The number of Americans who cannot keep up with the high cost of health care is growing and it is reported that medical bills are the leading cause of bankruptcy.
President Obama signed the Patient Protection and Affordable Care Act
(PPACA) Public Law 111-148, into law on March 23, 2010 and the Health Care and Education Reconciliation Act
(HCERA) Public Law 111-152, which amends the PPACA on March 30, 2010. Together, the PPACA and HCERA form the massive health care reform legislation with far-reaching implications for employers, employees, patients, providers and health plans.
The key provisions of the PPACA seek to protect and expand patient access to high-quality cost-effective health care.
The Patient Protection and Affordable Care Act
The PPACA expands access to health insurance, reduces health care spending, expands federal fraud and abuse authorities, increases transparency requirements and levies additional taxes and fees on health industry sectors as well as establishing various other health policy reforms.
The House Office of the Legislative Council (HOLC) has published a consolidated version of the PPACA and the HCERA of 2010. This document is not an official legal document but was published to provide an easier way to read the legislation which otherwise must be read side-by-side.
In this issue, we will focus on some of the major provisions of the health care reform legislation and the term PPACA will refer to PPACA as amended by the HCERA.
As is the case with most major pieces of legislature, the regulatory details and implementation requirements of the PPACA are not contained within the original bill but will be published in future rulemaking.
2010 PPACA PROVISIONS
EFFECTIVE JANUARY 1, 2010:
Timely Filing Limits
The statutory timely filing deadline for all Medicare fee-for-services claims has been reduced to one year effective for claims furnished on or after January 1, 2010. Medicare Part A and B claims with dates of service prior to January 1, 2010, must be filed by December 31, 2010.
Applicable Timely Filing Limits
Claim Must Be Filed By
01-01-2010 and after
1 year from the date of service
Medicare Prescription Drug Plans (Medicare Part D)
PPACA contains provisions to gradually eliminate the Medicare Part D coverage gap. The coverage gap, commonly referred to as the donut hole, is the period in the prescription drug benefit plan during which the beneficiary must pay 100% of the cost of their drugs until they reach catastrophic coverage.
In 2010 Medicare beneficiaries who enter the “donut hole” will receive a one-time $250 rebate check. The rebate checks will be sent automatically to qualifying Medicare beneficiaries, the first rebate checks have been sent and were scheduled to be received by June 10.
Medicare beneficiaries eligible for Medicare Extra Help, the Part D Low-Income Subsidy, will not receive the $250 rebate check, as these individuals never have a gap in their Part D coverage.
Geographical Practice Cost Indices (GPCIs):
The retroactive GPCI increases were implemented to help ensure patient access to care in rural areas. Specifically, the changes include:
- Retroactively extending the Work GPCI floor of 1.0 through December 31, 2010, and
- Increasing the Practice Expense (PE) GPCI for certain rural areas retroactive to January 1, 2010.
The AMA reports that changes to the GPCIs mandated in the PPACA will result in payment increases in 42 states and territories in 2010. The AMA estimates a 7.4% payment increase in much of Missouri, 14.9% in Puerto Rico, and average physician payment increases of $3,100 in Texas and $7,900 for physicians in Arkansas and Mississippi.
Section 6003 of the PPACA adds a new provision to the in-office ancillary services exception in the Stark statute. Previously, physicians could refer Medicare and Medicaid patients designated health services within their group practices as long as certain conditions were met. Under the new PPACA provision practices that provide magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET) and any other designated health services deemed appropriate by the Secretary, in their offices under the in-office ancillary services exception would be required to notify the patient, in writing at the time of the referral, of the following:
- The patient’s right to receive the service from a person other than the referring physician, a physician who is a member of the same group practice as the referring physician, or an individual directly supervised by the physician or by another physician in the group practice, and
- A list of alternative practices or imaging facilities near the patient’s residence.
In the 2011 Physician Fee Schedule Proposed Rule CMS clarifies the effective date of the regulation will not be retroactive to January 1, 2010 as stated in the PPACA proposing instead an effective date of January 1, 2011.
The Proposed Rule also includes the following patient disclosure proposals:
- The written notice, provided to the patient at the time of referral, is to include a list of 10 other suppliers within a 25-mile radius of the referring physician’s office. If there are fewer than 10 alternate suppliers the list should include all suppliers within the 25-mile radius.
- “Suppliers” are defined as a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services under this title. The list is not to include hospitals and critical access hospitals, among other facilities.
- The disclosure notification must be signed by the patient and maintained as an element of the patient’s medical record.
Another major change becomes effective July 1, 2010, when the reduction in payment for the Technical Component (TC) of certain imaging services increases from a 25% reduction to a 50% reduction in payments for consecutive procedures performed on contiguous body parts.
Fraud and Abuse Provisions
The PPACA strengthens current fraud and abuse programs and extends the exclusion program by giving the Secretary of Health and Human Services (HHS) the right to exclude individuals or entities that obstruct program audits or investigations.
PPACA also expands the list of offenses subject to civil monetary penalties to include:
- Ordering services while excluded,
- Making false statements on applications, and
- Failing to return and report a Medicare or Medicaid overpayment within 60 days after the date on which the overpayment was identified. Providers must also provide in writing the reason for the overpayment.
The new law makes it easier to obtain convictions of healthcare fraud and anti-kickback violations by clarifying the knowledge and intent standards. Changes in the healthcare fraud statute at 18 U.S.C. 1516 clarify that a person need not have actual knowledge of the law or a specific intent to violate the law. Rather, a person who knowingly acts, regardless of their knowledge of the law, would meet the statute’s intent requirement. Similarly, revisions in the anti-kickback statute state a person need not have actual knowledge of the law or specific intent to violate the law to meet the intent requirement.
Recovery Audit Contractors
The Recovery Audit Contractor (RAC) demonstration program, which ran for three years from 2005-2008, was so successful in recovering improper payments that it was made permanent through the Tax Relief and Health Care Act of 2006 (TRHCA). Under the RAC program, four contractors are currently identifying Medicare Part A and Part B overpayments and underpayments in all 50 states. The RACs are paid on a contingency fee basis, receiving a percentage of both overpayments and underpayments they identify.
The PPACA is expanding the RAC program by mandating that Medicaid programs, Medicare Part C (Medicare Advantage Plans) and Medicare Part D (Medicare Prescription Drug Plans) have a contract in place, by December 31, 2010, with one or more Recovery Audit Contractors (RACs) to identify underpayments and overpayments.
The new health care reform bill contains extensive payer reforms designed to improve patient coverage.
PPACA provides the following patient benefits in 2010:
- Establishes a temporary national high-risk pool to provide health coverage to individuals with pre-existing medical conditions, until all insurers are required to cover people with pre-existing conditions in 2014. (To qualify individuals can't have had health coverage for 6 months and enrollment may be capped in some states. )
- Provides dependent coverage for adult children up to age 26 for all individual and group policies.
- Prohibits individual and group health plans from placing a lifetime limit on the dollar value of coverage.
- Prohibits insurers from rescinding coverage except in cases of fraud.
- Prohibits pre-existing condition exclusions for individuals age 18 and under.
- Preventative services for women, such as mammograms, and immunizations for children must be covered by insurers, with no co-payments or deductibles.
Expansion of 340B Drug Pricing Access
The Affordable Care Act extends eligibility for the Section 340B Drug Pricing Program to certain critical access hospitals, freestanding cancer hospitals, rural referral centers, sole community hospitals, and children's hospitals.
Under the 340B Drug Program pharmaceutical manufacturers participating in the Medicaid program must provide up-front discounts on covered outpatient drugs purchased by certain covered entities. The prices charged to the qualified 340B entities must be at least as low as the price Medicaid agencies pay. Drugs provided in inpatient care settings are excluded from the 340B program.
The 340B Program is administered by the Office of Pharmacy Affairs (OPA), which is part of the HHS Health Resources and Services Administration (HRSA) and is supported by the Pharmacy Services Support Center (PSSC).
Prior to the passage of PPACA the 340B eligible entities included:
- Federally qualified health centers (FQHCs), including FQHC-lookalikes
- Ryan White/HIV clinics
- Black lung clinics
- Title X family planning clinics
- State-operated AIDS drug assistance programs
- Disproportionate share hospitals
- Certain children's hospitals
The PPACA also includes a provision increasing the mandatory Medicaid drug rebate percentage on brand name drugs from 15 percent to 23 percent. This provision may also result in lower 340B drug prices as they are tied to the Medicaid rebate.
Under the Fair and Accurate Credit Transactions Act of 2003 (FACTA) the Federal Trade Commission (FTC) is required to enact rules requiring creditors to develop and implement written identity theft prevention programs to protect consumers from identity theft. Under the “Red Flags Rule” legislation most physician practices would be considered a covered entity and have to comply with the Rule. The FTC recently called on Congress to exempt physician offices from the Red Flags Rule, and on May 31, the FTC announced they would delay enforcement of the Rule through December 31, 2010 while Congress considers legislation exempting physician, attorney and accounting offices with fewer than 20 employees from having to comply with the Rule. On June 25, in response to a lawsuit filed by the AMA and two other medical societies, the FTC announced they will delay enforcement of the Rule until after the U.S. Court of Appeals in Washington reviews a trial court decision in which the American Bar Association was successful in exempting legal offices from the Rule. This is the fifth delay in implementation of the Rule.
Changes to Enrollment
Under section 6401 of the PPACA, the HHS Secretary has the authority to require providers & suppliers to adopt and implement a compliance program as a condition of enrollment in Medicare, Medicaid and/or CHIP (Children’s Health Insurance Program). The HHS Secretary will determine the standards and timing of the compliance plan. Additionally, the Secretary and Office of Inspector General (OIG) will develop enhanced screening provisions for new enrollees as well as currently enrolled providers.
Furthermore, beginning March 2011 new enrollment or revalidation applicants must disclose any current or previous affiliation, direct or indirect, with a provider that:
- Has uncollected debt, or
- Has been suspended or excluded from participation in a federal health care program, or
- Has had its billing privileges denied or revoked.
The applicant may be denied enrollment if based on such an affiliation.
Reporting Quality Measures in the Physician Office
Incentive payments under the Physician Quality Reporting Initiative (PQRI) have been extended through 2014. Bonus payments, calculated on qualified services paid under the Medicare Physician Fee Schedule (MPFS), for successful reporters will be:
- 1% in 2011
- 0.5% in 2012-2014
Penalties are established for providers who do not report quality measures beginning in 2015:
- -1.5% penalty in 2015
- -2% penalty in 2016 and beyond
From 2011-2014 an additional 0.5% bonus payment is available to physicians who meet the requirements of a continuous assessment program such as the Maintenance of Certification Program, (MOCP). In addition, the physicians must participate in such a MOCP for a year and must successfully complete a Maintenance of Certification Program practice assessment.
Program enhancements include the requirement that CMS establish an informal PQRI appeals process for unsuccessful reporters no later than January 1, 2011 and the requirement that timely feedback reports be provided for PQRI participants.
Under a related Health Information Technology (HIT)/Electronic Health Record (EHR) provision, no later than January 1, 2012, the Secretary of HHS, must develop a plan to integrate reporting on quality measures with reporting requirements related to the meaningful use of EHRs.
Reporting Quality Measures in Cancer Hospitals
Effective beginning in 2014, the eleven Prospective Payment Services (PPS) exempt cancer hospitals will be required to submit data on quality measures to the Secretary of HHS. The new measures are to be published by September 30, 2012. Quality measures of process, structure, outcome, patients' perspective on care, efficiency, and costs of care related to services furnished in PPS-exempt cancer hospitals will be reported on the CMS Web site and made available to the public.
The 11 Exempt Cancer Centers are:
- City of Hope National Medical Center (Duarte, CA)
- USC Kenneth Norris Jr. Cancer Hospital (Los Angeles, CA)
- Dana Farber Cancer Institute (Boston, MA)
- Memorial Hospital for Cancer and Allied Disease (New York, NY)
- Roswell Park Memorial Institute (Buffalo, NY)
- American Oncologic Hospital (Fox Chase) (Philadelphia, PA)
- The University of Texas M.D. Anderson Cancer Center (Houston, TX)
- Fred Hutchinson Cancer Research Center (Seattle, WA)
- Arthur G. James Cancer Center Hospital and Research Institute (Columbus, OH)
- University of Miami Hospital and Clinics (Miami, FL)
- H. Lee Moffitt Cancer and Research Institute Hospital, Inc. (Tampa, FL)
In 2011 Medicare beneficiaries who enter the donut hole will receive a 50% discount, at the point of purchase, on covered brand name Part D drugs. By 2020, the donut hole is to be eliminated completely.
Future payer reforms under the PPACA are numerous, below is a list of some of the provisions effective January 1, 2014:
- Creation of state-based and state-administered health insurance exchanges for the individual and small group market.
- Insurers can no longer deny coverage to people with pre-existing conditions.
- Insurers are prohibited from imposing annual or lifetime monetary coverage limitations.
- Insurers are prohibited from denying routine care or dropping coverage if an enrollee participates in certain clinical trials.
- All qualified plans, with the exception of grandfathered plans, must provide essential health benefits package.
- Group health plans and health insurance issuers offering individual or group coverage can no longer utilize a waiting period that is longer than ninety days.
Of special interest to the cancer community is the provision of the health care reform bill that will require coverage for routine patient care costs for those with cancer and life-threatening illnesses who are enrolled in clinical trials. The clinical trials coverage provision applies to private insurance plans and the Federal Employees Health Benefits Program.
Future Reimbursement Changes
The PPACA also contains several major initiatives focused on the development and implementation of new payment models with the goal of saving costs and improving the quality of care. These initiatives include the development of the new Center for Medicare and Medicaid Innovation (CMI) office, the new Independent Payment Advisory Board (IPAB) and the expansion of Value Based Purchasing (VBP) programs.
Center for Medicare and Medicaid Innovation
By January 1, 2011, the new HHS office, the Center for Medicare and Medicaid Innovation (CMI), will be tasked with developing and testing new innovative payment and service models to reduce expenditures in the Medicare and Medicaid programs while preserving or enhancing health care quality.
The models to be tested must include models that support care coordination for chronically ill individuals at high risk of hospitalization through a HIT-enabled provider network that includes care coordinators, a chronic disease registry, and home telehealth technology. When selecting models to test, the CMI will take into consideration whether the model utilizes technology such as EHR and patient-based remote monitoring systems. There must also exist "evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures."
Included among the models the CMI may test are:
- Aligning nationally recognized, evidence-based guidelines of cancer care with payment incentives.
- Patient-centered medical homes that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.
- Direct contracting with provider groups to promote innovative care delivery models.
- Utilization of geriatric assessments and comprehensive care plans to coordinate care for individuals with multiple chronic conditions and an inability to perform two or more activities of daily living or a cognitive impairment such as dementia.
- Care coordination for chronically ill patients at high risk of hospitalization through the use of health information technology-enabled provider networks including care coordinators, a chronic disease registry, and home tele-health technology.
- Community-based health teams to support small-practice medical homes by assisting primary care practitioners in chronic care management.
- Assisting individuals in making informed health care choices by paying providers for using patient decision support tools.
- Allowing states to test and evaluate systems of all-payer payment reform for the medical care of residents.
- Improving post-acute care through continuing care hospitals.
- Funding home health care providers who offer chronic care management services in cooperation with interdisciplinary teams.
- The development of a collaborative of high-quality, low-cost health care institutions responsible for developing, documenting, and disseminating best practices and proven care methods and implementing and assisting other institutions in implementing such best practices and care methods.
CMS will evaluate each of the tested delivery models and make those results available to the public. The evaluations conducted by CMS are required to include an analysis of:
- The quality of care furnished under the model, including the measurement of patient-level outcomes and patient-centeredness criteria determined appropriate by CMS; and
- The changes in spending under the applicable titles by reason of the model.
Based on the evaluation results CMS may expand the duration and the scope of a model that is being tested or a demonstration project, if it meets the following criteria:
- The Secretary determines that such expansion is expected to reduce spending under Medicare or Medicaid without reducing the quality of care; or improve the quality of care and reduce spending; and
- The Chief Actuary certifies that such expansion would reduce program spending.
The Independent Payment Advisory Board
The health care reform bill restructures (and effectively eliminates) the existing Medicare Payment Advisory Commission (MPAC) and creates a new board, the Independent Payment Advisory Board (IPAB), to address the rising costs of Medicare. The IPAB will be comprised of 15- members appointed by the President.
The new IPAB differs from the MPAC in that the new board’s cost-saving recommendations to the Medicare program are binding unless Congress overrides it.
The appointed membership of the IPAB is to include (but not be limited to):
- Physicians and other health professionals,
- Experts in the area of pharmaco-economics or prescription drug benefit programs,
- Third-party payers,
- Individuals skilled in the conduct and interpretation of biomedical, health services, and health economics research and expertise in outcomes and effectiveness research and technology assessment, and
- Representatives of consumers and the elderly.
The HHS Secretary, the Administrator of CMS, and the Administrator of the Health Resources and Services Administration will also serve on the board as non-voting members.
The IPAB will be authorized to make proposals to save costs in the Medicare program and meet the program’s target rate of growth. The IPAB will first recommend cuts in 2014 for implementation in 2015. IPAB proposals will become law unless Congress adopts alternative cost savings proposals that meet or exceed the IPAB proposals.
The IPAB may not submit proposals that:
- Ration health care,
- Raise revenues, or Medicare beneficiary premiums,
- Increase Medicare beneficiary cost-sharing including deductibles, co-insurance and co-payments, or
- Restrict benefits or modify eligibility criteria.
The IPAB will also submit non-binding recommendations to slow the growth in national health care expenditures.
The American Medical Association (AMA) has stated they are opposed to the scope and authority of the IPAB and the lack of flexibility in its mandate. The AMA states, “Modification of the IPAB authority and framework is one of the highest legislative priorities for the AMA in the next session of Congress.”
Value-Based Purchasing Initiatives
CMS seeks to move away from the current Medicare reimbursement model, based on the quantity of resources consumed and services provided, towards Value-Based Purchasing (VBP), a model upon which payment is based on the cost and quality of services provided.
Under the VBP model CMS seeks to be an active purchaser of quality healthcare. There are two key elements to VBP:
- Quality measurements including patient outcomes and health status, and
- Incentives to encourage higher quality and avoidance of unnecessary costs.
CMS took the first step in the transition to a VBP program with the development and implementation of pay for reporting programs with the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program in the inpatient setting, the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), in the hospital outpatient setting, and the Physician Quality Reporting Initiative (PQRI) program in the physician office setting.
Under provisions in the PPACA CMS continues their methodical move towards VBP.
VBP in Hospitals
PPACA provisions transition the existing value-based purchasing program from payment for reporting quality measures to payment for meeting quality measures. Under the VBP program, beginning in fiscal year 2013, value-based incentive payments will be made to hospitals that meet or exceed certain performance standards.
The total amount available for all value-based incentive payments in a fiscal year is equal to the amount of reduction to the base operating DRG (diagnosis related group) payment for all hospitals in that fiscal year.
The reduction percentage to the base operating DRG and therefore the amount available for the VBP incentive payment is reported as follows:
Reduction to DRG/
Available VBP Incentive Payment
|2017 & succeeding fiscal years
VBP in the Physician Office
The Secretary of HHS is directed to establish a budget-neutral value-based payment modifier that provides for a differential payment to a physician or group of physicians based upon the quality and cost of care. The Secretary is required to establish quality and cost measures that are risk-adjusted and geographically standardized. The measures are to be published no later than January 1, 2012.
The payment modifier will be implemented in two phases:
- Beginning on January 1, 2015, for specific physicians and groups of physicians, and
- Beginning January 1, 2017, for all physicians and groups of physicians.
Under the Physician Feedback Program the Secretary will provide confidential reports to physicians that compare patterns of resource use of the individual physician to the patterns of resource use of other physicians.
VBP in SNFs, Home Health Agencies & ASCs
Under PPACA the Secretary is required to develop a plan to implement a VBP program for payments under Medicare for each of the following:
- Skilled Nursing Facilities (SNFs)
- Home Health Agencies (HHAs); and
- Ambulatory Surgical Centers (ASCs).
The plan for ASCs must be submitted to Congress no later than January 1, 2011, and the plans for SNFs and HHAs must be submitted no later than October 1, 2011.
Demonstration and Pilot Projects
National Pilot Program on Payment Bundling
By January 1, 2013 the Secretary of HHS must establish a pilot program for integrated care during an episode of care, beginning three days prior to an inpatient admission and continuing for thirty days after discharge, provided to applicable Medicare beneficiaries in order to improve the coordination, quality, and efficiency of health care services. The payment bundling pilot program is not applicable to Medicare beneficiaries enrolled under Part C or a PACE (Program of All Conclusive Care for the Elderly) program.
The payment bundling program will apply to one or more of ten conditions selected by the Secretary. When selecting the applicable conditions the Secretary will consider the following factors:
- Whether the conditions include a mix of chronic and acute conditions;
- Whether the conditions include a mix of surgical and medical conditions;
- Whether the conditions provide an opportunity for providers and suppliers to improve the quality of care furnished, while reducing total expenditures;
- Whether the conditions have sufficient variation in the number of readmissions and amount of post-acute care spending; and
- Which conditions are most amenable to bundling.
While the pilot bundling program is similar to the DRG payment model Medicare uses in the hospital it would expand the bundled payments to include all services provided to a patient during the episode of care.
New HHS Offices Created by PPACA:
» Office of Consumer Information and Insurance Oversight (CIIO) will oversee implementation of the PPACA private insurance provisions and the CIIO office will be in charge of:
» Office of the Director reports to the HHS Secretary will oversee CIIO.
» Office of Oversight will perform rate reviews & give states grants to set up rate review programs.
» Office of Insurance Programs will administer the temporary high-risk pool programs & the early retiree reinsurance program.
» Office of Consumer Support will put comparative price data on the HHS web site.
» Office of Health Insurance Exchanges will develop and implement policies and rules governing state-based exchanges & oversee operations of the new state-based exchange health coverage distribution entities.
» MGMA Healthcare Reform and the PPACA Resource Center
» National Association of Insurance Commissioners
COMPLIANCE PLANS AND THE OIG
In the PPACA the Secretary of HHS is directed to develop, in consultation with the Inspector General (IG) of the Department of Health and Human Services, core elements of a compliance program. The Secretary is also to determine which providers and suppliers will be required to have such a compliance plan in place.
The Secretary and IG have yet to publish the core elements for the mandatory compliance plan. However, the Office of Inspector General (OIG) has consistently identified the following seven core elements as fundamental to an effective compliance program:
1. Implementing written policies and procedures;
2. Designating a compliance officer and compliance committee;
3. Conducting effective training and education;
4. Developing effective lines of communication;
5. Conducting internal monitoring and auditing;
6. Enforcing standards through well-publicized disciplinary guidelines; and
7. Responding promptly to detected problems and undertaking corrective action.
Providers and suppliers are urged to watch for further rule-making and communication on the development and implementation of the new mandatory compliance programs. In the interim, Click Here to access the OIG’s previously published voluntary compliance program guidance for hospitals, pharmaceutical manufacturers, third-party medical billing companies, clinical laboratories, and individual and small group physician practices.
Risë Marie Cleland
113 W. 7th Street
Vancouver, WA 98660
Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com
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ABOUT THE EDITOR
Risë Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc. Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.
CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided that it is forwarded unedited and in its entirety.