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Contents

  1. Diamond Mens Black Earrings Ct Square Black Round Cut Square
  2. TUESDAY, JUNE 24
  3. Radiation Safety in Nuclear Medicine
  4. Book Uspas Radiation Safety Presentation Slides 2004

Utilization of this new program will be assessed monthly and, as those spaces fill up, more are expected to be allocated. Building managers or their designees are the points of contact for requesting more carpool spaces. No doubt about it, the upcoming parking crunch will be a problem, but with four thousand of the smartest people anywhere, surely we can figure out how to mitigate the effects. A forum has been added to commute.

As scientists, we push ourselves hard: caught up in experiments, troubleshooting apparatus or debugging code long into the night, making sure users get their beamtime, hurrying to the airport to catch a plane to a conference….

X-Ray Imaging: Radiation Safety (Arabic Narration)

This takes its toll on sleep, and therefore on safety. The National Highway Traffic Safety Administration reports that simply being well rested reduces the risk of a crash by 7 percent and the risk of a fatal one by Understanding Drowsy Driving and What States Can Do , full of useful tips at the personal as well as the policy levels.

Finally, consider taking public transit. Its guidance and the reports of blue-ribbon committees like the Particle Physics Project Prioritization Panel help us make sure our efforts are aligned with agency priorities and the needs of the research community. We are proud to be the partner of choice for some of the most difficult aspects of forefront accelerators across the US and worldwide—a capability that can only come from a strong foundation in the fundamentals of accelerator science and technology.

Future issues of this newsletter will highlight the status and science and technology progress of ALS-U. LPAs are poised for further progress in both technique and enabling technologies. Our initiatives and spinoff prospects will be the subjects of more articles in the coming months. The work is driven by national level planning efforts such as the recently released Advanced Accelerator Development Strategy Report. The power of exascale computing will be a game changer for our ability to maximize the potential of familiar types of accelerators and explore the potential of the innovations now being developed.

Here, too, stay tuned as we focus more on these efforts in upcoming issues. As we look toward upgrades of the Large Hadron Collider and beyond it toward a notional future circular collider, pushing magnets beyond the present state of the art — not only in field strength and quality but in cost per tesla-meter — looms even larger in importance. Many other disciplines, from charged-particle therapy to fusion energy, would also benefit from these advances.

Injector Source Moves Cleanly Out Of Design Phase The electron gun and the photocathode load-lock systems, and the low-energy beamline, recently went through Final Design Review and then, this month, a Production Readiness Review that examined planning and quality assurance for successful delivery of the gun. Far left: components of the gun nose being prepared for brazing.

Left: cathode wall end plate being machined. Right: stainless steel flange for cathode end wall being machined. The gun and beamline components are being fabricated in the LBNL main shops. The main features are magnetic modules and a strongback structure to position them — and move them upon command — with micron accuracy in the face of tens of thousands of kg of magnetic force. Each undulator array will consist of many 3. In recent target experiments, the 1. The element and thickness were chosen such that the expected beam-induced heating would bring the foil near its melting temperature.

Integrating Simulation and Accelerator Diagnostics Data This achievement followed recent advances in the integration of the accelerator diagnostics with detailed particle-in-cell modeling of the beam dynamics. This allows them to directly compare measured diagnostic results to the simulation, and thus tune the accelerator to produce the conditions desired for the target experiment within minutes of acquiring the experimental data. To Learn More… P. Byrd r. Wim Leemans; faculty advisor, Prof. Swanson also gave a talk at the conference.

Make suggestions to improve Labwide policies After discussion with the ATAP program heads, the task force issued a report with a variety of recommendations and action items. Parking Update: Winter Is Coming — Get Ready We have a temporary reprieve on the expected parking crisis — but only in its onset, not its inevitability. Displaying 1 - 25 of The Manufacturing Cost Guide is a tool that estimates the costs that US manufacturers face and can be used to help gauge the potential returns on manufacturing This tool is used to implement Monte Carlo analysis, which uses probabilistic sensitivity analysis to account for uncertainty.

This tool is developed to follow ASTM subcommittee E The Method was We have developed a virtual measurement and analysis laboratory in a 3D immersive virtual environment using a CAVE hardware configuration and a software One of the main drivers of HVAC-Cx is a semi-automated commissioning software tool designed to facilitate performance analysis for heating, ventilating, and air conditioning HVAC This decision support software is The basic The implementation is based on the open source ns-3 simulator and currently supports Development was sponsored as part of video quality Comment: Many commenters supported CMS' efforts to recognize the advances in digital technology and take them into account through updated RVUs.

Several commenters agreed that the clinical labor tasks outlined in Table 5 reflected the PE Subcommittee's film to digital workgroup recommendations. The commenters suggested that the staff types in the tasks should be made more generalized and less specific such as technologist to clinical staff or radiologist to physician , and stated that specialty societies should be afforded the opportunity to request deviations that is, increases from the standard times.

Response: We believe that providing specific guidelines for the staff types associated with these tasks will aid in determining the most accurate value for each service. We also agree that specialties should be afforded the opportunity to request deviations from the standard times for unusual situations, when supported with the presentation of additional justification for the added time.

Comment: The RUC commented that it had not supported standard times for clinical staff activities related to digital imaging in the past, as the RUC had recommended that the specialties should have an opportunity to determine the appropriate inputs at the individual distinct service level and there was too much variability across imaging modalities to propose standards.

While the RUC continued to hold to its previous position on this subject, it also agreed that four of the five clinical labor activities proposed by CMS in Table 5 are representative across imaging and could appropriately be used as standard times. For example, a cardiac MR with hundreds of images would require more quality control time than a single view X-ray of the chest. The RUC recommended that this line item remain nonstandard, and that specialties should continue to have the opportunity to make a recommendation on the appropriate number of minutes based on clinical judgment.

The commenter stated that CMS did not have any data to support its belief in the standard time of 2 minutes, and recommended considering the commenter's data and information from other stakeholders regarding the appropriate standard minutes for the clinical labor tasks associated digital imaging. We are interested in soliciting public comment and feedback on this subject, with the anticipation of including a proposal in next year's proposed rule. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue.

As with the clinical labor tasks associated with digital imaging, many of the specialized clinical labor tasks associated with pathology services do not have consistent times across those Start Printed Page codes. In reviewing the recommendations for pathology services, we have not identified information that supports the judgment that the same tasks take significantly more or less time depending on the individual service for which they are performed, especially given the specificity with which they are described.

Therefore, we developed standard times that we have used in finalizing direct PE inputs. These times are based on our review and assessment of the current times included for these clinical labor tasks in the direct PE input database. We have listed these standard times in Table 6. For services reviewed for CY , in cases where the RUC-recommended times differed from these standards, we have refined the time for those tasks to align with the values in Table 6. We solicited comments on whether these standard times accurately reflect the typical time it takes to perform these clinical labor tasks when furnishing pathology services.

Comment: Many commenters stated that they did not support the standardization of clinical labor activities across pathology services. Commenters stated that a single standard time for each clinical labor task was infeasible due to the differences in batch size or number of blocks across different pathology procedures.

Several commenters indicated that it may be possible to standardize across codes with the same batch sizes, and urged CMS to consider pathology-specific details, such as batch size and block number, in the creation of any future standard times for clinical labor tasks. One commenter stated that the CMS clinical labor times were uniformly too low, and that CMS did not provide enough information about how it arrived at these revised standard times.

The commenter provided five examples of inadequate labor times, and stated that CMS should provide stakeholders with information about the source of its data and why it rejected the RUC recommendations for these clinical labor tasks. Response: We appreciate the extensive feedback provided by commenters on the standard times for clinical labor tasks associated with pathology services. As we stated in the CY PFS proposed rule, we developed the proposed standard times based on our review and assessment of the current times included for these clinical labor tasks in the direct PE input database.

We believe that clinical labor tasks with the same work description are comparable across different pathology procedures. We concur with commenters that accurate clinical labor times for pathology codes may be dependent on the number of blocks or batch size typically used for each individual service. We have received detailed information regarding batch size and number of blocks during review of individual pathology services on an intermittent basis in the past. We request regular submission of these details on the PE worksheets as part of the review process for pathology procedures, as a means to assist in the determination of the most accurate direct PE inputs.

Were we to receive this information as part of standard recommendations, we would include these assumptions as part of the information open for comment in proposed revaluations. We also believe that many of the clinical labor activities that we discussed in Table 6 are tasks that do not depend on number of blocks or batch size. For the rest of the clinical labor tasks associated with pathology services, we are interested in soliciting further public comment and feedback on this subject as part of this final rule with comment period, with the anticipation of including a proposal in next year's proposed rule.

Comment: Several commenters, including the RUC, did not agree with the proposal to eliminate the minutes associated with this clinical labor task. Commenters maintained that the clinical labor task of completing the botox log was a medically reasonable direct resource cost. One commenter stated that it was critical for clinical staff to maintain accurate bookkeeping of split botox vials, and that documentation must reflect the exact dosage of the drug given to patients and a statement that the unused portion of the drug was discarded.

We believe that this is a quality control issue for clinical staff. Maintaining accurate administrative records, even for public safety, is not a task we generally allocate to individual services, instead we consider these costs as attributable across a range of services, and therefore, as an indirect PE. Subsequent to the publication of the CY PFS final rule with comment period, stakeholders alerted us to several clerical inconsistencies in the clinical labor nonfacility intraservice time for several vertebroplasty codes with interim final values for CY , based on our understanding of RUC recommended values.

The following is a summary of the comments we received regarding clinical labor input inconsistencies. Comment: Two commenters indicated that although they appreciated CMS' efforts to clean up errors in the direct PE database, they had specific concerns regarding the proposed changes.

The commenters indicated that this did not appear to be consistent with how CMS was proposing to handle the same clinical labor task in the prior two codes discussed. The commenters requested that CMS outline specifically which line items from the PE spreadsheet it proposed to change and the effects these changes would have on the direct inputs for these three codes.

Response: We appreciate the detailed feedback from the commenters on the clinical labor inconsistencies in these three codes. We agree with the commenters that there were remaining clinical labor errors in these procedures beyond those detailed in the CY PFS proposed rule, and appreciate the opportunity to clarify the discrepancies Start Printed Page in clinical labor for these three procedures.

The clinical labor staff type was also incorrectly entered as LC, which is priced at the same rate but refers to a second Radiologic Technologist for Vertebroplasty. We agree with the commenters that the clinical labor time for the office visit was missing from CPT code , and we will add it to the direct PE database. This clinical labor time appears to have been incorrectly entered for the facility setting instead; we will remove this time and add it to its proper non-facility setting.

We agree with the commenters that the clinical labor time for the office visit was again missing from CPT code , and we will add it to the direct PE input database. We agree that the clinical labor for this activity should not be treated differently from the rest of the codes in the family, and therefore these 5 minutes are included in the direct PE input database.

After consideration of comments received, we are finalizing our proposed changes to clinical labor along with the additional corrections described above. We do not believe that minutes should be allocated to items such as freezers since the storage of any particular specimen or item in a freezer for any given period of time would be unlikely to make the freezer unavailable for storing other specimens or items.

Instead, we proposed to classify the freezer as an indirect cost because we believe that would be most consistent with the principles underlying the PE methodology since freezers can be used for many specimens at once. We did not receive comments on this proposal, and therefore, we are finalizing as proposed. In the CY PFS final rule with comment period 75 FR , we finalized a process to act on public requests to update equipment and supply price and equipment useful life inputs through annual rulemaking beginning with the CY PFS proposed rule.

In reviewing the request, it is evident that the requested price update does not apply to the SH item but instead represents a different item than the one currently included as an input in CPT code skin test, coccidioidomycosis. Comment: Several commenters strongly supported the CMS proposal to create a new supply code for Spherusol that reflects the current price for the antigen and to update the direct inputs for CPT code to include this item.

Commenters asked whether this was a technical error and urged CMS to correct the input files to be consistent with the proposal described in the regulation preamble. Response: We appreciate support for our proposal and acknowledge our inadvertent omission of this change in the proposed direct PE input database. After consideration of comments received, we are finalizing our proposal to create a supply item for Spherusol and it is included as a direct PE input for CPT code We also received a request to update the price for EQ Patient Worn Telemetry System used only in CPT code External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage retrievable with query with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care.

The requestor noted that we had previously proposed and finalized a policy to remove wireless communication and delivery costs related to the equipment item that had previously been included in the direct PE input database as supply items. In the proposed rule, we stated that we considered this request in the context of the unique nature of this particular equipment item. This equipment item is unique in several ways, including that it is used continuously 24 hours per day and 7 days per week for an individual patient over several weeks. It is also unique in that the equipment is primarily used outside of a healthcare setting.

Within our current methodology, we currently account for these unique properties by calculating the per minute costs with different assumptions than those used for most other equipment by increasing the number of hours the equipment is available for use. Therefore, we also believe it would be appropriate to incorporate other unique aspects of the operating costs of this item in our calculation of the equipment cost per minute. We believe the requestor's suggestion to do so by increasing the price of the equipment is practicable and appropriate.

We did not receive any comments opposing the proposal. Response: After consideration of comments received, we are finalizing our proposal regarding the Patient Worn Telemetry System equipment. In the CY final rule with comment period, we indicated that we obtained new information suggesting that further study of the price of this item was necessary before proceeding to update the input price.

We solicited comments on how to consider the higher-priced invoice, which is 53 percent higher than the price listed, relative to the price currently in the direct PE database. Specifically, we solicited information on the price of the disposable supply in the typical case of the service furnished to a Medicare beneficiary, including, based on data, whether the typical Medicare case is furnished by an entity likely to receive a volume discount. The lowered price referenced in the CY PFS proposed rule indicated that the purchaser may be receiving a competitive contractually arranged price.

The commenter stated that the lowered price referenced is what might be expected to be acquired by the largest hospitals, which would be expected to buy supplies in greater volume than a small community hospital or mid-sized laboratory, and the price indicated does not reflect the prices for a laboratory of typical size. Other commenters stated that they were unable to find this pricing information through publicly available sources, suggesting that it may not reflect typical transactions.

The commenters also stated that it was unclear as to whether the proposed price referred to FDA-approved kits, which are more expensive than non-approved kits. The commenters suggested that CMS should adopt a weighted-average of the probe kit prices for the probe kits currently used to perform these procedures. Response: Without robust, auditable information regarding the actual prices paid by a range of practitioners that would allow us to reasonably determine a recommended price to be typical, we believe that we should assume that the best publicly available price is typical.

Generally speaking, we do not believe vendors are likely to allow public display of pricing that is not broadly available to potential customers since that would present significant competitive disadvantages in the market. Therefore, given the options between the best publicly available price or prices on invoices selected for the distinct purpose of pricing individual services, we believe the best publicly available price is more likely to be typical. Therefore, we are not making any changes to the price of this supply item at this time.

The commenters stated that the complexity of many laboratory services demands highly-skilled, highly-trained, certified, and experienced personnel who typically must be paid higher wages than the current rates provided by CMS. Commenters stated that CMS has underestimated the actual labor costs associated with the work that these more specialized laboratory personnel perform by 20 to 30 percent, after accounting for costs related to benefits, taxes, and training.

Response: The clinical labor costs per minute are based on data from the Bureau of Labor Statistics. We believe that it is important to update that information uniformly among clinical labor types and will consider updating the clinical labor costs per minute in the direct PE database in future rulemaking. In reviewing public comments in response to the CY PFS final rule with comment period, we re-examined issues around the typical number of pathology tests furnished at once. In the CY final rule with comment period 77 FR , we noted that the number of blocks assumed for a particular code significantly impacts the assumed clinical labor, supplies, and equipment for that service.

We indicated that we had concerns that the assumed number of blocks was inaccurate, and that we sought corroborating, independent evidence that the number of blocks assumed in the current direct PE input recommendations is typical. We refer readers to section II. Comment: Several commenters addressed the number of blocks and batch size for prostate biopsies in particular.

We direct readers to section II. We continue to seek stakeholder input regarding the best sources of information for typical number of blocks and batch sizes for pathology services. We noted that not all PFS services are priced in the nonfacility setting, but as medical practice changes, we routinely develop nonfacility prices for particular services when they can be furnished outside of a facility setting. We noted that the valuation of a service under the PFS in particular settings does not address whether those services are medically reasonable and necessary in the case of individual patients, including being furnished in a setting appropriate to the patient's medical needs and condition.

According to Medicare claims data, there are a relatively small number of these services furnished in nonfacility settings. Advancements in technology have significantly reduced operating time and improved both the safety of the procedure and patient outcomes. As discussed in the proposed rule, we believe that it now may be possible for cataract surgery to be furnished in an in-office surgical suite, especially for routine cases. Cataract surgery patients require a sterile surgical suite with certain equipment and supplies that we believe could be a part of a nonfacility-based setting that is properly constructed and maintained for appropriate infection prevention and control.

We also noted in the proposed rule that we believe there are potential advantages for all parties to furnishing appropriate cataract surgery cases in the nonfacility setting. Cataract surgery has been for many years the highest volume surgical procedure performed on Medicare beneficiaries. For beneficiaries, cataract surgery in the office setting might provide the additional convenience of receiving the preoperative, operative, and post-operative care in one location. It might also reduce delays associated with registration, processing, and discharge protocols associated with some facilities.

Similarly, it might provide surgeons with greater flexibility in scheduling patients at an appropriate site of service depending on the individual patient's needs. For example, routine cases in patients with no comorbidities could be performed in the nonfacility surgical suite, while more complicated cases for example, pseudoexfoliation could be scheduled in the ASC or HOPD. In addition, furnishing cataract surgery in the nonfacility setting could result in lower Medicare expenditures for cataract surgery if the nonfacility payment rate were lower than the sum of the PFS facility payment rate and the payment to either the ASC or HOPD.

We solicited comments from ophthalmologists and other stakeholders on office-based surgical suite cataract surgery. In addition, we solicited comments from the RUC and other stakeholders on the direct PE inputs involved in furnishing cataract surgery in the nonfacility setting in conjunction with our consideration of information regarding the possibility of development of nonfacility cataract surgery PE RVUs. We received comments from stakeholders including professional medical societies, the RUC, ambulatory surgical centers ASCs , practitioners, and the general public.

The RUC deferred to the specialty societies regarding the appropriateness of performing these services in the nonfacility setting. Comment: A few commenters suggested that development of PE RVUs would allow for greater flexibility regarding scheduling and location where services are performed.

Commenters provided information about clinical considerations related to furnishing these services in a nonfacility setting, with many commenters citing safety concerns involved in furnishing cataract surgery in the office setting. Response: We will use this information as we consider whether to proceed with development of nonfacility PE RVUs for cataract surgery. A stakeholder indicated that due to changes in technology and technique, several codes that describe endoscopic sinus surgeries can now be furnished in the nonfacility setting.

We solicited input from stakeholders, including the RUC, about the appropriate direct PE inputs for these services. We received 53 comments from stakeholders including specialty societies, device manufacturers, medical centers, and physician practices otolaryngology, allergy, facial, and plastics specialists.

Some commenters submitted information about their respective PEs related to CPT codes , , , , , and Other commenters limited their comments to CPT codes and , noting clinical concerns about performance of other sinus surgery procedures in the nonfacility setting. A few commenters did not support development of nonfacility direct PE RVUs for endoscopic sinus surgery due to clinical considerations such as patient safety, possible complications, use of anesthesia, and need for establishment of standards and oversight of in-office surgical suites.

Response: We appreciate the feedback we received from all commenters. We will use this information as we consider whether to proceed with development of nonfacility PE RVUs or functional endoscopic sinus surgery services. Malpractice RVUs for new codes after were extrapolated from similar existing codes or as a percentage of the corresponding work RVU.

Section c 2 B i of the Act also requires that we review, and if necessary adjust, RVUs no less often than every 5 years. The MP crosswalks for those new and revised codes were subject to public comment and we are responding to comments and finalizing them in section II. The MP crosswalks for new and revised codes with interim final values established in this CY final rule with comment period will be implemented for CY and subject to public comment.

We will then respond to comments and finalize them in the CY PFS final rule with comment period. We discussed the exclusion of MP RVUs from this process at the time, and we stated that, since it is not feasible to obtain updated specialty level MP insurance premium data on an annual basis, we believe the comprehensive review of MP RVUs should continue to occur at 5-year intervals. In the CY PFS proposed rule 79 FR through , we stated that there are two main aspects to the update of MP RVUs: 1 Recalculation of specialty risk factors based upon updated premium data; and 2 recalculation of service level RVUs based upon the mix of practitioners providing the service.

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In the CY PFS final rule with comment period 79 FR , in response to several stakeholders' comments, we stated that we would address potential changes regarding the frequency of MP RVU updates in a future proposed rule. Under this approach, the specialty-specific risk factors would continue to be updated every 5 years using updated premium data, but would remain unchanged between the 5-year reviews.

However, in an effort to ensure that MP RVUs are as current as possible, our proposal would involve recalibrating all MP RVUs on an annual basis to reflect the specialty mix based on updated Medicare claims data. We direct the reader to section II. To determine the specialty mix assigned to each code, we also proposed to use the same process used in the PE methodology, described in section II. We note that for CY , we proposed and are finalizing a policy to modify the specialty mix assignment methodology to use an average of the 3 most recent years of available data instead of a single year of data.

TUESDAY, JUNE 24

We anticipate that this change will increase the stability of PE and MP RVUs and mitigate code-level fluctuations for all services paid under the PFS, and for new and low-volume codes in particular. We also proposed to no longer apply the dominant specialty for low volume services, because the primary rationale for the policy has been mitigated by this proposed change in methodology.

However, we did not propose to adjust the code-specific overrides established in prior rulemaking for codes where the claims data are inconsistent with a specialty that could be reasonably expected to furnish the service. We believe that these proposed changes serve to balance the advantages of using annually updated information with the need for year-to-year stability in values. We solicited comments on both aspects of the proposal: Updating the specialty mix for MP RVUs annually while continuing to update specialty-specific risk factors every 5 years using updated premium data ; and using the same process to determine the specialty mix assigned to each code as is used in the PE methodology, including the proposed modification to use the most recent 3 years of claims data.

We also solicited comments on whether this approach will be helpful in addressing some of the concerns regarding the calculation of MP RVUs for services with low volume in the Medicare population, including the possibility of limiting our use of code-specific overrides of the claims data. Commenters, including the RUC, stated a preference for the annual collection of professional liability insurance PLI premium data to insure the MP RVUs for every service is accurate, as opposed to only collecting these data every five years.

We also appreciate the comments from stakeholders regarding the frequency that we currently collect premium data. We will continue to consider the appropriate frequency for doing so, and we would address any potential changes in future rulemaking. Comment: Commenters, including the RUC, support CMS's proposal to use the 3 most recent years of available data for the specialty mix assignment. Response: We appreciate the commenters' support. Comment: Commenters supported CMS' proposal to maintain the code-specific overrides established in previous rulemaking for codes where the claims data are inconsistent with a specialty that could be reasonably expected to furnish the service.

Commenters also requested that CMS publish the list of overrides annually to receive stakeholder feedback related to necessary modification to the list, and in an effort to be as transparent as possible. Response: We appreciate the comments and agree that we should increase the transparency regarding the list of services with MP RVU overrides. Publication of this list will also allow commenters to alert us to any discrepancies between MP RVUs developed annually under the new methodology and previously established overrides.

Therefore, we have posted a public use file containing the overrides. Comment: One commenter stated that CMS should be particularly mindful of using the specialty mix in the Medicare claims data for services with low Medicare volume but high volume in the United States health care system more generally, such as pediatric procedures; and that CMS' MP RVU methodology needs to differentiate between services that are truly low volume and those that occur frequently, but not among Medicare beneficiaries. Response: We believe that the list of overrides we are making available as a public use file on the CMS Web site will help address the commenter's concern since the purpose of the code-specific overrides is to address circumstances where the claims data are inconsistent with the specialty that could be reasonably expected to furnish the service.

We have previously accepted comment on services like those identified by the commenter and will continue to consider comments regarding the need to use overrides for particular services, especially for high volume services outside the Medicare population. Comment: One commenter requested that CMS continue to use the dominant specialty for low volume codes. Response: We acknowledge the concern about using the dominant specialty for low volume codes, and will continue to monitor the resulting RVUs to determine if adjustments become necessary. In general, we believe the 3-year average mitigates the need to apply the dominant specialty for low volume services.

Radiation Safety in Nuclear Medicine

However, we have a long history of applying the dominant specialty for low volume services in instances where the specialty indicated by the claims data is inconsistent with the specialty that could be reasonably expected to furnish the service, and we are maintaining that practice. Comment: Some commenters requested more information on how specialty impacts were determined.

Two commenters expressed concerns about the estimated impact of the several proposed changes in the MP methodology on some specialties—particularly gastroenterology, colon and rectal surgery, and neurosurgery. Those commenters state that they appreciate the assertion that it may be difficult to obtain premium data for some specialties, such as neurosurgery, and state that CMS must thoroughly vet the methodology used by its contractor to determine MP premiums for such specialties.

The commenters urge CMS to review the data, continue to try to obtain premium data in as many states as possible, and to share the data with the public for the agency and specialties to determine its accuracy. Response: Specialty impacts are determined by comparing the estimated overall payment for each specialty that would result from the proposed RVUs and policies to the estimated overall payment for each specialty under the current year RVUs and policies, using the most recent year of available claims data as a constant. We note that for MP RVUs, there were several refinements that resulted in minor impacts to particular specialties, especially those at the higher end of specialty risk factors.


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We believe that these impacts are consistent with the general tendency of greater change in MP RVUs for specialties with risk factors of greater magnitude. We agree with the commenters regarding of the importance of making certain that the collection of premium data and the methodology of calculating MP RVUs are as accurate as possible. This is the reason we continue to examine the methodology and develop technical improvements such as the ones described in this section of the final rule.

After consideration of the public comments received, we are finalizing the policies as proposed. That is, we are finalizing the proposal to conduct annual MP RVU updates to reflect changes in the mix of practitioners providing services and to adjust MP RVUs for risk, and to modify the specialty mix assignment methodology to use an average of the 3 most recent years of available data instead of a single year.

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We note that we will continue to maintain the code-specific overrides where the claims data are inconsistent with a specialty that would reasonable be expected to furnish the services. Historically, we have used a floor of 0. In general, we believe this approach accounts for the minimum MP costs associated with each service furnished to a Medicare beneficiary. However, in examining the calculation of MP RVUs, we do not believe that this floor should apply to add-on codes. Since add-on codes must be reported with another code, there is already an MP floor of 0.

By applying the floor to add-on codes, the current methodology practically creates a 0. Therefore, we proposed to maintain the 0. We will continue to calculate, display, and make payments that include MP RVUs for add-on codes that are calculated to 0. These commenters suggested that the incremental risk associated with performing an additional procedure is not mitigated by the risk inherent in the base procedure.

Another commenter stated that each service should be considered separately for the purposes of calculating MP RVUs, and therefore, each service should be given the 0. Response: We appreciate commenters' feedback, but note that we do not believe the comments respond to the rationale for the proposed refinement. We agree that the incremental risk in procedures described by add-on codes is not mitigated by the risk inherent in the base procedure.


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  8. Instead, we believe that when the incremental risk is calculated to be a number closer to 0. We continue to believe that this refinement is the most appropriate approach, since we would continue to account for the incremental risk associated with add-on codes without overestimating the risk in circumstances where the MP RVU falls below 0.

    Therefore, we are finalizing the policy as proposed. We also solicited comments regarding how to best reflect updated MP premium amounts under the anesthesiology fee schedule. As we previously explained, anesthesia services under the PFS are paid based upon a separate fee schedule, so routine updates must be calculated in a different way than those for services for which payment is calculated based upon work, PE, and MP RVUs. To apply budget neutrality and relativity updates to the anesthesiology fee schedule, we typically develop proxy RVUs for individual anesthesia services that are derived from the total portion of PFS payments made through the anesthesia fee schedule.

    We then update the proxy RVUs as we would the RVUs for other PFS services and adjust the anesthesia fee schedule conversion factor based on the differences between the original proxy RVUs and those adjusted for relativity and budget neutrality. We believe that taking the same approach to update the anesthesia fee schedule based on new MP premium data is appropriate.


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    One commenter supported the delay in proposing to update the MP for anesthesia at the same time as updating the rest of the PFS, and another commenter suggested using mean anesthesia MP premiums per provider over a 4- or 5-year period prorated by Medicare utilization to yield the MP expense for anesthesia services; no commenters offered alternatives to calculating updated MP for anesthesia services.

    The latter suggestion might apply more broadly to the MP methodology for the PFS and does not address the methodology as much as the data source.

    Book Uspas Radiation Safety Presentation Slides 2004

    We continue to believe that payment rates for anesthesia should reflect MP resource costs relative to the rest of the PFS, including updates to reflect changes over time. Therefore, for CY , to appropriately update the MP resource costs for anesthesia, we proposed to make adjustments to the anesthesia conversion factor to reflect the updated premium information collected for the 5 year review. Again, this is consistent with our longstanding approach to making annual adjustments to the PE and work RVU portions of the anesthesiology fee schedule.

    To reflect differences in the complexity and risk among the anesthesia fee schedule services, we multiplied the service-specific risk factor for each anesthesia fee schedule service by the CY imputed proxy work RVUs and used the product as the updated raw proxy MP RVUs for each anesthesia service for CY We then adjusted the portion of the anesthesia conversion factor attributable to MP proportionately; we refer the reader to section VI.

    We invited public comments regarding this proposal. The following is a summary of the comments we received regarding this proposal.