2006 proposed fee schedule - American Society of Clinical Oncology

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(1) Historical Drug Expenditure Data To develop the drug add-on adjustment we used historical total aggregate payments for separately billed 128 ESRD drugs for half of CY 2000 and all of CY 2001, CY 2002 and CY 2003. For EPO, these payments were broken down according to type of ESRD facility (hospital-based versus independent). We also used the number of dialysis treatments performed by these two types of facilities over the same period. (2) ASP +6 Percent Prices We obtained the ASP +6 percent prices, for the second quarter of CY 2005, as shown in the following table. For purposes of this proposed rule, we have used the latest ASP pricing available, which are second quarter prices. For the final rule, we will have prices for all 4 quarters of CY 2005 and plan to develop prices representing the average CY 2005 ASP payments for the drugs listed in Table 20 below. TABLE 20 Drugs Second Quarter ASP +6 Percent Epogen $9.25 Calcitriol $0.86 Doxercalciferol $2.78 Iron_dextran $11.22 Iron_sucrose $0.37 Levocarnitine $11.12 Paricalcitol $3.97 Sodium_ferric_glut $4.73 Alteplase, Recombinant $30.09
Drugs Second Quarter ASP +6 Percent Vancomycin $3.19 (3) Estimated Medicare Payments using 95 Percent of AWP In order to estimate AWP payments we used the first quarter 2005 AWP prices and updated them to the second 129 quarter by applying, for drugs other than EPO, an estimated AWP quarterly growth of approximately 0.74 percent (annual growth factor of 3 percent). This growth factor is based on historical trends of AWP pricing (for all drugs) for the year 1997-2003. We did not increase the payment rate for Epogen since payment was maintained at $10.00 per thousand units prior to MMA. (See Table 21.) TABLE 21 Drugs AWP Rates for the Second Quarter of 2005 Epogen $10.00* Calcitriol $1.40 Doxercalciferol $3.11 Iron_dextran $18.04 Iron_sucrose $0.66 Levocarnitine $36.75 Paricalcitol $5.37 Sodium_ferric_glut $8.23 Alteplase, Recombinant $38.82 Vancomycin $5.55 *Statutory rate. (4) Dialysis Treatments We updated the number of dialysis treatments by the actuarial projected growth in the number of ESRD beneficiaries. Since Medicare covers a maximum of three treatments per week, utilization growth is limited, and,
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DEPARTMENT OF HEALTH AND HUMAN SERV
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2. By mail. You may mail written co
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Rick Ensor (410) 786-5617 (for issu
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service of the U.S. Government Prin
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4. Proposed Revisions to §413.170
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AGA American Gastroenterological As
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GAO General Accounting Office GPCI
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PLI Professional liability insuranc
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Initially, only the physician work
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This resource-based system was base
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effect in 1997, published on Novemb
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● Revised requirements for superv
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efinement of work RVUs; and solicit
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historical allowed charges. This le
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November 1, 2001 (66 FR 55246).) Th
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The CPEPs identified specific input
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codes that the RUC has not yet revi
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procedure: $27,305,408. In this exa
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as a whole. Indirect costs include
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● The unscaled indirect expense a
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BNF is applied to (multiplied by) t
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NPWP Step 2--Calculation of Charge-
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In Table 11, the scaled total direc
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TABLE 13--Budget Neutrality and Fin
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The following discussion outlines t
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exist, and suggests that the need f
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TABLE 14--Practice Expense Per Hour
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We believe that we have consistentl
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Due to the ongoing refinement by th
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indirect PE methodology is inaccura
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multi-specialty PEAC that were base
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the needed survey or other data or
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PERC/RUC recommendations for these
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eflect the typical number of cast c
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on comments received and additional
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We have reviewed the PE database an
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the ACR. We have accepted the follo
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● Clinical Labor for G-codes Rela
Page 77 and 78: proposed associated prices that we
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Page 81 and 82: ● Supply and Equipment Items Need
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Page 85 and 86: Code 2005 Description Price EQ212 p
Page 87 and 88: Effective January 1, 2006, this pro
Page 89 and 90: challenge the validity of a new loc
Page 91 and 92: ones reconfigured). Yet we also rec
Page 93 and 94: The issue of payment locality desig
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Page 103 and 104: 103 However, as noted previously in
Page 105 and 106: ● Category #1: Services that are
Page 107 and 108: G0270, G0271 and 97802 through 9780
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Page 111 and 112: 111 furnished in the group setting
Page 113 and 114: CMS Review 113 As noted previously,
Page 115 and 116: system that permits the physician a
Page 117 and 118: 117 associated with the provided se
Page 119 and 120: 119 overlapping surgeries, the teac
Page 121 and 122: anesthesia programs that have arran
Page 123 and 124: 123 Section 623 of the MMA also req
Page 125 and 126: 125 hospital-based facilities; whil
Page 127: 127 The next step would be to devel
Page 131 and 132: 131 independent facilities, to acco
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Page 135 and 136: distributed this over a total proje
Page 137 and 138: 137 additional 0.7 percent addition
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Page 141 and 142: 141 than 0.9000 are paid more than
Page 143 and 144: adoption of the new hospital wage i
Page 145 and 146: of geographic designations for purp
Page 147 and 148: and they may or may not be suitable
Page 149 and 150: the Medicare Geographic Classificat
Page 151 and 152: (2) Metropolitan Divisions Under OM
Page 153 and 154: 153 applying revised composite paym
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Page 157 and 158: 157 actual cost structure faced by
Page 159 and 160: 159 ESRD facilities is 53.711, as s
Page 161 and 162: from the cost reports. To avoid dou
Page 163 and 164: from Worksheet A. The resulting mar
Page 165 and 166: (1) Hospital Data Used In this prop
Page 167 and 168: wage data ended. However, since the
Page 169 and 170: approach to phasing-in the proposed
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Page 173 and 174: 173 wage index values and then simu
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179 CBSA Code Urban Area Wage (Cons
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TABLE 28--Proposed ESRD Wage Index
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● Extraordinary circumstances (§
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effect as long as the rate exceeds
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● Adding a definition of a “ped
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exception rate. The facility would
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their intermediaries. Current parag
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229 costs are reasonable and allowa
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231 revised paragraph, a facility w
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H. Payment for Covered Outpatient D
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calculation. We also discuss the su
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customers (for example, physicians)
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239 We believe the weighted average
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number of 11-digit NDCs sold for ea
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243 included in the template, it is
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current reporting format is an appr
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247 section 1847A of the Act for th
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each quarter at the following web s
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251 We also note MedPAC’s recomme
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costs and units. We seek comments a
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255 pays for DME and associated sup
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pharmacy activities required to get
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259 representing 42 percent of the
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261 basic pharmacy services such as
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seek comment on the potential impac
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265 overpaying for the costs associ
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267 and information about how pharm
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269 takes good faith efforts to res
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271 Specifically, we consider that
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supplies. Using billing data, we id
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70481 CT orbit/ear/fossa w/ dye 704
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K. Therapy Cap 73223 MRI joint uppe
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provided for an active subluxation
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is less than 2 percent of spending
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(2) entities determined by the Secr
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285 We are proposing a supplemental
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FQHC claim form to effectuate the b
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289 can issue a final determination
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291 conclude that Hispanic persons
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293 nuclear medicine services in ei
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adiopharmaceuticals. In the final r
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297 (including Nuclear Medicine and
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we would resolve any doubt on the m
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facility payment rather than a TC c
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ventures and leases, pose a risk of
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305 Underlying the projected rate r
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decisions are central to the health
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however. We are particularly intere
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The collection requirement in this
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eporting requirements are discussed
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IV. Response to Comments Because of
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achieve the objectives with less si
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319 The analysis and discussion pro
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321 for a new code may change becau
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323 TABLE 30--Impact of Practice Ex
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hour for these specialties. As note
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Both physical/occupational therapy
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329 proposing to add cardiology cat
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Speciality Impact of Removing Aberr
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Family TABLE 32--Impact of Multiple
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335 column includes the current est
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Specialty Medicare Allowed Charges
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339 Non-Facility Facility % % HCPCS
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341 have undertaken a similar analy
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of the updated GPCI data. For the R
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C. Medicare Telehealth Services In
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347 TABLE 37--Impact of Proposed Ch
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349 of the increase to the drug add
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plus current AAP priced drug paymen
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353 the center up to what it would
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satisfies the requirements of the i
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357 certainty the extent of these s
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delivery arrangements and would hel
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List of Subjects 42 CFR Part 405 Ad
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(including by refunding amounts in
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(2) Any financial incentives provid
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7. The authority citation for part
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* * * * * PART 413--PRINCIPLES OF R
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371 D. Redesignating paragraphs (l)
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373 (3) The additional nursing hour
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cost components relating to trainin
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CAPD and CCPD) when the facility ac
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Indirect Sales means from the manuf
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amount for the quarter to the neare
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383 25. The heading for Part 426 is
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385 (Catalog of Federal Domestic As
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1. CPT/HCPCS code. This is the CPT
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grace period. This indicator is no
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5. Physician work RVUs. These are t
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ADDENDUM B: RELATIVE VALUE UNITS (R
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CPT Code Short Descriptors 21480 Re
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CPT Code Short Descriptors 92284 Da
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Addendum D 2006 GEOGRAPHIC PRACTICE
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Carrier Locality Locality name Work
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Carrier Locality Locality Name 2006
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Addendum F ESRD FACILITIES- METROPO
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715 SSA State/County Code County an
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2006 proposed fee schedule - American Society of Clinical Oncology

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