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"We proposed the RUC-recommended work RVU of 7.86 for CPT code 27278. We also proposed the RUC-recommended direct PE inputs without refinement."
Comment: Several commenters supported CMS’ proposed valuation of 7.86 work RVUs for CPT code 27278. They also supported CMS’ proposed RUC-recommended direct PE inputs for the non-facility site of service as they noted that current study data has sufficiently demonstrated safety and efficacy in the non-facility setting. However, several commenters expressed concern that the non-facility site of service is not appropriate for this procedure. They stated that the procedure is new and without a pre-established safety record.
Response: We thank commenters for their support of our proposed work RVU and nonfacility direct PE inputs. However, we also acknowledge other commenters’ concerns regarding CPT code 27278 being performed in the non-facility setting. At this time, we agree with the RUC’s recommended valuations, including the non-facility direct PE inputs. However, given consideration of all comments received, we believe that CPT code 27278 could benefit from additional future review by the RUC, as a service that includes a new technology supply item (dorsal SI joint arthrodesis implant), as well as considerations for the site of service.
If we were to receive new RUC recommendations at a future date, we would consider that information and any discussions with interested parties for rulemaking.
Comment: Some commenters expressed concerns about the cost of the direct PE supply item, dorsal SI joint arthrodesis implant, valued at $11,500. They stated that the high cost of this supply will negatively impact PE RVUs and cause undesirable effects on the PFS budget neutrality as a service with one of the highest costs on the fee schedule. Commenters were also concerned with the potential overutilization of the service in the non-facility setting.
Response: The payment for the dorsal SI joint arthrodesis implant is based on invoices received from the manufacturer and a formal review to determine if each direct PE input is typical and medically necessary, which is part of our standard code review process. While we acknowledge that the supply is a high-cost item, we do not believe it is appropriate to undervalue a service to minimize impacts on budget neutrality. We also remind commenters that the utilization for this new CPT category I code is crosswalked from CPT code 0775T. As such, we do not anticipate a large impact on budget neutrality and will continue to monitor utilization as part of our standard ratesetting process.
After consideration of the public comments, we are finalizing the RUC-recommended work RVU of 7.86 and direct PE inputs as proposed for CPT code 27278.
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