PRACTICE RESOURCES > Regulation/AUA Positions, Letters, and Talking Points > HCFA Regarding 2000 Final Fee Schedule Changes

HCFA Regarding 2000 Final Fee Schedule Changes

January 3, 2000

The Honorable Nancy-Ann Min DeParle
Health Care Financing Administration
Department of Health and Human Services
Room C5-16-03
7500 Security Boulevard
Baltimore, MD 21244-1850

Re: HCFA-1065-FC—Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2000; Final Rule.

Dear Ms. DeParle:

On behalf of the American Urological Association (AUA), representing 9,200 American urologists, I am pleased to submit comments on the physician fee schedule revisions for 2000.

I. Resource-Based Practice Expense Relative Value Units

  1. Refinement/Methodological Issues

    As we move into the second year of the transition to resource-based practice expense relative value units (RVUs), refinement continues to be a particularly challenging issue. Currently, the main vehicles for refinement are the American Medical Association's (AMA) Practice Expense Advisory Committee (PEAC) and the Health Care Financing Administration's (HCFA) contract with The Lewin Group to provide expert advice and technical support on methodological issues. Unfortunately, as participants in the PEAC process, we question whether the enormous amount of work required can realistically be completed within this forum.

    We did attend the September 15, 2001 meeting hosted by Lewin, and appreciated the opportunity to provide input and hear about Lewin's preliminary ideas and plans. However, we are still particularly concerned about the following unresolved refinement issues:

    1. Use of Survey Data Other than SMS Data

      To increase the reliability and validity of the practice expense data collected in the AMA's Socioeconomic Monitoring System (SMS) survey, HCFA must establish conditions under which it would accept alternate data sources. Section 212 of the recently-enacted Balanced Budget Refinement Act of 1999, as well as Lewin's preliminary recommendations, provide valuable guidance on this issue. Based on this, we hope that HCFA will be able to come up with guidelines for acceptance of alternative data sources in the near future.

    2. Adjusting AMA SMS Data to Account for Non-billable Hours

      It has come to our attention that, in answering SMS questions regarding hours worked, some specialties may have inadvertently inflated the number of hours they work each week by including "down time" in their answers. Down time refers to the time a physician spends in a hospital between surgeries. The AUA believes HCFA should find a way to identify this down time for surgeons and make sure this time is not included in the work week hours. Otherwise, these physicians would be arbitrarily punished by having a lower practice expense per hour figure by including time that should not be included in the calculation.

    3. Mean vs. Median for SMS Practice Expense per Hour Data

      As stated previously, the AUA believes that using median values to calculate practice expense pools derives the fairest possible relative ranking of practice expenses per hour among the medical specialties. While HCFA did not accept our suggestion to use medians in the calculation, it did say that it would revisit this issue during the refinement period. In its February 1999 report, Medicare Physician Payments, the General Accounting Office suggested that HCFA further review this issue and decide how to proceed by developing alternatives and analyzing the effect of any changes. We would appreciate an update from HCFA on any determinations it has made regarding this issue.

  2. Refinement/CPEP Data


    1. RUC Recommendations on CPEP Inputs for Heat Therapy Codes

      The AUA is concerned that HCFA did not accept the AMA Relative Value Scale Update Committee's (RUC) recommendations for developing in-office practice expense RVUs for the following urologic procedures:

      CPT® code 52647

      Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete

      CPT® code 53850

      Transurethral destruction of prostate tissue; by microwave thermotherapy

      CPT® code 53852

      Transurethral destruction of prostate tissue; by microwave thermotherapy

      HCFA did not change the CPEP inputs for these codes based on the conclusion that further review is required before the proposed changes can be adopted or rejected. From discussions with HCFA staff, we have learned that there may be concerns that the direct cost inputs approved by the RUC conflict with the data submitted by industry sources. The AUA would like to work with HCFA to facilitate the development of in-office values for these procedures, and we would appreciate the opportunity to meet with HCFA staff to resolve any issues regarding the clinical staff, equipment and supply costs for these three procedures.

      We anticipate that HCFA will be able to clear up any misunderstandings or questions regarding the data for these procedures in time to develop in-office RVUs for the April 2000 fee schedule revisions. HCFA's continued failure to develop in-office practice expense RVUs causes Medicare beneficiaries to be denied access to these new technologies. And, because many private payors reimburse for these procedures in an office setting, this results in an unfortunate difference in coverage between Medicare and non-Medicare patients for these procedures.

      We also seek clarification on whether the transition of practice expense values called for in the Balanced Budget Act of 1997 (BBA) will apply to resource-based in-office practice expense RVUs for these codes. As you know, actual costs incurred by physicians performing these services are much greater than the current practice expense RVUs assigned to these codes. If HCFA interprets the BBA phase-in provision as applying to these codes, the payment will be partly based on historical charge in-office practice expense RVUs that have no remote connection to the actual costs incurred. This would inevitably delay the shift of the site of service from more expensive hospital settings to less costly office settings for these procedures. This is despite the fact that in many instances, these services can be performed safely and appropriately in the office.

      Thus, we believe the BBA transition does not apply to these codes for the following reasons, and that paying for these codes in the office based on the full resource-based amount will facilitate the introduction of these new cost-saving procedures:

      1. The in-office practice expense RVUs assigned to these codes bear no resemblance to their actual costs.

      2. The purpose of the transition is to ease the significant reductions some hospital-based procedures will see under the new payment system. It does not apply to services with no reimbursement history which have not been previously provided in the office setting.

      3. Assigning a 50/50 ratio of historical charge practice expense RVUs to resource-based practice expense RVUs in 2000 essentially guarantees that the services will be performed in the more expensive hospital setting.

    2. Egregious errors and anomalies

      The AUA thanks HCFA for adding a lithotriptor to the list of in-office CPEP equipment data for CPT® code 50590, Extracorporeal Shock Wave Lithotripsy, as requested in our January 4, 1999 comments. However, in those same comments, we also submitted a list of other codes with inaccurate inputs which lead to anomalous RVUs. Therefore, we have listed them again, below, and would like to know the status of these suggested changes.

      Table I. Procedure Codes with Inaccurate Inputs

      CPT® Code


      Correction Requested


      Cystourethroscopy with direct vision internal urethrotomy

      The practice expenses for this procedure are very similar to 52340, but the facility PERVUs are much lower (1.96 vs. 5.03).


      Cystourethroscopy, with insertion of indwelling ureteral stent

      Decrease supply cost for stent (93119) from $359 to $150.


      Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete

      Increase number of post-operative office visits from 3 to 5. Now, patients often go home the same day of or the morning after surgery.


      Prostatectomy, perineal, subtotal

      Increase number of post-operative office visits from 4 to 5.


      Prostatectomy, perineal radical;

      Increase number of post-operative office visits from 4 to 5.


      Prostatectomy, perineal radical; with lymph node biopsy(s)

      Increase number of post-operative office visits from 5 to 6.


      Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes

      Increase number of post-operative office visits from 5 to 6.


      Prostatectomy; suprapubic, subtotal, one or two stages

      Increase number of post-operative office visits from 3 to 5.


      Prostatectomy; retropubic, subtotal

      Increase number of post-operative office visits from 3 to 5.


      Prostatectomy, retropubic radical, with or without nerve sparing;

      Increase number of post-operative office visits from 5 to 6.


      Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s)

      Increase number of post-operative office visits from 5 to 6.


      Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes

      Increase number of post-operative office visits from 5 to 6.


      Sling operation for stress incontinence

      Increase post-operative office visits from 3 to 4. These patients often go in and out of urinary retention following surgery, thus requiring multiple catheterizations.

      Also, while we agree with HCFA's decision to fix egregious errors and anomalies that were easy to deal with, we are concerned about HCFA's decision to remove certain supply items from the CPEP data. For example, page 59392 of the rule reads, "In addition, we have made minor adjustments to the CPEP supply list by deleting a few supplies either because of the difficulty in measuring their use, or because the supplies were not fully used up during a single procedure and do not fit the definition that we use for direct supply costs. Therefore, the costs for tissues, biohazard bags and Lysol spray will be treated as indirect costs."

      We are concerned that the difficulty in measuring the use of a supply justifies its removal from the CPEP supply list, as physicians still must pay for that supply. If physicians are counting these items as supplies when they report their expenses in the SMS, shouldn't they be allocated to procedure codes using the CPEP supply category, rather than the indirect methodology? While we realize this change will not significantly affect practice expense RVUs, we believe keeping these supplies as direct expenses better matches the actual expenses incurred for these supplies with the actual payment. We would welcome HCFA analysis of this change and request that HCFA ensure that all these costs are accurately accounted for under the indirect cost category.

    3. Removal of Betadine from Post-procedure Visits

      Although urologists do not perform the 65 procedures from which Betadine was removed, the AUA strongly disagrees with HCFA's decision to remove betadine from post-procedure visits in general and requests that this supply item be reinstated in the CPEP supply database. Contrary to HCFA's belief that Betadine is only used on the day of a procedure, Betadine is currently used in post-operative visits, as illustrated by the examples below:

      • A patient returns to the office post op for suture or staple removal. The skin is cleaned before and after removal with betadine.

      • A patient returns to the office post op to have a silastic or rubber drain removed. Before removing the drain the skin is cleaned with betadine.

      • A patient returns to the office post op for removal of abdominal "retention sutures". The sutures are cleaned with betadine before they are pulled through the deep tissue and removed.

      • A patient returns to the office after surgery with a superficial skin infection in the incision. The wound is opened and cleaned with betadine.

      • A patient returns to the office after pelvic surgery for removal of a vaginal pack. After the pack is removed the vaginal vault is gently cleansed with betadine.

  3. Calculation of Physician Practice Expense Pools/Zero Work Pool

    We applaud HCFA's decision to move certain procedure codes out of the zero work pool in response to requests from specialty societies. Because the resource-based values are still interim, we hope that HCFA will consider our request to take the technical component portion of the urologic procedures listed below out of the zero work pool and instead calculate their RVUs using the resource-based method. As these procedures are performed mostly by urologists, calculating their values based on urology's practice expense per hour would be more appropriate.

    Table II. Urologic Procedures to Remove from Zero Work Pool

    CPT® Code


    Percent Performed by Urologists


    Simple cystometrogram



    Complex cystometrogram



    Simple uroflowmetry



    Complex uroflowmetry



    Urethra pressure profile studies, any technique



    Electromyography studies of anal or urethral sphincter, other than needle, any technique



    Needle electromyography studies of anal or urethral sphincter, any technique



    Stimulus evoked response



    Voiding pressure studies; bladder voiding pressure, any technique



    Voiding pressure studies; intra-abdominal voiding pressure



    Penile plethysmography



    Nocturnal penile tumescence and/or rigidity test


II. CPT® Modifier -25

We appreciate HCFA's clarification of the requirement to use modifier -25 with procedures having a global period of XXX, and are pleased that this will only apply to certain codes rather than being a routine requirement. Also, by allowing the AMA's Correct Coding Policy Committee (CCPC) to review any changes before they are made, HCFA will be able implement this policy more effectively.

III. Coverage of Prostate Cancer Screening Tests

Although we agree that the effect of this rule will be positive, we question the budget impacts shown in the Estimated Medicare Costs table on page 59439 of the rule. Specifically, we believe the estimated cost of $8 billion between 2000 and 2004 is unreasonably high. This error may be due to HCFA's assumption of the number of men who will receive this test as a result of the new benefit. Many Medicare beneficiaries currently receive annual PSA screening tests even though Medicare does not pay for them, and many other Medicare patients get tested by their physician when presenting with lower urinary tract symptoms. Thus, for the most part, there will not be a spectacular rise in the demand for these services as a result of this policy, and we urge HCFA to modify its cost estimates accordingly.

We have also identified an error in HCFA's National Physician Fee Schedule Relative Value File for Calendar Year 2000 regarding the payment for G0102, prostate cancer screening; digital rectal exam (DRE). HCFA previously noted that, if a screening DRE was billed as an individual service, it would be paid at the same level as CPT® Code 99211, Office of other outpatient visit. However, because HCFA did not set the RVUs for G0102 equal to the RVUs for 99211, the 2000 payments do not match; the payment for 99211 will be $20.14, while the payment for G0102 will be $9.52. While we understand that a G0102 will rarely be billed as an individual service, this mistake should nevertheless be corrected to avoid confusion. HCFA staff have confirmed that this error will be resolved in an upcoming correction notice, and we hope the correction notice can be published soon.

IV. Refinement of Relative Value Units for Calendar Year 2000

The AUA strongly opposes HCFA's decision to reject the RUC-recommended work RVU of 1.92 for CPT® code 76873, prostate volume study for the following reasons:

Thank you for considering our comments. If you have any questions, feel free to contact Robin Hudson, Manager of Regulatory Affairs, at 410-689-3762 or


Lloyd H. Harrison, MD
American Urological Association

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