designed to collect data on the number of minutes spent on clinical and administrative functions 
by practice support staff as well as information on the utilization of medical equipment and 
disposable medical supplies. Attachment 1 presents a listing of the functions for each worksheet 
type that were used to develop the labor inputs. When completing the worksheets, participants 
were asked to provide data on the resources required to provide the service for the "typical" 
patient and to draw not only from their own practice's experience, but also on their knowledge of 
other practices or cross country variations of "typical" practice patterns or "typical" patients. The 
completed worksheets were submitted to Abt, summarized, and presented to the panel members 
during these first round of CPEP meetings to facilitate and initiate discussions on the resources 
required to provide each reference service. 



Separate labor worksheets were developed for each "type" of service : G worksheet - service with a global 
period; P worksheet - service or procedure without a global period; Pa worksheet - pathology services; and M 
worksheet - Evaluation and Management Services. Each worksheet had similar categories for detailing the mputs 
associated with labor and staff requirements. Since the functions associated with the provision of pathology services 
substantially differed from other procedures, it was determined that a separate worksheet should be developed to 
effectively capture the inputs associated with these services. Separate worksheets were also used to capture the name, 
type, turn-around time (equipment) and quantities (supplies) for a service's equipment and supply requirements. 



Abt Associates Inc. 



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2.3 Round 1 CPEP Process 



Round 1 CPEP meetings, (a total of 14 separate panels) were convened in Baltimore from 
February 13 through February 28 to initiate the development of resource based practice 
expenses. 2 Each CPEP was responsible for developing resource profiles for between 1 1 and 36 
CPT codes or reference services. Each meeting consisted of a two day process that began with an 
evening session commencing at approximately 8:00 p.m., directly following a dinner and 
introductory speech. The evening session was dedicated to obtaining detailed staff requirements 
for one particular reference service, coined the "walk-through" code. Time requirements for pre-, 
intra-, and post-service clinical and administrative functions were separately identified. In 
addition, resource profiles were developed for each site-of-service in which the reference service 
is performed. CPEP members were asked to perform validation or "reasonableness" checks on the 
clinical and administrative times that were developed for each reference service. Following 
completion of the labor profiles, equipment and supply requirements for providing the service in- 
office and/or out-of-office were determined. 

2.4 Achieving Consensus 

CPEP members' prior exposure to the worksheets and the types of data required to 
develop the resource requirements facilitated the consensus building process. Even though 
summaries of the worksheet data that the CPEP members and societies provided were available as 
a reference source during the meeting, it was emphasized to the panel members that it was their 
responsibility to provide the final consensus values. 

Discussions among the panel members focused on clarifying and resolving any initially 
divergent views in order to achieve the agreement of all panel members. These discussions were 
moderated by a senior Abt Associates staff member whose responsibility was to guide discussions 
and assist in the resolution of divergent views. HCFA staff were also available during the 
meetings to serve as resources for answering questions regarding payment policies, CPT coding, 
and other issues that required resolution prior to determining consensus. In addition, staff from 
the societies which nominated CPEP members were invited to attend the meetings as observers. 
Society observers served as an additional resource for explaining society data when and where 
appropriate. The final consensus values and any notes the panel thought were necessary to 
explain a value were recorded by Abt Associates staff in a laptop computer. 



2 A mock CPEP involving members of CPEP 4 (Obstetrics and Gynecology) was convened m Cambridge 
during the last week of January. The meeting served as an opportunity to test various approaches for obtaining 
consensus estimates on practice expense inputs. Many of the lessons learned during this pilot CPEP were subsequently 
employed in the following panels. Since resource profiles were not developed for all of the references services of this 
panel (due to time constraints), and since the format of the meeting differed from the following fourteen CPEPs, the 
Obstetrics and Gynecology CPEP was reconvened on April 17. At that time, consensus estimates for all reference 
services in CPEP 4 were developed. 



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2.5 Data Processing Following the Round I CPEP Meetings 

Following the conclusion of all meetings, the data were reviewed by Abt Associates to 
ensure accuracy and clarity as well as to standardize the method of recording staff times, staff 
types, equipment, and supply usage across CPEPs. The data was subsequently distributed to 
panel members for review to validate that the values recorded were the values discussed during 
the meeting. Attachment 2 is an example of an aggregated data collection form, modeled after the 
worksheets, that was used to enumerate labor, equipment and supply inputs for procedures 
without a global period (Worksheet P). 



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ATTACHMENT I 
Functions for Services with a Global Period CWorksheet G) 



< Tl 



Clinical 



GO. 1 - Pre Procedure Visit - Clinical 
Pre visit 

Review Patient Charts 
Greet Patient 
Room Prep 

Prep and Position Patient 
Obtain Vital signs 

Intra visit 

Assist in Performing Visit 
Record/Obtain Medical History 
Record Notes 

Post Visit 

Clean Room/Equipment 

Provide Education Prior to Procedure 

Complete Pre-op Diagnostic Medical Forms 

Review Results 

Arrange for Check-out 



Gl - Procedure - Clinical 
Pre Procedure 

Obtain medical history** (this should be removed, it is 

counted in the pre visit) 

Provide final pre procedure education 

Greet patient/provide gowning 

Perform room prep 

Prep patient 

obtain vital signs 

Intra Procedure 

Sedate/apply anesthesia 

Assist in performing procedure 

Record notes 

Post Procedure 

Monitor patient 

Clean room / equipment 

Provide post procedure education 

Complete diagnostic medical forms 

Review results 

Arrange discharge 

Conduct follow-up calls 



Gl.l -G1.9 Post Procedure E&M - Clinical 
Pre- Service 

Review Patient Charts 
Greet Patient / Gowning 
Perform room prep 
Prep patient 
Obtain vital signs 

Intra - Service 
Assist in performing E&M 
Obtain medical history 
Record Notes 

Post - Service 

Clean room/equipment 

Provide education/ instruction after E&M service 
Complete diagnostic medical forms 
Review/read X-rays 
Checkout 

Conduct follow-up phone calls 



Administrative 



G2 - Pre visit and pre Procedure - Administrative* * (this 
captures the administrative time associated with both GO and Gl- 
pre-visit and pre-procedure) 
Pre Procedure 

Obtain referral from referring MD 
Schedule patient remind patient of appointment 
Obtain medical records manage patient database 
Pre-certify patient conduct preservice billing 
Verify insurance 

Register Patient * (this is a new function that was previoulsy not on 
the worksheet) 

Post Procedure 

Transcribe results 

Schedule Post -op or return E&M service 
Notify and complete report to referring MD's 
Conduct billing activities 



G2.1 - G2.9 Post Procedure E&M service - Administrative 
Pre Service 

Schedule Patient and remind of visit * (this function should be 
removed. The first E&M service is already accounted for in the post 
procedure of G2 and additional visits are accounted for in the post 
E&M service time of Gl.l. 

Obtain medical records 
Register Patient 



Post E&M Service Time 

Transcribe results/file and manage patient records 
Schedule subsequent post procedure E&M 



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ATTACHMENT I (cont) 

Functions for E&M Services (Worksheet M) and 
Services Without aGlobal Period (Worksheet P) 



Clinical 



Pre Procedure 

Obtain medical history/ review patient charts 
Provide final pre-procedure education/obtain patient 
consent (Worksheet P only) 
Greet patient/provide gowning 

Perform room prep/prepare medical equipment'~'scrub" 

before procedure 
Prep patient 
Obtain vital signs 
Other 



Intra Procedure 

Sedate/apply anesthesia (Worksheet P only) 

Assist in performing procedure 

Obtain medical history (Worksheet M only) 

Record notes 

Other 



Post Procedure 

Monitor patient following procedure (Worksheet P 
only) 

Clean room/equipment/shut down equipment 

Provide post-procedure education 

Complete diagnostic medical forms, x-ray requisitions, 

prescriptions 
Review results 

Checkout/provide discharge instructions- complete 

nursing forms 
Conduct follow-up phone calls to patient/ respond to 

patient calls'call-in prescription refills 
Other 



Administrative 



Pre Procedure 

Obtain referral from referring MD 

Schedule patient'remind patient of appointment 

Obtain medical records, manage/recall patient database, 

assemble- develop patient chart 

Pre-certify patient/conduct pre-procedure billing 

Verify insurance/review coverage register patient 



Post Procedure 

Transcribe results/file and manage patient records 

Schedule post-op or return E&M services arrange for hospital 

readmission 

Notify and complete reports to referring MDs 

Conduct billing activities (coordinate bill collection/rebilling, 

collect co-pays or deductibles, post-certify patient) 



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OVERVIEW OF THE EXTRAPOLATION METHOD FOR ROUND 2 OF THE CPEPs 
Data Collection and Analysis for Generating Procedure-Specific 
Practice Expense Estimates 

Introduction 

Under contract to the Health Care Financing Administration, Abt Associates Inc. is developing 
resource-based practice expense values for the services in the Medicare Fee Schedule (MFS). As 
part of the project, the first round of Clinical Practice Expert Panels (CPEPs) were conducted in 
February, 1996, during which profiles of direct clinical and administrative resources were developed 
for a set of "reference services." Each of the 229 service families contained in the classification 
system of CPT-4 codes (developed in an earlier phase of the project) has a reference service 1 . In the 
second round of CPEP meetings to be held in June, 1996, the work of the panels will focus on 
extrapolation of the reference service resource profile to all CPT codes in the service family, for each 
family within each CPEP. The reference service data collected during round one will serve as the 
baseline profile for each family, and the panels will identify differences in resource requirements for 
the extrapolated codes at a level that is more aggregated than was used in the first round of CPEP 
meetings. This paper provides an overview of the methodology that will be employed during the 
June extrapolation meetings. Please take some time to familiarize yourself with the process. 
Successful implementation of this process will require that all participants have an understanding of 
the approach. 

Labor 

The labor extrapolation will be performed in two basic steps, with the first activity implemented prior 
to the CPEP and the remaining activities being performed during the two-day meetings. 

Step 1 : Review reference materials (enclosed in this mailing) prior to meeting 
Step 2: Identify and arrive at consensus on key drivers 

Each of these steps is described below. 

Step 1: Review reference materials and identify potential key "drivers" 

Definition: "Drivers" are characteristics that differentiate groups of CPT codes from the reference 
service within a family. For example, in a pilot test of the extrapolation process, physicians noted 
that for some surgical service families, the number of post-discharge office visits is the key driver of 
practice expense differences within the family. This observation allowed the participants to group 
the services in a family into sub-groups, each of which contained services with the same number of 



1 There are a small number of families which contain two reference services. 



Abt Associates Inc. 



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post-discharge office visits. The resource profile for each sub-group was defined to be that of the 
reference service, plus (or minus) the resources required to deliver the greater (lesser) number of 
office visits. In this example, post-discharge office visits was identified as the key driver. Similarly, 
the presence or absence of malignancy is another potential driver, as is the degree of pre-surgical 
authorization required. 

Please review the enclosed material, keeping in mind the task of identifying the key drivers or factors 
which determine practice expense differences: 

• A complete listing of the CPT-4 codes within your CPEP, arranged in family order 
and sorted by CPT code within each family and, 

• Information on each procedure that may assist you in identifying additional key 
drivers for each family (e.g., physician intra-service time, number of post-operative 
visits). 

Please bring the above documents with you for further discussion at the CPEP meeting along with 
recommendations for other key drivers for each family. 

Step 2: Identify and arrive at consensus on the key drivers of labor time for each family 

One of the initial tasks during the first day of the CPEP meeting will involve arriving at consensus 
among the CPEP members on the key drivers that distinguish sets of codes within a given family. 
Using the data provided in the briefing package, as well as discussing potential drivers that CPEP 
members may suggest, the panel will arrive at consensus on the critical factors, or drivers, that affect 
resource use. This will require that the panel address a number of questions for each family: 

■ Are the labor requirements for each code in this family the same as for the reference service? 

■ If the requirements are different from those of the reference service then the following questions 
will be addressed: 

► what is it about the codes with different requirements that determines the differences (e.g., 
cancer-related, number of post-discharge visits)? 

► can you categorize the codes into sub-groups that are highly similar in these dimensions? 

► can you provide increments (or decrements) to the labor time of the reference service for each 
of the sub-groups (by staff type and function)? - 

These questions will help us to identify and come to consensus on the key distinguishing features 
between sets of codes within a family, as well as provide the different time requirements by staff type 
for the extrapolated codes. See Attachment A for a sample worksheet of extrapolated staff times. 



Abt Associates Inc. 



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Extrapolation of equipment and disposable supplies will be completed in "grids." The grids will be -a i. 

tables that contain supply (or equipment) items along the vertical axis and service periods along the 2. <J> 

horizontal axis (See Attachment B and C). All panelist will receive the grids prior to the meetings. 5 7 

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Guidelines/Ground Rules for Extrapolation 

Moving Codes. If agreed upon by the CPEP, codes will be allowed to move from one family to 
another family within the CPEP. CPEPs must extrapolate all codes in their CPEP, regardless of their 
familiarity with the codes. 

Code-specific Extrapolation. It is important that to the extent possible the panel stay focused on 
groups, or sub-families, of codes, rather than individual codes. The level of detail and effort required 
when addressing specific individual codes is inefficient. The objective of the extrapolation is to focus 
on groups of codes that are similar in their resource use along one or more dimensions (e.g., number 
of post-operative visits, cancer-related codes, intra-service time, etc.) 

Sub-specialty Input . There are specific codes in each family that are performed by specialists other 
than the CPEP members (e.g., hand surgeons vs. general orthopaedic surgeons). We will be 
obtaining input from sub-specialists for the relevant codes by allowing participation at the CPEP 
meetings by sub-specialists for specific sub-sets of codes. 



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Glossary of Terms Used in Family Listing of CPT Codes 



HCPCS 

'94 Vol 
% in Office 

% Fam Chgs 

Expected Sites 

Global 



Post Op 
Visits 



Codes selected from the 1995 Medicare Fee Schedule published by HCFA 
{Federal Register Vol. 59, No. 235, electronic version). 

Total 1994 Part B Medicare volume for the procedure. 

Percent of the procedure's 1994 Part B Medicare volume that was performed in 
an office setting. 

The procedure's 1994 Part B Medicare allowed charges as a percent of the total 
allowed charges for the family. 

The sites of service for which the service is to be costed, based on the " 1 0% 
rule" (i.e., a service should be costed for a site if that site accounted for 10% or 
more of 1994 Medicare volume). 

The 1995 Medicare Fee Schedule Global Period for the procedure, in days. 
Values of MMM, XXX, YYY, and ZZZ indicate that there is no global period, 
or that the concept of a global period does not apply to the procedure. 

Number of post-operative office visits, according to AMA RUC five-year review 
recommendations (where available) or the Hsiao Phase III study (where five-year 
review data are not available). 



Intra Time Intra-service physician time, according to the Hsaio study. 



Shading indicates the reference service(s) for the family. 



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Instructions for Completing the Equipment and Supply Grids 



The enclosed grids will be used during the extrapolation process to record equipment and supply needs for 
the services in each family for your CPEP. To the extent feasible, please review and complete the grids 
prior to arriving at the Baltimore meetings. 

General Instructions: Whenever possible, services in a given family should be grouped into "like" 
procedures. The enclosed equipment and supply grids are designed to accommodate such sub-groupings 
but can, if necessary, be used to identify the resources for a single procedure. For each family there is a 
listing (printed on legal-size paper) of all items identified as necessary for the provision of the reference 
service. Enclosed with each packet are copies of blank grids printed on % l A x 1 1 -sized paper with columns 
corresponding to general aspects of a medical procedure (e.g., pre-service, intra-service, and post-operative 
office visits). These are designed to be an overlay to the legal-sized equipment and supply grids (align the 
top right edges). Each 8!/2 x 11 page is designed to capture the equipment or supply needs for a particular 
sub-group of services (as defined by the panelists) within the same family as the reference serv ice. Copy 
as many of the blank grids as needed to accommodate the number of sub-groups within each family. 
The equipment and supply needs of these sub-groups should be compared to those of the reference serv ice 
and usage of each item should be noted in the appropriate columns. 

Note that at the bottom of each list of equipment or supply items for a reference service there are lines 
labeled "Pack." When possible, we will identify during the meetings a list of items that are commonly used 
for a multitude of procedures and label them a "pack". For example, panelists may identify' a list of 
supplies commonly used during excisions or the treatment of lacerations. If possible, please consider the 
potential composition of such packs. We will compile lists of items for each pack during the meetings and 
refer to them during the extrapolation process. Past pilot tests of the extrapolation process have shown that 
such an approach significantly simplifies and expedites the process. 

Supplies: CPEP members should complete the grids (including the addition of new supply types) by 
reporting quantities of supplies in the table cells for the pre-service visit, intra-service time, and all post- 
operative office visits. If it is more convenient to consider supplies required for the provision of all aspects 
of the service, panelists may instead indicate the total quantities for each supply in the "total" column 
Please note that the supplies listed for the reference service correspond to the total quantities required for 
all aspects of the provision of that service (e.g.. all pre-service. intra-service. and post-operative needs). 

Equipment: For equipment the cells should simply be checked when the listed piece of equipment is used 
for a specific service. If additional pieces of equipment not listed for the reference service are used for the 
extrapolated codes, then these should be added to the list and the appropriate columns should be checked 
Again, panelists may find only the 'lotal" column necessary for recording equipment usage for the various 
services within a family. Please do not feel obligated to complete the grid for even, aspect of the provision 
of a service if this is not appropriate or convenient. 

Should you have any questions regarding the use of the equipment and supply grids, please contact (Abt 
Contact and Phone Number). 



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Goal of the CPEP meeting: 5" 8 

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To provide HCFA with estimates of the resources needed to provide each service. We | 2, 

will arrive at consensus on extrapolated values, based on reference service values, for <« £ 

codes or groups of codes within each family. 



Substantive: 

1 . Focus on PRACTICE EXPENSES and not WORK (see Attachment A for 
inclusions/exclusions guidelines) : 

practice expenses are relevant only if they are incurred by the practice 

2. Moving Codes 

if agreed upon by the CPEP, codes will be allowed to move from one family to 
another family within the CPEP. CPEPs must extrapolate all codes in their CPEP, 
regardless of their familiarity with the codes. 

3. Code-specific Extrapolation 

it is important that to the extent possible the panel stay focused on groups, or sub- 
families, of codes, rather than individual codes. The level of detail and effort 
required when addressing specific individual codes is inefficient. The objective of 
the extrapolation is to focus on groups of codes that are similar in their resource 
use along one or more dimensions (e.g., number of post-operative visits, cancer- 
related codes, intra-service time, etc.) 

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each CPEP member is acting as an expert in his/her field 

CPEP members are not representing their medical societies, but are to present their < 
judgement about practice expenses from the perspective of their own practices and 

their knowledge of typical practice g 

v>' = 

the function of the CPEP members who are not the primary providers of the = =• 

reference service is to act as independent assessors of the resource estimates w S 

suggested, to ask questions to ensure validity and reality, and to add their own S 

clinical judgement | 



6. Role of Sub-specialty Representatives: 

provide input on relevant codes that are performed by the sub-specialist. 

7. Role of Society Observers: 

explain data that may have been included 
serve as a resource to the entire CPEP process 

8. Role of Abt Moderator: 

keep the pace moving 

help group decide when they are stuck (using the process defined below) 

ensure that all panel members participate and have the opportunity to speak (do 
not let one member dominate) 

maintain a neutral role regarding content matters, but actively assist in managing 
group processes 

9. Role of Abt/HCFA Floater. 

serve as a resource for technical issues and questions across all CPEPs 
provide assistance in resolving particularly difficult consensus discussions 

10. Role of Recorders: 

check participants and observers in at the door 
enter consensus data into laptop/worksheet 

take notes about general discussion, particularly on disagreements and 
justifications for consensus values 

Process: 

1 . Start and end sessions on time 

2. Take breaks only at designated times (to avoid the 'busybody syndrome" - people coming 
and going during the course of the meeting to take phone calls, etc.); the group may 
decide when each break is warranted 

3. Respect all contributions and contributors - divergent views are encouraged 



4. 



Allow only one person to speak at a time 



5. In order to minimize interruptions during the CPEP meetings, communication among 
CPEP members and Society Observers during the sessions is limited to written notes and 
messages. Society Observers can communicate verbally to CPEP members only during 
the designated breaks. 

6. Disagreements should not become personal. 

7. Resolution of conflicts: in cases where consensus cannot be reached in a reasonable time 
frame, agree to disagree and move on. Before attempts to obtain consensus are 
abandoned, outlier opinions should be excluded if they keep the panel from reaching 
consensus. In situations where consensus is not achieved, the views of each CPEP member 
will be recorded and analyzed subsequent to the CPEP meeting. 



: 



Attachment A: 
Guidelines for Inclusion/Exclusion 



«< 



Resource Profiles 



SHOULD: 



SHOULD NOT: 



Include activities most commonly not performed by physicians 
as defined by Medicare (MDs, DOs, ODs, Psychologists, 
Chiropractors, Dentists, Podiatrists). 

Be based on recent, accepted clinical practice. 



3. Be based on the typical patient across all age groups. 



4. Reflect the practice's variable costs. Variable costs include 
costs of resources directly attributable to performing a 
particular service. 



Reflect time required to perform service-specific functions by 
support staff who are typically employed or contracted by a 
practice and who cannot bill separately. Examples of support 
staff include: 

•Registered nurses(RNs) 
•Licensed Practical Nurses (LPNs) 
•Medical Secretaries 
•Receptionists 
•Technicians 



6. Include medical equipment, with acquisition cost > $500, that 
is purchased or leased by practice and that is used in the direct 
provision of a given service. 

7. Include disposable medical supplies that are purchased by 
practice and that are used in direct provision of a given service. 



Include activities most commonly performed by physicians as 
defined by Medicare. 



2. Be based on outmoded clinical practices or new practices that 
have yet to be adopted by most providers. 

3. Be based on an unusually easy or difficult case. Nor should 
resource estimates be based only on the Medicare population. 

4. Reflect the practice's overhead costs. Overhead costs include 
fixed expenses of the practice and are not directly related to a 
specific service. These costs are the focus of the Survey of 
Practices. Examples of resources that are part of overhead 
costs, but are often mistaken as part of variable costs include: 

Standbv time 



Time to transport/courier patient test results/specimens 
Time to restock supplies 
Quality assurance activities 

Employee training 

Include time spent performing service-specific functions by 
staff, who are employed and paid by a hospital, nor time spent 
by fellows or physicians. 

Reflect time spent on service-specific functions by staff who 
bill separately for their services through the physician work 
component. Since these staff bill through the work component 
of the fee schedule, they are not considered part of practice 
expenses. Staff who can bill separately include: 



•Certified Registered Nurse 

Anesthetists (CRNAs) 
•Clinical Social Workers(CSWs) 
•Chiropractors 
•Dentists 

•Doctors of Osteopathy 
•Nurse Midwives (NMs) 
•Nurse Practitioners (NPs)/ 

Clinical Nurse Specialists (CNSs) 



•Optometrists 
•Podiatrists 

•Physical/Occupational 
Therapists (PT/OTs) 
•Physician Assistants(PAs) 
•Physicians 

•Clinical Psychologists(CPs) 



Include any medical equipment owned or provided by a 
hospital, nor any non-medical capital items (e.g., office 
computers and software, photocopiers, or desks) . 

Include any medical supplies purchased or provided by a 
hospital. 



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GROUND RULES AND GUIDELINES 



Goal of the CPEP meeting: 

To provide HCFA with estimates of the resources needed to provide each service. We 
will arrive at consensus on extrapolated values, based on reference service values, for 
codes or groups of codes within each family. 

Substantive: 

1 . Focus on PRACTICE EXPENSES and not WORK (see Attachment A for 
inclusions/exclusions guidelines): 

practice expenses are relevant only if they are incurred by the practice 

2. Moving Codes 

if agreed upon by the CPEP, codes will be allowed to move from one family to 
another family within the CPEP. CPEPs must extrapolate all codes in their CPEP, 
regardless of their familiarity with the codes. 

3. Code-specific Extrapolation 

it is important that to the extent possible the panel stay focused on groups, or sub- 
families, of codes, rather than individual codes. The level of detail and effort 
required when addressing specific individual codes is inefficient. The objective of 
the extrapolation is to focus on groups of codes that are similar in their resource 
use along one or more dimensions (e.g., number of post-operative visits, cancer- 
related codes, intra-service time, etc.) 

4. Changing Reference Service Values 

changes to the reference values will only be considered if the CPEP unanimously 
agrees. 

5. Role of CPEP members: 

each CPEP member is acting as an expert in his/her field 

CPEP members are not representing their medical societies, but are to present their 
judgement about practice expenses from the perspective of their own practices and 
their knowledge of typical practice 

the function of the CPEP members who are not the primary providers of the 
reference service is to act as independent assessors of the resource estimates 
suggested, to ask questions to ensure validity and reality, and to add their own 
clinical judgement 



6 Role of Sub-specialty Representatives: 

provide input on relevant codes that are performed by the sub-specialist. 

7. Role of Society Observers: 

explain data that may have been included 
serve as a resource to the entire CPEP process 

8. Role of Abt Moderator: 

keep the pace moving 

help group decide when they are stuck (using the process defined below) 

ensure that all panel members participate and have the opportunity to speak (do 
not let one member dominate) 

i 

maintain a neutral role regarding content matters, but actively assist in managing 
group processes 

9. Role of Abt/HCFA Floater: 

serve as a resource for technical issues and questions across all CPEPs 
provide assistance in resolving particularly difficult consensus discussions 
10 Role of Recorders: 

check participants and observers in at the door 
enter consensus data into laptop/worksheet 

take notes about general discussion, particularly on disagreements and 
justifications for consensus values 

Process: 

1 . Start and end sessions on time 

2. Take breaks only at designated times (to avoid the 'busybody syndrome" - people coming 
and going during the course of the meeting to take phone calls, etc.); the group may 
decide when each break is warranted 

3. Respect all contributions and contributors - divergent views are encouraged 



4. Allow only one person to speak at a time 

5. In order to minimize interruptions during the CPEP meetings, communication among 
CPEP members and Society Observers during the sessions is limited to written notes and 
messages. Society Observers can communicate verbally to CPEP members only during 
the designated breaks. 

6. Disagreements should not become personal. 

7. Resolution of conflicts: in cases where consensus cannot be reached in a reasonable time 
frame, agree to disagree and move on. Before attempts to obtain consensus are 
abandoned, outlier opinions should be excluded if they keep the panel from reaching 
consensus. In situations where consensus is not achieved, the views of each CPEP member 
will be recorded and analyzed subsequent to the CPEP meeting. 



Attachment A: 
Guidelines for Inclusion/Exclusion 



«< Tl 



Resource Profiles 



SHOULD: 



SHOULD NOT: 



Include activities most commonly not performed by physicians 
as defined by Medicare (MDs. DOs, ODs, Psychologists, 
Chiropractors, Dentists, Podiatrists). 

Be based on recent, accepted clinical practice. 



Be based on the typical patient across all age groups. 



Reflect the practice's variable costs. Variable costs include 
costs of resources directly attributable to performing a 
particular service. 



Reflect time required to perform service-specific functions by 
support staff who are typically employed or contracted by a 
practice and who cannot bill separately. Examples of support 
staff include: 

•Registered nurses(RNs) 
•Licensed Practical Nurses (LPNs) 
•Medical Secretaries 
•Receptionists 
•Technicians 



Include medical equipment, with acquisition cost > $500, that 
is purchased or leased by practice and that is used in the direct 
provision of a given service. 

Include disposable medical supplies that are purchased by 
practice and that are used in direct provision of a given service. 



Include activities most commonly performed by physicians as 
defined by Medicare. 



2. Be based on outmoded clinical practices or new practices that 
have yet to be adopted by most providers. 

3. Be based on an unusually easy or difficult case. Nor should 
resource estimates be based only on the Medicare population. 

4. Reflect the practice's overhead costs. Overhead costs include 
fixed expenses of the practice and are not directly related to a 
specific service. These costs are the focus of the Survey of 
Practices. Examples of resources that are part of overhead 
costs, but are often mistaken as part of variable costs include: 

Standby time 



Time to transport/courier patient test results/specimens 
Time to restock supplies 
Quality assurance activities 

Employee training 

nclude time spent performing service-specific functions by 
staff, who are employed and paid by a hospital, nor time spent 
by fellows or physicians. 

Reflect time spent on service-specific functions by staff who 
bill separately for their services through the physician work 
component. Since these staff bill through the work component 
of the fee schedule, they are not considered part of practice 
expenses. Staff who can bill separately include: 



•Certified Registered Nurse 

Anesthetists (CRNAs) 
•Clinical Social Workers(CSWs) 
•Chiropractors 
•Dentists 

•Doctors of Osteopathy 
•Nurse Midwives (NMs) 
•Nurse Practitioners (NPs)/ 

Clinical Nurse Specialists (CNSs) 



•Optometrists 
•Podiatrists 

•Physical/Occupational 
Therapists (PT/OTs) 
•Physician Assistants(PAs) 
•Physicians 

•Clinical Psychologists(CPs) 



7. 



Include any medical equipment owned or provided by a 
hospital, nor any non-medical capital items (e.g., office 
computers and software, photocopiers, or desks) . 

Include any medical supplies purchased or provided by a 
hospital. 



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CN 

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CN 


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co 
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0-4(4) 


o 


O 


o 


o 


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4-5(4.5) 


1-4(1) 


3-7(3) 


0-5(4) 


2.5-7(4) 


3.5-6.5(6) 


2.5-3.5(3) 


o 


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rr* 

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2-5(5) 


4-7.5(4) 














































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racteristics 


Worksh 


eu 
% 




1 


1 




1 


1 


o 




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o 


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1 


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o 
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sted 


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fN 


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fN 


rr 


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# of codes 


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X 
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X 
X 
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Reference 
Service 


67314 


92012 


99203 


99213 


99243 


92353 


66984 


67840 


67904 


65420 


66170 


65755 


66821 


65222 


76519 


67141 


67108 


67010 




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Reference 
Service 


77413 


77430 


4700 


35474 




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Worksheet 


X 
X 
X 


X 
X 
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X 
X 
X 


X 
X 
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X 
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X 


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X 


X 


X 


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X 


X 


X 


X 


X 


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Reference 
Service 


85095 


95024 


86580 


95165 


95115 


95900 


95819 


95951 


93015 


99213 


99232 


99253 


32020 


36000 


62270 


90780 


96410 


36430 


90921 




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in 


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o 


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o 


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Oh 


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X 
X 
X 


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X 
X 
X 


X 
X 
X 


X 
X 
X 


X 
X 
X 


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X 
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CU 


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X 
X 
X 


X 
X 
X 


X 
X 
X 


X 
X 
X 


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X 


X 


X 


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X 


X 


X 




X 


X 


X 


X 


X 




X 




X 




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X 




X 






X 


X 










X 


X 


X 


X 


X 




Reference 
Service 


31500 


33208 


93736 


93620 


99213 


99232 


99253 


99243 


93224 


92982 


35474 


36489 


93510 


93798 


93000 


93307 


93015 


78465 




Priority 


Order/ 
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fN 


m 




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NO 




00 




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Family 
Number 


1316 


1320 


1348 


1352 


o 


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0-6.5(2.5) 


o 






































eet Type; 


< 

Oh 

5t 






























sties 


Worksh 


CU 


fN 


o 


o 


CN 








o 












fN 


racteri: 




O 

=tt 


o 


00 


VO 


vO 




Ov 


Ov 










f- 
in 


vo 




family Cha 


isted 


ft Both 


o 


fN 


in 


in 
fN 




in 


fN 




fN 


vO 






in 


vO 


Urn 


Sites to be Cc 


ft Out 






r- 
m 


m 


o 


in 


00 


TT 


o 




o 


in 


ON 

in 








o 


fN 


m 


o 


o 


O 


o 


o 


r~ 


o 


o 




O 


O 




w 

u 

T3 

O 

Cm 
O 




00 


00 

■"3- 






vo 
m 


o 


[~- 


r- 






in 


NO 
VO 


o 






> 


X, 


in 
fN 




fO 






O 


m 
fN 








Q 






o 


ice Service 


Worksheet 


o 


o 


o 


O 


O 


O 


o 


o 








a 


o 




Referer 


Sites Costed 


Out 


X 


x 


X 


X 


X 


X 


X 


X 




X 


X 


X 


X 


X 






















X 




X 










Reference 
Service 


61154 


64610 


62223 


64721 


64861 


22842 


63276 


63030 


99213 


99253 


99243 


61312 


61700 


62284 




Priority 


Order/ 
Group ft 




fN 


m 




in 


vo 


r» 


00 




Family 
Number 


1500 


1536 


1528 


1524 


1520 


vO 


1512 


1516 


O 


fN 


00 
fN 

r- 


1504 


1508 


VO 
vO 



Codes Profiled by Follow-up Interviews 







No. of Codes 

DrAlilafl Kif 










f*OTIUf*0f*t 




CPEP 


Family 


rTOTHBU Dy 

Interviews 


Code Number 


CPT/HCPCS Code Descriptor 


1 Integumentatry and Physical Medicine 


104 


1 


M0101 


Cutting or removal of corns 


5 Ophthalmology 


528 


1 


65235 


Remove foreign body from eye 


5 Ophthalmology 


552 


1 


92260 


Ophthalmoscopy/dynamometry 


6 Radiology 


600 


1 


R0075 


Transport portable x-ray 


6 Radiology 


660 


1 


77470 


Special radiation treatment 


6 Radiology 


664 


3 


77261 


Radiation therapy planning 








77262 


Radiation therapy planning 








77263 


Radiation therapy planning 


6 Radiology 


1332 


1 


R0076 


Transport portable EKG 


7 Evaluation and Management 


1332 


3 


93220 


Vectorcardiogram 








93221 


Vectorcardiogram tracing 








93278 


ECG/signal-averaged 


8 General Surgery 


800 


1 


67415 


Aspiration orbital contents 


8 General Surgery 


812 


1 


43300 


Repair of esophagus 


9 Otolaryngology 


900 


4 


21300 


Treatment of skull fracture 








21310 


Treatment of nose fracture 








21400 


Treat eye socket fracture 








21450 


Treat lower jaw fracture 


9 Otolaryngology 


912 


3 


30120 


Revision of nose 








30580 


Repair upper jaw fistula 








30600 


Repair mouth/nose fistula 


9 Otolaryngology 


940 


3 


31820 


Closure of windpipe lesion 








31825 


Repair of windpipe defect 








31830 


Revise windpipe scar 


10 Miscellaneous Internal Medicine 


1013 


1 


86580 


TB intradermal test 


10 Miscellaneous Internal Medicine 


1064 


28 


89350 


Sputum specimen collection 








94010 


Breathing capacity test 








94060 


Evaluation of wheezing 








94070 


Evaluation of wheezing 








94150 


Vital capacity test 








94160 


Vital capacity screening 








94200 


Lung function test (MBC/MW) 








94240 


Residual lung capacity 








94250 


Expired gas collection 








94260 


Thoracic gas volume 








94350 


Lung nitrogen washout curve 








94360 


Measure airflow resistance 








94370 


Breath airway closing volume 








94375 


Respiratory flow volume loop 








94400 


C02 breathing response curve 








94450 


Hypoxia response curve 








94620 


Pulmonary stress testing 



CPT only copyright 1994 American Medical Association. All rights reserved. 



Codes Profiled by Follow-up Interviews 







No. of Codes 






CPEP 


Family 


Profiled by 
Interviews 


CPT/HCPCS 
Code Number 


CPT/HCPCS Code Descriptor 


10 Miscellaneous Internal Medicine (Cont'd) 


1064 


28 


94680 


Exhaled air analysis: 02 








94681 


Exhaled air analysis: 02.C02 








94690 


Exhaled air analysis 








94720 


Monoxide diffusing capacity 








94725 


Membrane diffusion capacity 








94750 


Pulmonary compliance study 








94760 


Measure blood oxygen level 








94761 


Measure blood oxygen level 








94762 


Measure blood oxygen level 








94770 


Exhaled carbon dioxide test 








94772 


Breath recording, infant 


12 Cardiothoracic and Vascular 


812 


1 


43300 


Repair of esophagus 


12 Cardiothoracic and Vascular 


1204 


2 


30915 


Ligation nasal sinus artery 








30920 


Ligation upper jaw artery 


13 Cardiology 


1308 


1 


92977 


Dissolve clot, heart vessel 


13 Cardiology 


1336 


4 


76826 


Echo exam of fetal heart 








76827 


Echo exam of fetal heart 








76828 


Echo exam of fetal heart 








93350 


Echo exam of heart 


13 Cardiology 


1344 


1 


93210 


Intracardiac phonocardiogram 


14 Anesthesiology/Pathology 


1432 


44 


62274 


Inject spinal anesthetic 








62275 


Inject spinal anesthetic 








62276 


Inject spinal anesthetic 








62277 


Inject spinal anesthetic 








62278 


Inject spinal anesthetic 








62279 


Inject spinal anesthetic 








62280 


Treat spinal cord lesion 








62281 


Treat spinal cord lesion 








62282 


Treat spinal canal lesion 








62288 


Injection into spinal canal 








62289 


Injection into spinal canal 








62298 


Injection into spinal canal 








64400 


Injection for nerve block 








64402 


Injection for nerve block 








64405 


Injection for nerve block 








64408 


Injection for nerve block 








64410 


Injection for nerve block 








64412 


Injection for nerve block 








64413 


Injection for nerve block 








64415 


Injection for nerve block 








64417 


Injection for nerve block 



CPT only copyright 1994 American Medical Association. All rights reserved. 



Codes Profiled by Follow-up Interviews 



■ 

CPEP 


Family 


NO. Or wooes 
Profiled by 
Interviews 


CPT/HCPCS 
Code Number 


CPT/HCPCS Code Descriptor 


14 Anesthesiology/Pathology (Cont'd) 


1432 


44 


64418 


Injection for nerve block 








64420 


Injection for nerve block 








64421 


Injection for nerve block 








64425 


Injection for nerve block 








64430 


Injection for nerve block 








64435 


Injection for nerve block 








64440 


Injection for nerve block 








64441 


Injection for nerve block 








64442 


Injection for nerve block 








64443 


Injection for nerve block 








64445 


Injection for nerve block 








64450 


Injection for nerve block 








64505 


Injection for nerve block 








64508 


Injection for nerve block 








64510 


Injection for nerve block 








64520 


Injection for nerve block 








64530 


Injection for nerve block 








64620 


Injection treatment of nerve 








64622 


Injection treatment of nerve 








64623 


Injection treatment of nerve 








64630 


Injection treatment of nerve 








64640 


Injection treatment of nerve 








64680 


Injection treatment of nerve 



CPT only copyright 1994 American Medical Association. All rights reserved.