2016 RVU Revenue Impact Report for Podiatry

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1 Guerrilla Podiatry: Revenue Impact Report RVU Revenue Impact Report for Podiatry by Pamela Thompson All RIGHTS RESERVED Contact: Copyright Pamela Thompson. ALL RIGHTS RESERVED

2 Guerrilla Podiatry: Revenue Impact Report RVU Revenue Impact Report for Podiatry Most Office Based Services Reimbursement Increases by Pennies Loses 20%. The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law on April 16,, repealing the SGR. The legislation provided for positive annual payment updates of 0.5 percent starting July 1,, increasing by.5% each year thereafter until The 2% sequester reduction remains unchanged for. What wasn't revealed in the hoopla over the repeal is that other regulations can decrease reimbursement regardless of what the SGR repeal bill states. That will happen in. Although many code values were unaffected and will see a.5% increase, an average.3% decrease in reimbursement overall resulted from other regulations trumping MACRA. The good news: the majority of podiatric office-based CPT reimbursement either stayed the same or increased slightly (by pennies, but who's quibbling?). Office consult codes ( ) decreased by a dollar or two. Unfortunately, reimbursement decreased almost 20%. This was the biggest loser in office-based care for podiatry. ASC/hospital-based surgery codes are a bit all over the place. Some dropped by double digit percentages, others went up by the same. If you do a lot of surgery, look at the codes carefully. How Your Reimbursement is Calculated CMS (and now, MACRA) assigns the value of the Conversion Factor, which is the dollar value of one Relative Value Unit. Changes in the Conversion Factor is often the more recognizable influence in reduced reimbursement. The conversion factor for is $ ; in it started out at $ until April 1st, then increased to $ for the remainder of. CMS s allowable (your reimbursement) is calculated by multiplying the Conversion Factor by the "value" of the expense you incurred to deliver the CPT you ve billed. CMS is repaying you for the expense you incurred to deliver your medical service. That's why it's called "reimbursement", not payment. You are being reimbursed for your costs. Each CPT code has 3 different cost values assigned to it (work expense, practice expense and malpractice expense), and those are further adjusted for practice location. These aggregated costs for a specific service are called Relative Value Units (RVUs). If that s not confusing enough, each CPT s RVU component values are different from any other CPT code s values. Copyright Pamela Thompson. ALL RIGHTS RESERVED

3 Guerrilla Podiatry: Revenue Impact Report Why It Matters Every year CMS reviews utilization of physician services and makes adjustments to the next year s CPT work, expense and malpractice values (Relative Value Units) in order to maintain budget neutrality mandated by law, temper "abusive" overuse, and generally disturb what peace and quiet private practitioners might have. (A mini- Primer on RVUs, budget neutrality, etc., appears at the end of this report.) Here's what's most important: even if the Conversion Factor increases, if RVUs decrease, reimbursement can ultimately decrease as well. Sometimes by a significant amount. Consequently it is very, very difficult for practice owners to assess the yearly financial impact these constantly changing RVUs (and thus, the allowable) have on their practice without some kind of analysis tool. That's why I created the Guerrilla Podiatry RVU Revenue Impact Tool. It's an interactive tool designed for my clients to predict revenue changes they need to address in the coming year, based on CMS's changes to RVUs and the Conversion Factor. They can enter how many of each CPT they delivered, and the tool shows them the revenue difference by CPT and total for the physician, new year to previous 2 years. I use the same RVU Revenue Impact Tool to prepare this report each year as a free service to all podiatrists, so they can have some idea of what may affect their revenue, and mitigate untoward surprises. Your Per Minute Costs are Important CMS contracts with the Lewin Group to determine medical practice "costs" by specialty, using an accounting method called "activity-based costing" to set RVU values for reimbursement.. Activity-based costing (aka "ABC") assigns costs by resource (e.g., a physician, support employee or piece of equipment) and includes the share of overhead used by that resource. ABC is standardly used all over the world in manufacturing and service businesses to find out exactly what it costs every time a resource performs an action. It's how businesses know whether they are earning or losing profit. In service businesses, use of activity-based costing lets managers (and the Lewin Group) "see" each task in a work flow as a cost. They take this into account when they decide how much you spend per minute to deliver care, and therefore, how much CMS should reimburse you. For example, your check-in staffer costs you something for every minute she (or he) is at work. Those costs include their pay, your payroll tax costs, any benefits they have and a portion of your overhead. Every time a staff member performs a task, they incur a cost to you. Of course, they also incur a cost to you if they do nothing, or if what they do serves no productive purpose. You pay for it either way. Copyright Pamela Thompson. ALL RIGHTS RESERVED

4 Guerrilla Podiatry: Revenue Impact Report Activity-based costing can be used to measure the per minute cost of productive activity, which is its main purpose in profitable operations management (and is a service Guerrilla Podiatry provides for physician practices). If your total cost for a staff member was $1 per minute every minute they were on the clock in your office, theoretically your per minute cost would be $1. But it isn't, because practically speaking, there is always some time where nothing productive occurs. If you remove that time from the equation, say 10% of the time you pay for, then your cost per minute goes up. What you pay stays the same, but there are less minutes actually worked (only counting productive time), which increases cost per minute. CMS Says Your Costs Are... I don't know how much "slop" (unproductive time) is included in the Lewin Group's calculation of podiatric per minute costs. I do know they determined that podiatry reimbursement rates should be based on a $2.72 overall cost per minute. This $2.72/minute includes $1.52/minute for practice expense (56% of the total), $1.14/minute for physician work (42%) and $.06/minute for malpractice expense (2%). Most government literature concerning assignment of work, practice expense and malpractice cost to each RVU says that physician work accounts for 52 percent of the RVU, practice expense is 44 percent and malpractice expenses are 4 percent of the total. Well, not for podiatry. Podiatry work allocation is only 42%, with practice expense at 56%. Our analysis of podiatric RVUs shows the following cost allocation to work, practice expense, and malpractice cost specifically for podiatry: The Lewin Group applied activity-based costing to sample podiatric practices, of a typical size, to arrive at this $2.72/minute costing. What size practice has costs of $2.72/minute? CMS Cost Per Minute Assignment for Podiatry RVU Cost Per Hour Cost Per Minute % of Total RVU Practice Expense $91.20 $ % Physician Work $68.40 $ % Malpractice $3.60 $0.06 2% TOTAL $ $ % Data extrapolated from 2011 CMS PE per hour determination for Podiatry, based on 2011 Lewin Group RVU cost analysis Practices whose gross revenue (which CMS defines as expense) doesn't exceed about $308,000 a year, with CPT delivery 5 full days a week, 50 weeks a year. As soon as practice gross revenue exceeds $308,000, or is delivered in less time, actual cost per minute goes up. This would not be problematic if the practice was not losing too much productivity. Copyright Pamela Thompson. ALL RIGHTS RESERVED

5 Guerrilla Podiatry: Revenue Impact Report I know how a practice that does not fit the $2.72/minute mold must function to be profitable. My company is the only one in the country who actually performs activity-based costing for private medical practices and uses that data to efficiently solve profit issues and reduce the owner's need for "practice management". Though we use activity-based costing to find unnecessary profit loss, the cost data provided by CMS can be used to help you "time-manage" your practice a bit, if you wanted a quick 'n dirty way to spiff things up. You could use CMS's per minute calculation to "see" how long you could spend delivering a particular CPT and not lose revenue at CMS reimbursement rates. Here's a quick, very simplified, example of practical use of the $2.72/minute metric: Delivery of (.91 RVUs) and (1.65 RVUs) reimburse $32.60 and $59.12 respectively (not adjusted for locale). At $2.72/minute, you should be able to deliver those 2 CPTs in under 11 minutes, including documentation, and all other staff work from beginning to end, including collection, posting, all other practice admin and overhead, would be completed in less than 23 minutes. CPT Work RVU Physician Minutes $ PE RVU Staff Minutes $ MP RVU $ $ $ $ $ $ $ 0.72 Total I think this is where the huge disconnect happens when private practice physicians and payers discuss reimbursement. Can those two CPTs be delivered in under 11 minutes? Of course they can. Happens every day, and done well. Delivery of those CPTs isn't close to the whole story. Physicians participate in Meaningful Use, PQRS, document in an EHR, have a sicker patient demographic, or have a surgically based practice. Even without waste, these factors add time. Include some time-wasting activities in the mix and reimbursement may not be enough if it takes 11 minutes to deliver the service. This is what physicians are actually targeting when they object to reimbursement decreases. They can't seem to maintain their personal income (or profit) while accommodating increased expenses associated with practice today. However, our analyses, using the same activity-based costing methodology, have found significant practice expense in many "top" practices that "buys" no or unnecessary activity. It's just wasted. This wasted expense results in unnecessary profit loss of about 20% of gross revenue each year. Copyright Pamela Thompson. ALL RIGHTS RESERVED

6 Guerrilla Podiatry: Revenue Impact Report When this waste is found, practice owners can convert most of this loss back into profit. Reimbursement rate issues are then no longer a real world threat to the practice. This capability will be key to surviving payment change from fee for service to value, which is essentially capitation. As you know, success in capitation depends almost entirely on keeping costs well in check. This doesn't necessarily mean "costs" like most view them (electric bills, rent, payroll) but "activity" costs: what it costs you to deliver service. In value payment, your costs to deliver service, just like shown above, will make the difference in thriving in the new environment, or not. RVU Impact First Look A chart at the end of this report provides a complete code by code comparison of RVUs for, showing percentage changes from the previous 2 years and reimbursement. Here are a few highlights: GPCIs (adjustments to reimbursement based on practice locale) appear to be unaffected at this time, compared to last year. Copyright Pamela Thompson. ALL RIGHTS RESERVED

7 Guerrilla Podiatry: Revenue Impact Report To summarize: RVUs went up a little for many, down some for others. Conversion Factor went up a little. Take a look. Wishing you success, Pam Thompson Guerrilla Podiatry PamThompson@GuerrillaPodiatry.com Copyright Pamela Thompson. ALL RIGHTS RESERVED

8 Guerrilla Podiatry: Revenue Impact Report About the Author Pamela Thompson, a nationally recognized physician practice management consultant, lecturer and author, is the owner of Thompson & Associates Management Consultancy, Guerrilla Podiatry and GuerrillaMD. Thompson & Associates Management Consultancy specializes in helping practice owners build highly profitable, healthcare "reform-proof" practices. Financial profitability development and optimization and aggressive, profitable growth, are common client engagements. With over 25 years of experience helping podiatrists achieve their personal and practice goals, she brings an unparalleled depth and breadth of practical knowledge to the business of podiatric medicine. Her concern for the future of independent private practice prompted her to start Guerrilla Podiatry and GuerrillaMD, companies that provide smart, affordable tools to help any practitioner protect practice and lifestyle as healthcare reform creates the most fundamental change to physician financial stability in a generation. On her occasional day off Pam sometimes sleeps, or taunts her dog. Copyright Pamela Thompson All rights reserved. No parts of this work may be reproduced in any form or by any means - graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems - without the written permission of the publisher. Permission is given to licensed customers of Guerrilla Podiatry or GuerrillaMD products to print this guide for private/educational use. Microsoft Excel and Office are registered trademarks of Microsoft Corporation. Some products referred to in this document may be either trademarks and/or registered trademarks of owners not associated with Thompson & Associates, Guerrilla Podiatry or Guerrilla MD. The publisher and author make no claim to these trademarks. While every precaution has been taken in the preparation of this document, the publisher and the author assume no responsibility for errors or omissions, or for damages resulting from the use of information contained in this document or from the use of programs and source code that may accompany it. In no event shall the publisher and the author be liable for any loss of profit or any other commercial damage caused or alleged to have been caused directly or indirectly by this document. Copyright Pamela Thompson. ALL RIGHTS RESERVED

9 Guerrilla Podiatry: Revenue Impact Report The RVU Mini-Primer Components of an RVU An RVU has three component parts: Work (physician cost), Practice expense (overhead), and Malpractice expense. The Work RVU (aka RVU W, WP or "W ) is the amount of the total RVU assigned to cover physician compensation. It normally accounts for 45-50% of the total RVU. The "Practice Expense RVU" (aka RVU PE or PE ) accounts for about 45-55% of the total RVU formula. This includes all non-physician and administrative payroll, staff benefits, office expenses, medical supplies, equipment, rent, utilities, accounting, legal and licenses. The place of service is part of the practice expense component. Procedures performed in an ASC or hospital have different practice expense RVUs than in an office. The "Malpractice RVU" (aka RVU MP or MP ) component accounts for malpractice costs, often about 5% of the total RVU. RVUs are adjusted for the practice's locale, as costs vary around the country. This cost adjuster is called a Geographic Practice Cost Index (GPCI). A GPCI is applied to each component of the RVU. Where New York might have a GPCI adjuster of 1.2, Iowa might have an adjuster that's only.88 (sorry, Iowa). The GPCI tables are updated each year and available from CMS, free, on their website. The formulas that reflect the above components and result in the physician fee schedule payment amount for each CPT codes are: Non-Facility Payment Amount = [(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * [Conversion Factor adjusted for budget neutrality] Built into CMS's process for determining both RVUs and the conversion Factor (CF), is a modifier called the Budget Neutrality Adjuster. What is the Budget Neutrality Adjuster? CMS is obligated to keep its total payments within $20 million of the previous year's budget. They use a modifier called the Budget Neutrality Adjuster (BNA) to ensure this occurs with each new year's budget. Until a very few years ago, this adjuster would be applied, with no transparency, to work RVUs (I believe it now applies, when triggered, to the CF). It triggered twice since its inception, in 2007 and This is why you collected less revenue from Medicare beyond what was expected from changes to the Conversion Factor for those two years. Copyright Pamela Thompson. ALL RIGHTS RESERVED

10 Guerrilla Podiatry: Revenue Impact Report While everyone was fighting to keep the CF higher, CMS was quietly reducing RVUs. For example, in 2008, the 10% SGR (Sustainable Growth Rate) scheduled cut was fixed, resulting in a.5% increase to the Conversion Factor. However, CMS reduced RVUs 11% using the BNA. So, instead of a.5% reimbursement increase there was a 10.5% hidden cut. Cheeky. There was no Budget Neutrality Adjustment for Obviously CMS can and will still adjust RVUs as they see fit, BNA or no BNA. The BNA just makes it mandatory under certain circumstances. What Can You Do With an RVU? Set the Practice's Charges (called a Chargemaster ) Analyze reimbursement Analyze payer contracts Evaluate physician productivity and compensation (at least until the change to value payment) Pretty handy. Copyright Pamela Thompson. ALL RIGHTS RESERVED

11 Guerrilla Podiatry RVU Revenue Impact Calculator Click to HIDE or SHOW Unused CPTs Total Revenue Impact (GAIN or LOSS) over : $351 Provider Name: INSTRUCTIONS: Using a Procedure (aka Productivity) Report from billing software, enter the number of times the Provider used a CPT code in BLUE-GRAY cells. When all data are entered, hide unused codes by clicking the HIDE button. Show them again using the SHOW button. Enter Conversion Factor $ Choose Your Locale National 1.00 CPT Description Total RVU Total RVU Compared to Compared to CMS GPCI Drainage of skin abscess % $ % $0.38 $0.38 $ Drainage of skin abscess % $ % $0.03 $0.03 $ Remove foreign body (0.23%) ($0.34) (0.23%) ($0.34) ($0.34) $ Remove foreign body % $ % $2.19 $2.19 $ Drainage of hematoma/fluid (0.22%) ($0.33) (0.22%) ($0.33) ($0.33) $ Puncture drainage of lesion % $ % $1.09 $1.09 $ Complex drainage wound % $ % $1.11 $1.11 $ Debride infected skin % $ % $0.37 $0.37 $ Debride infected skin add on % $ % $0.72 $0.72 $ Debride skin at fx site % $ % $3.65 $3.65 $ Debride skin musc at fx site % $ % $11.18 $11.18 $ Deb skin bone at fx site % $ % $11.93 $11.93 $ Deb subq tissue 20 sq cm/< % $ % $0.38 $0.38 $ Deb musc/fascia 20 sq cm/< % $ % $1.47 $1.47 $ Deb bone 20 sq cm/< % $ % $1.48 $1.48 $ Deb subq tissue add on % $ % $0.01 $0.01 $ Deb musc/fascia add on % $ % $0.37 $0.37 $ Deb bone add on % $ % $1.45 $1.45 $ Trim skin lesion % $ % $0.37 $0.37 $ Trim skin lesions 2 to % $ % $0.37 $0.37 $ Trim skin lesions over % $ % $0.37 $0.37 $ Biopsy skin lesion % $ % $1.09 $1.09 $ Biopsy skin add on % $ % $0.36 $0.36 $ Removal of skin tags <w/ % $ % $0.37 $0.37 $ Remove skin tags add on % $ % $0.36 $0.36 $ Shave skin lesion 0.5 cm/< % $ % $0.37 $0.37 $ Shave skin lesion cm % $ % $0.73 $0.73 $121.10

12 Total RVU Total RVU Compared to Compared to CMS GPCI Shave skin lesion cm % $ % $1.10 $1.10 $ Shave skin lesion >2.0 cm % $ % $0.38 $0.38 $ Shave skin lesion 0.5 cm/< % $ % $1.09 $1.09 $ Shave skin lesion cm % $ % $1.09 $1.09 $ Shave skin lesion cm % $ % $1.45 $1.45 $ Shave skin lesion >2.0 cm % $ % $1.45 $1.45 $ Shave skin lesion 0.5 cm/< % $ % $1.09 $1.09 $ Shave skin lesion cm % $ % $0.73 $0.73 $ Shave skin lesion cm % $ % $1.10 $1.10 $ Shave skin lesion >2.0 cm % $ % $1.82 $1.82 $ Exc tr ext b9+marg 0.5 cm< % $ % $0.38 $0.38 $ Exc tr ext b9+marg cm % $ % $0.02 $0.02 $ Exc tr ext b9+marg cm % $ % $0.38 $0.38 $ Exc tr ext b9+marg 2.1 3cm/< % $ % $0.39 $0.39 $ Exc tr ext b9+marg cm % $ % $1.11 $1.11 $ Exc tr ext b9+marg >4.0 cm % $ % $1.84 $1.84 $ Exc h f nk sp b9+marg 0.5/< % $ % $0.38 $0.38 $ Exc h f nk sp b9+marg (0.00%) $0.02 (0.00%) $0.02 $0.02 $ Exc h f nk sp b9+marg % $ % $0.03 $0.03 $ Exc h f nk sp b9+marg % $ % $0.03 $0.03 $ Exc h f nk sp b9+marg (0.15%) ($0.32) (0.15%) ($0.32) ($0.32) $ Exc h f nk sp b9+marg >4 cm % $ % $2.56 $2.56 $ Exc h f nk sp mal+marg 0.5/< (0.18%) ($0.33) (0.18%) ($0.33) ($0.33) $ Exc s/n/h/f/g mal+mrg % $ % $1.11 $1.11 $ Exc s/n/h/f/g mal+mrg % $ % $1.83 $1.83 $ Exc s/n/h/f/g mal+mrg % $ % $2.19 $2.19 $ Exc s/n/h/f/g mal+mrg % $ % $2.56 $2.56 $ Exc s/n/h/f/g mal+mrg >4 cm % $ % $4.00 $4.00 $ Exc f/e/e/n/l mal+mrg 0.5cm< % $ % $0.75 $0.75 $ Exc f/e/e/n/l mal+mrg % $ % $1.11 $1.11 $ Exc f/e/e/n/l mal+mrg % $ % $2.19 $2.19 $ Exc f/e/e/n/l mal+mrg % $ % $1.84 $1.84 $ Exc f/e/e/n/l mal+mrg % $ % $4.00 $4.00 $ Exc f/e/e/n/l mal+mrg >4 cm % $ % $5.09 $5.09 $528.10

13 Total RVU Total RVU Compared to Compared to CMS GPCI Trim nail(s) any number % $ % $0.36 $0.36 $ Debride nail % $ % $0.00 $0.00 $ Debride nail 6 or more % $ % $0.01 $0.01 $ Removal of nail plate % $ % $0.73 $0.73 $ Remove nail plate add on % $ % $0.01 $0.01 $ Drain blood from under nail % $ % $0.37 $0.37 $ Removal of nail bed (19.43%) ($44.04) (19.43%) ($44.04) ($44.04) $ Remove nail bed/tip (0.00%) $0.05 (0.00%) $0.05 $0.05 $ Biopsy nail unit % $ % $0.74 $0.74 $ Repair of nail bed (14.37%) ($33.29) (14.37%) ($33.29) ($33.29) $ Reconstruction of nail bed (0.12%) ($0.32) (0.12%) ($0.32) ($0.32) $ Excision of nail fold toe % $ % $0.38 $0.38 $ Rpr s/n/ax/gen/trnk 2.5cm/< % $ % $0.01 $0.01 $ Rpr s/n/ax/gen/trnk cm (0.65%) ($0.70) (0.65%) ($0.70) ($0.70) $ Rpr s/n/ax/gen/trk cm (0.28%) ($0.34) (0.28%) ($0.34) ($0.34) $ Rpr s/n/a/gen/trk cm (2.56%) ($4.28) (2.56%) ($4.28) ($4.28) $ Rpr s/n/a/gen/trk cm (3.73%) ($7.50) (3.73%) ($7.50) ($7.50) $ Rpr s/n/ax/gen/trnk >30.0 cm (3.21%) ($7.49) (3.21%) ($7.49) ($7.49) $ Closure of split wound % $ % $11.51 $11.51 $ Closure of split wound % $ % $4.32 $4.32 $ Cmplx rpr s/a/l cm % $ % $3.27 $3.27 $ Cmplx rpr s/a/l cm % $ % $4.00 $4.00 $ Cmplx rpr s/a/l addl 5 cm/> % $ % $1.09 $1.09 $ Cmplx rpr f/c/c/m/n/ax/g/h/f % $ % $3.64 $3.64 $ Cmplx rpr f/c/c/m/n/ax/g/h/f % $ % $4.73 $4.73 $ Cmplx rpr f/c/c/m/n/ax/g/h/f % $ % $1.82 $1.82 $ Tis trnfr s/a/l 10 sq cm/< % $ % $7.98 $7.98 $ Tis trnfr s/a/l sqcm % $ % $10.16 $10.16 $ Tis trnfr f/c/c/m/n/a/g/h/f % $ % $8.71 $8.71 $ Tis trnfr f/c/c/m/n/a/g/h/f % $ % $10.88 $10.88 $ Tis trnfr e/n/e/l 10 sq cm/< % $ % $8.35 $8.35 $ Tis trnfr e/n/e/l sqcm % $ % $10.89 $10.89 $1, Tis trnfr any sq cm % $ % $13.05 $13.05 $1, Tis trnfr addl 30 sq cm/< % $ % $2.54 $2.54 $230.02

14 Total RVU Total RVU Compared to Compared to CMS GPCI Filleted finger/toe flap % $ % $6.55 $6.55 $ Wound prep trk/arm/leg % $ % $4.71 $4.71 $ Wound prep addl 100 cm % $ % $0.73 $0.73 $ Harvest cultured skin graft % $ % $3.98 $3.98 $ Skin pinch graft (0.56%) ($3.14) (0.56%) ($3.14) ($3.14) $ Skin splt grft trnk/arm/leg % $ % $8.72 $8.72 $ Skin splt grft t/a/l add on % $ % $2.18 $2.18 $ Epidrm autogrft trnk/arm/leg (1.21%) ($9.91) (1.21%) ($9.91) ($9.91) $ Epidrm autogrft t/a/l add on % $ % $0.73 $0.73 $ Derm autograft trnk/arm/leg (0.21%) ($1.33) (0.21%) ($1.33) ($1.33) $ Derm autograft t/a/l add on % $ % $10.05 $10.05 $ Cult skin grft t/arm/leg % $ % $6.55 $6.55 $ Cult skin grft t/a/l addl % $ % $2.53 $2.53 $ Cult skin graft t/a/l +% % $ % $2.89 $2.89 $ Skin full graft sclp/arm/leg % $ % $8.35 $8.35 $ Skin full graft add on % $ % $1.09 $1.09 $ Skin sub graft trnk/arm/leg % $ % $0.74 $0.74 $ Skin sub graft t/a/l add on % $ % $0.00 $0.00 $ Skin sub grft t/arm/lg child % $ % $0.76 $0.76 $ Skn sub grft t/a/l child add % $ % $0.73 $0.73 $ Skin pedicle flap arms/legs % $ % $12.67 $12.67 $ Delay flap arms/legs % $ % $3.28 $3.28 $ Muscle skin graft leg % $ % $20.27 $20.27 $1, Composite skin graft % $ % $9.44 $9.44 $ Derma fat fascia graft % $ % $10.85 $10.85 $ Dermabrasion other than face % $ % $5.47 $5.47 $ Dermabrasion suprfl any site (4.09%) ($19.99) (4.09%) ($19.99) ($19.99) $ Abrasion lesion single % $ % $2.18 $2.18 $ Abrasion lesions add on % $ % $0.37 $0.37 $ Chemical peel nonfacial % $ % $12.60 $12.60 $ Chemical peel nonfacial % $ % $3.30 $3.30 $ Excise excessive skin leg % $ % $3.71 $3.71 $ Remove sutures same surgeon % $ % $2.16 $2.16 $ Remove sutures diff surgeon % $ % $0.37 $0.37 $ Dressing change not for burn (0.74%) ($0.35) (0.74%) ($0.35) ($0.35) $48.37

15 Total RVU Total RVU Compared to Compared to CMS GPCI Test for blood flow in graft % $ % $1.09 $1.09 $ Initial treatment of burn(s) % $ % $0.37 $0.37 $ Dress/debrid p thick burn s % $ % $0.01 $0.01 $ Dress/debrid p thick burn m % $ % $0.74 $0.74 $ Dress/debrid p thick burn l % $ % $4.68 $4.68 $ Incision of burn scab initi % $ % $1.46 $1.46 $ Escharotomy addl incision % $ % $0.73 $0.73 $ Destruct premalg lesion % $ % $0.73 $0.73 $ Destruct premalg les % $ % $0.00 $0.00 $ Destroy premal lesions 15/> % $ % $0.74 $0.74 $ Destruction of skin lesions % $ % $1.48 $1.48 $ Destruction of skin lesions % $ % $6.15 $6.15 $ Destruction of skin lesions % $ % $2.60 $2.60 $ Destruct b9 lesion % $ % $1.09 $1.09 $ Destruct lesion 15 or more % $ % $0.74 $0.74 $ Chemical cautery tissue % $ % $0.37 $0.37 $ Destruction of skin lesions % $ % $1.45 $1.45 $ Destruction of skin lesions % $ % $1.10 $1.10 $ Destruction of skin lesions % $ % $1.10 $1.10 $ Destruction of skin lesions % $ % $1.82 $1.82 $ Destruction of skin lesions % $ % $1.82 $1.82 $ Destruction of skin lesions % $ % $1.82 $1.82 $ Destruction of skin lesions % $ % $0.74 $0.74 $ Destruction of skin lesions % $ % $0.74 $0.74 $ Destruction of skin lesions % $ % $1.46 $1.46 $ Destruction of skin lesions % $ % $1.10 $1.10 $ Destruction of skin lesions % $ % $2.18 $2.18 $ Destruction of skin lesions % $ % $2.91 $2.91 $ Cryotherapy of skin % $ % $0.01 $0.01 $ Skin peel therapy % $ % $1.09 $1.09 $ I&d abscess subfascial % $ % $2.91 $2.91 $ Muscle biopsy % $ % $0.03 $0.03 $ Deep muscle biopsy % $ % $1.48 $1.48 $ Needle biopsy muscle (0.30%) ($0.68) (0.30%) ($0.68) ($0.68) $240.05

16 Total RVU Total RVU Compared to Compared to CMS GPCI Bone biopsy trocar/needle % $ % $0.02 $0.02 $ Bone biopsy trocar/needle (0.20%) ($1.00) (0.20%) ($1.00) ($1.00) $ Bone biopsy excisional (27.74%) ($61.59) (27.74%) ($61.59) ($61.59) $ Bone biopsy excisional (15.79%) ($99.87) (15.79%) ($99.87) ($99.87) $ Open bone biopsy % $ % $1.13 $1.13 $ Open bone biopsy % $ % $4.72 $4.72 $ Removal of foreign body % $ % $0.39 $0.39 $ Removal of foreign body % $ % $3.65 $3.65 $ Inj tendon sheath/ligament % $ % $0.73 $0.73 $ Inj tendon origin/insertion % $ % $0.73 $0.73 $ Inj trigger point 1/2 muscl % $ % $0.01 $0.01 $ Inject trigger points 3/> % $ % $0.01 $0.01 $ Place ndl musc/tis for rt (1.05%) ($3.53) (1.05%) ($3.53) ($3.53) $ Drain/inj joint/bursa w/o us % $ % $0.37 $0.37 $ Drain/inj joint/bursa w/o us % $ % $0.72 $0.72 $ Drain/inj joint/bursa w/o us % $ % $0.73 $0.73 $ Aspirate/inj ganglion cyst % $ % $0.37 $0.37 $ Treatment of bone cyst (0.57%) ($1.40) (0.57%) ($1.40) ($1.40) $ Insert and remove bone pin % $ % $3.25 $3.25 $ Apply rem fixation device (0.14%) ($0.32) (0.14%) ($0.32) ($0.32) $ Removal of fixation device % $ % $1.45 $1.45 $ Removal of support implant % $ % $3.28 $3.28 $ Removal of support implant % $ % $3.67 $3.67 $ Apply bone fixation device % $ % $4.03 $4.03 $ Apply bone fixation device % $ % $6.25 $6.25 $1, Adjust bone fixation device (0.39%) ($1.73) (0.39%) ($1.73) ($1.73) $ Remove bone fixation device % $ % $0.78 $0.78 $ Comp multiplane ext fixation (0.14%) ($1.61) (0.14%) ($1.61) ($1.61) $1, Comp ext fixate strut change (5.61%) ($120.43) (5.61%) ($120.43) ($120.43) $2, Removal of bone for graft (0.25%) ($1.01) (0.25%) ($1.01) ($1.01) $ Removal of bone for graft (0.12%) ($0.32) (0.12%) ($0.32) ($0.32) $ Remove cartilage for graft (9.70%) ($45.43) (9.70%) ($45.43) ($45.43) $ Remove cartilage for graft % $ % $5.09 $5.09 $ Removal of fascia for graft % $ % $0.42 $0.42 $ Removal of fascia for graft % $ % $26.24 $26.24 $644.19

17 Total RVU Total RVU Compared to Compared to CMS GPCI Removal of tendon for graft (0.55%) ($2.79) (0.55%) ($2.79) ($2.79) $ Removal of tissue for graft (0.73%) ($3.16) (0.73%) ($3.16) ($3.16) $ Sp bone algrft struct add on % $ % $0.73 $0.73 $ Sp bone agrft morsel add on (2.04%) ($3.56) (2.04%) ($3.56) ($3.56) $ Sp bone agrft struct add on (2.21%) ($4.27) (2.21%) ($4.27) ($4.27) $ Fluid pressure muscle % $ % $6.84 $6.84 $ Fibula bone graft microvasc % $ % $7.89 $7.89 $2, Other bone graft microvasc % $ % $ $ $2, Bone/skin graft microvasc % $ % $35.52 $35.52 $2, Bone/skin graft metatarsal % $ % $69.48 $69.48 $2, Bone/skin graft great toe % $ % $ $ $2, Electrical bone stimulation % $ % $0.73 $0.73 $ Electrical bone stimulation (1.17%) ($2.12) (1.17%) ($2.12) ($2.12) $ Us bone stimulation % $ % $0.72 $0.72 $ Ablate bone tumor(s) perq (19.54%) ($746.11) (19.54%) ($746.11) ($746.11) $3, Amputate lower leg at knee % $ % $9.42 $9.42 $ Decompression of lower leg % $ % $3.64 $3.64 $ Decompression of lower leg (1.32%) ($6.03) (1.32%) ($6.03) ($6.03) $ Decompression of lower leg % $ % $10.10 $10.10 $ Drain lower leg lesion % $ % $4.02 $4.02 $ Drain lower leg bursa % $ % $6.52 $6.52 $ Incision of achilles tendon % $ % $3.27 $3.27 $ Incision of achilles tendon (0.97%) ($2.82) (0.97%) ($2.82) ($2.82) $ Treat lower leg bone lesion (0.11%) ($0.63) (0.11%) ($0.63) ($0.63) $ Explore/treat ankle joint % $ % $2.60 $2.60 $ Exploration of ankle joint (1.29%) ($7.44) (1.29%) ($7.44) ($7.44) $ Biopsy lower leg soft tissue % $ % $2.54 $2.54 $ Biopsy lower leg soft tissue % $ % $6.17 $6.17 $ Resect leg/ankle tum < 5 cm % $ % $12.69 $12.69 $1, Resect leg/ankle tum 5 cm/> % $ % $15.59 $15.59 $1, Exc leg/ankle tum < 3 cm % $ % $0.42 $0.42 $ Exc leg/ankle tum deep <5 cm (0.07%) ($0.29) (0.07%) ($0.29) ($0.29) $ Explore/treat ankle joint (0.38%) ($1.72) (0.38%) ($1.72) ($1.72) $ Remove ankle joint lining % $ % $2.95 $2.95 $ Remove ankle joint lining % $ % $2.60 $2.60 $ Removal of tendon lesion % $ % $2.59 $2.59 $577.55

18 Total RVU Total RVU Compared to Compared to CMS GPCI Exc leg/ankle les sc 3 cm/> % $ % $3.29 $3.29 $ Exc leg/ankle tum dep 5 cm/> % $ % $7.27 $7.27 $ Remove lower leg bone lesion % $ % $2.59 $2.59 $ Remove/graft leg bone lesion (2.09%) ($16.37) (2.09%) ($16.37) ($16.37) $ Remove/graft leg bone lesion (1.52%) ($12.07) (1.52%) ($12.07) ($12.07) $ Partial removal of tibia % $ % $1.91 $1.91 $ Partial removal of fibula % $ % $2.96 $2.96 $ Resect tibia tumor % $ % $0.98 $0.98 $1, Resect fibula tumor % $ % $0.59 $0.59 $1, Resect talus/calcaneus tum % $ % $2.30 $2.30 $1, Injection for ankle x ray % $ % $2.53 $2.53 $ Repair achilles tendon % $ % $3.68 $3.68 $ Repair/graft achilles tendon % $ % $0.46 $0.46 $ Repair of achilles tendon % $ % $1.54 $1.54 $ Repair leg fascia defect % $ % $2.60 $2.60 $ Repair of leg tendon each (0.28%) ($1.02) (0.28%) ($1.02) ($1.02) $ Repair of leg tendon each % $ % $1.50 $1.50 $ Repair of leg tendon each (0.57%) ($2.10) (0.57%) ($2.10) ($2.10) $ Repair of leg tendon each % $ % $1.49 $1.49 $ Repair lower leg tendons % $ % $5.44 $5.44 $ Repair lower leg tendons % $ % $12.27 $12.27 $ Release of lower leg tendon (0.89%) ($3.88) (0.89%) ($3.88) ($3.88) $ Release of lower leg tendons % $ % $1.87 $1.87 $ Revision of lower leg tendon % $ % $0.46 $0.46 $ Revise lower leg tendons (0.68%) ($3.86) (0.68%) ($3.86) ($3.86) $ Revision of calf tendon (0.31%) ($1.37) (0.31%) ($1.37) ($1.37) $ Revise lower leg tendon % $ % $0.09 $0.09 $ Revise lower leg tendon % $ % $1.54 $1.54 $ Revise additional leg tendon % $ % $0.73 $0.73 $ Repair of ankle ligament (1.31%) ($6.38) (1.31%) ($6.38) ($6.38) $ Repair of ankle ligaments % $ % $6.89 $6.89 $ Repair of ankle ligament % $ % $2.24 $2.24 $ Revision of ankle joint % $ % $13.34 $13.34 $ Reconstruct ankle joint (0.14%) ($1.29) (0.14%) ($1.29) ($1.29) $ Reconstruction ankle joint % $ % $1.60 $1.60 $1, Removal of ankle implant % $ % $5.10 $5.10 $ Incision of tibia % $ % $9.07 $9.07 $ Incision of fibula % $ % $3.64 $3.64 $ Incision of tibia & fibula (0.21%) ($2.34) (0.21%) ($2.34) ($2.34) $1,208.83

19 Total RVU Total RVU Compared to Compared to CMS GPCI Realignment of lower leg % $ % $0.88 $0.88 $1, Revision of lower leg % $ % $28.46 $28.46 $1, Repair of tibia % $ % $2.99 $2.99 $ Repair/graft of tibia (0.78%) ($7.03) (0.78%) ($7.03) ($7.03) $ Repair/graft of tibia % $ % $1.62 $1.62 $1, Repair of lower leg (0.97%) ($12.00) (0.97%) ($12.00) ($12.00) $1, Repair fibula nonunion % $ % $8.02 $8.02 $1, Repair of lower leg % $ % $ $ $1, Reinforce tibia (0.14%) ($0.96) (0.14%) ($0.96) ($0.96) $ Treatment of tibia fracture % $ % $2.20 $2.20 $ Treatment of tibia fracture % $ % $5.45 $5.45 $ Treatment of tibia fracture (0.36%) ($2.07) (0.36%) ($2.07) ($2.07) $ Treatment of tibia fracture % $ % $2.64 $2.64 $ Treatment of tibia fracture % $ % $4.80 $4.80 $1, Cltx medial ankle fx % $ % $2.56 $2.56 $ Cltx med ankle fx w/mnpj % $ % $5.08 $5.08 $ Optx medial ankle fx % $ % $1.88 $1.88 $ Cltx post ankle fx % $ % $0.04 $0.04 $ Cltx post ankle fx w/mnpj % $ % $1.86 $1.86 $ Optx post ankle fx % $ % $12.29 $12.29 $ Treatment of ankle fracture % $ % $1.84 $1.84 $ Treatment of ankle fracture % $ % $3.64 $3.64 $ Treatment of ankle fracture % $ % $2.96 $2.96 $ Treatment of ankle fracture % $ % $2.20 $2.20 $ Treatment of ankle fracture % $ % $4.37 $4.37 $ Treatment of ankle fracture % $ % $3.34 $3.34 $ Treatment of ankle fracture % $ % $1.12 $1.12 $ Treatment of ankle fracture % $ % $4.37 $4.37 $ Treatment of ankle fracture % $ % $4.06 $4.06 $ Treatment of ankle fracture % $ % $3.01 $3.01 $ Treat lower leg fracture % $ % $3.63 $3.63 $ Treat lower leg fracture (0.06%) ($0.28) (0.06%) ($0.28) ($0.28) $ Treat lower leg fracture % $ % $4.42 $4.42 $ Treat lower leg fracture % $ % $4.10 $4.10 $1, Treat lower leg fracture % $ % $4.49 $4.49 $1, Treat lower leg joint % $ % $2.61 $2.61 $ Treat lower leg dislocation % $ % $6.86 $6.86 $ Treat lower leg dislocation (1.48%) ($6.03) (1.48%) ($6.03) ($6.03) $ Treat lower leg dislocation % $ % $4.77 $4.77 $784.27

20 Total RVU Total RVU Compared to Compared to CMS GPCI Treat ankle dislocation % $ % $1.13 $1.13 $ Treat ankle dislocation % $ % $1.86 $1.86 $ Treat ankle dislocation (0.52%) ($3.83) (0.52%) ($3.83) ($3.83) $ Treat ankle dislocation % $ % $0.12 $0.12 $ Fixation of ankle joint % $ % $2.53 $2.53 $ Fusion of ankle joint open % $ % $2.66 $2.66 $1, Fusion of tibiofibular joint % $ % $0.10 $0.10 $ Amputation of foot at ankle (0.00%) $0.10 (0.00%) $0.10 $0.10 $ Amputation of foot at ankle % $ % $7.26 $7.26 $ Decompression of leg % $ % $7.96 $7.96 $ Decompression of leg (0.23%) ($1.34) (0.23%) ($1.34) ($1.34) $ Decompression of leg (0.08%) ($0.59) (0.08%) ($0.59) ($0.59) $ Drainage of bursa of foot (1.12%) ($3.18) (1.12%) ($3.18) ($3.18) $ Treatment of foot infection % $ % $1.50 $1.50 $ Treatment of foot infection % $ % $6.19 $6.19 $ Treat foot bone lesion % $ % $1.52 $1.52 $ Incision of foot fascia (0.40%) ($1.73) (0.40%) ($1.73) ($1.73) $ Incision of toe tendon (0.60%) ($1.40) (0.60%) ($1.40) ($1.40) $ Incision of toe tendons (0.43%) ($1.39) (0.43%) ($1.39) ($1.39) $ Exploration of foot joint (1.02%) ($5.65) (1.02%) ($5.65) ($5.65) $ Exploration of foot joint % $ % $3.30 $3.30 $ Exploration of toe joint % $ % $0.07 $0.07 $ Decompression of tibia nerve (0.07%) ($0.28) (0.07%) ($0.28) ($0.28) $ Exc foot/toe tum sc 1.5 cm/> % $ % $5.09 $5.09 $ Exc foot/toe tum dep 1.5cm/> % $ % $5.44 $5.44 $ Exc foot/toe tum sc < 1.5 cm % $ % $0.42 $0.42 $ Exc foot/toe tum deep <1.5cm % $ % $2.22 $2.22 $ Resect foot/toe tumor < 3 cm % $ % $1.90 $1.90 $ Resect foot/toe tumor 3 cm/> % $ % $1.23 $1.23 $1, Biopsy of foot joint lining (11.53%) ($57.25) (11.53%) ($57.25) ($57.25) $ Biopsy of foot joint lining % $ % $17.26 $17.26 $ Biopsy of toe joint lining % $ % $21.19 $21.19 $ Neurectomy foot (0.64%) ($2.45) (0.64%) ($2.45) ($2.45) $ Partial removal foot fascia % $ % $1.15 $1.15 $ Removal of foot fascia % $ % $5.82 $5.82 $ Removal of foot joint lining % $ % $1.51 $1.51 $ Removal of foot joint lining (1.34%) ($7.09) (1.34%) ($7.09) ($7.09) $525.95