In this 2009 PQRI Special Issue we will explore the basis for the development of the Physician Quality Reporting Initiative (PQRI), the continued push by the Centers for Medicare and Medicaid Services (CMS) to a reimbursement system that is centered on Value-Based Purchasing (VBP), and identify the resources necessary to understand and successfully participate in the PQRI.
Value-Based Purchasing is pay-for-performance The current Medicare reimbursement system for most physician services is based on the Medicare Physician Fee Schedule (MPFS). The MPFS is based solely on quantity and resources consumed; the provider is paid for each separately payable CPT or HCPCS code billed. Under this fee-for-service system Medicare is a passive payer and providers are incentivized to provide more services.
Under the Value-Based Purchasing (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
The Agency for Health Care Policy and Research (AHCPR) published a report, Theory and Reality of Value-Based Purchasing: Lessons from the Pioneers in which they provide the following definition of VBP:
“The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. This strategy can be contrasted with more limited efforts to negotiate price discounts, which reduce costs but do little to ensure that quality of care is improved.”
CMS offers the following equation for healthcare value:
According to CMS VBP aligns with their stated vision for healthcare quality; “The right care for every person every time,” care that is:
CMS has defined the following goals for the VBP Program:
- Improve clinical quality
- Reduce adverse events and improve patient safety
- Encourage more patient-centered care
- Avoid unnecessary costs in the delivery of care
- Stimulate investments in effective structural components or systems
- Make performance results transparent and comprehensible
- To empower consumers to make value-based decisions about their health care
- To encourage hospitals and clinicians to improve quality of care
CMS identifies the following strategies for achieving this vision:
- Work through partnerships
- Measure quality and report comparative results
- Value-Based Purchasing: improve quality and avoid unnecessary costs
- Encourage adoption of effective health information technology
- Promote innovation and the evidence base for effective use of technology
A necessary first step in this transition to VBP is to be able to measure quality performance and for providers to successfully report it. Medicare’s pay-for-reporting programs have been developed as this first step.
RHQDAPU, HOP QDRP & PQRI ARE PAY FOR REPORTING
Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU)
The Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 required the development of the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative and section 5001(a) of the Deficit Reduction Act (DRA) of 2005 established new requirements for the program.
Much like the PQRI the RHQDAPU initiative is a pay-for-reporting program. However, unlike the PQRI, hospitals that are required to report the data but fail to do so will receive a reduction of 2 percent in their Medicare Annual Payment Update for inpatient services in 2009.
According to CMS in fiscal year (FY) 2007, nearly 95 percent of hospitals participated successfully in the RHQDAPU and received the full market basket update for FY 2008. This is in stark contrast with the percentage of physicians who successfully reported in the PQRI for the same year (more about that later in this newsletter).
Section 5001(b) of the Deficit Reduction Act of 2005 (DRA) authorized CMS to develop a plan for VBP for Medicare hospital services beginning in 2009. The VBP plan defined in the DRA does not apply to Critical Access Hospitals or to other hospital types that are not paid under the Inpatient Prospective Payment System (IPPS).
Hospital Outpatient Quality Data Reporting Program (HOP QDRP)
The Outpatient Prospective Payment System (OPPS) final rule released November 1, 2007, enacted a new program, the Hospital Outpatient Quality Data Reporting Program (HOP QDRP). This reporting program was mandated by the Tax Relief and Health Care Act (TRHCA) of 2006, and applies to all hospitals paid under the hospital outpatient prospective payment system (OPPS). The program does not apply to:
- Hospitals excluded from the OPPS:
- Maryland hospitals subject to special payment rules reflecting state hospital payment laws;
- Hospitals situated outside of the 50 states, the District of Columbia and Puerto Rico ;
- Indian Health Service Hospitals; and
- Certain other OPPS-exempt hospitals.
Like the RHQDAPU program it is modeled after, the HOP QDRP required hospitals to report data for 2008 services on the quality of hospital outpatient care in order to receive the full annual update to their OPPS payment rate, effective for payments beginning in calendar year (CY) 2009. Eligible hospitals that do not successfully report outpatient quality data will receive an update that is reduced by 2 percent.
CMS reports that 99.3 percent of all hospitals that participated in the program in 2008 successfully reported and will receive the full payment update for CY 2009.
In 2008, hospitals participating in the program were required to report data on seven quality measures:
- The percentage of heart attack patients given aspirin when they arrive at the emergency room;
- The amount of time it takes for a heart attack patient to receive clot-busting drugs;
- The percentage of heart attack patients who received clot-busting drugs within 30 minutes of arriving in the emergency room;
- The average time it takes a heart attack patient to receive an electrocardiogram test to assess heart damage once they arrive in the emergency room;
- The average time it takes for a heart attack patient to transfer to another hospital to receive a coronary angioplasty as acute treatment for a heart attack;
- The percentage of surgery patients who receive an antibiotic within one hour before surgery to help prevent infection; and
- The percentage of surgery patients who receive the right kind of antibiotic to help prevent infection.
The OPPS CY 2009 final rule adds four imaging efficiency measures to the seven original measures for reporting to receive the full update in CY 2010:
- MRI lumbar spine for low back pain
- Mammography follow-up rates
- Abdomen computed tomography (CT) — use of contrast material
- Thorax CT — use of contrast material
Proposed HOP QDRP measures for 2011 include data reporting for the following topics:
- Emergency department throughput
- Stroke and rehabilitation
- Medication reconciliation
Speaking on the HOP QDRP CMS Acting Administrator Kerry Weems said, “The reporting program represents another major step toward value-based purchasing of health care services to ensure that patients with Medicare and the American taxpayers get the best outcomes for their health care dollars.”
Physician Quality Reporting Initiative (PQRI)
In 2005 CMS launched the Physician Voluntary Reporting Program (PVRP). This program was established to encourage providers to report on the quality of care they were delivering. The program was voluntary, was limited in scope (with no oncology measures) and there was no payment associated with participation. The PVRP was discontinued when the Tax Relief and Healthcare Act of 2006 (TRHCA) authorized the establishment of a physician quality reporting system linking payments to reporting.
Medicare’s PQRI was initiated in 2007, continued in 2008 and the Medicare Improvement for Patients & Providers Act of 2008 (MIPPA) made the program permanent although payments are only authorized through 2010.
CMS says that the PQRI is an important first step toward establishing a value-based purchasing program for physicians.
Who Can Participate?
All Medicare-enrolled eligible professionals (EPs), as defined in the Tax Relief and Health Care Act of 2006 or the Medicare Improvements for Patients and Providers Act of 2008, may participate in PQRI. EPs need not take assignment and there is no enrollment or registration required for the program.
PQRI ELIGIBLE PROFESSIONALS 2009
- Doctor of Medicine
- Doctor of Osteopathy
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Doctor of Oral Surgery
- Doctor of Dental Medicine
- Physical Therapist
- Occupational Therapist
- Qualified Speech-Language Pathologist
- Physician Assistant
- Nurse Practitioner
- Clinical Nurse Specialist
- Certified Registered Nurse Anesthetist
- Certified Nurse-Midwife
- Clinical Social Worker
- Clinical Psychologist
- Registered Dietitian
- Nutrition Professional
What Services Are Included In The PQRI?
Services paid under the Medicare Physician Fee Schedule (PFS) are included in the PQRI. Services payable under fee schedules or methodologies other than the PFS are not included in PQRI. Services provided in federally qualified health centers, independent laboratories, hospitals, rural health clinics, ambulance providers, and ambulatory surgery center facilities are not paid under the PFS and are therefore not included in the PQRI.
PQRI applies to Medicare fee-for-service only, Medicare Advantage plans and Medicare Advantage fee-for-service plans are excluded (with the exception of reporting measures groups on consecutive patients through a registry).
What Are The Benefits of Participation?
EPs who successfully report in 2009 can earn a 2 percent bonus payment of their total allowed charges for PFS covered professional services furnished during that same period. Successful reporters will receive one consolidated payment in mid-2010; these payments will be paid to the holder of the taxpayer identification number (TIN).
CMS continues to urge EPs to participate in this voluntary reporting program citing the following benefits of PQRI participation:
- You will receive feedback reports to support quality improvement
- You may earn a bonus incentive payment
- You will be making an investment in the future of your practice
- Prepare for higher bonus incentives over time
- Prepare for pay for performance
- Prepare for public reporting of performance results
Calculating Potential Bonus
When Is The Reporting Period?
The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110-173), required CMS to establish two alternative reporting periods for the reporting of measures groups and for the submission of data on PQRI quality measures through clinical data registries:
- January 1, 2009 – December 31, 2009 and
- July 1, 2009 – December 31, 2009
The reporting period you choose may be determined by your decision to report through claims or an approved clinical registry and whether you choose to report on individual measures or measures groups. Regardless of the method through which you report claims must reach the National Claims History (NCH) file by February 29, 2010.
|2009 REPORTING OPTIONS
1. At least 3 PQRI measures (1-2 if less than 3 apply), for 80% of applicable Medicare Part B FFS patients of each eligible professional
5. At least 3 PQRI measures for 80% of applicable Medicare Part B FFS patients of each eligible professional
2. One measures group for 30 consecutive Medicare Part B FFS Patients
3. One measures group for 80% of applicable Medicare Part B FFS patients of each eligible professional (minimum of 30 patients during reporting period)
7. One measures group for 30 consecutive patients (patients may include, but may not be exclusively, non-Medicare patients)
8. One measures group for 80% of applicable Medicare Part B FFS patients of each eligible professional (minimum of 30 patients during the reporting period)
6. At least 3 PQRI measures for 80% of applicable Medicare Part B FFS patients of each eligible professional
4. One measures group for 80% of applicable Medicare Part B FFS patients of each eligible professional (minimum of 15 patients during reporting period)
9. One measures group for 80% of applicable Medicare Part B FFS patients of each eligible professional (minimum of 15 patients during the reporting period)
2009 Quality Measures
There are 153 quality measures in 2009. 18 of these measures specifically pertain to oncology:
||MDS And Acute Leukemias Cytogenetic Testing
||MDS Documentation of Iron Stores
||Multiple Myeloma: Treatment With Bisphosphonates
||CLL Baseline Flow Cytometry
||Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer
||Chemotherapy for Stage III Colon Cancer Patients
||Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer
||Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer
||Overuse of bone scan for staging low risk cancer patients
||Adjuvant hormonal therapy for high-risk prostate cancer patients
||Three-dimensional radiotherapy for patients with prostate cancer
||Melanoma: Follow Up Aspects of Care
||Melanoma: Continuity of Care
||Melanoma: Coordination of Care
||Oncology Med/Rad: Pain Intensity Quantified
||Oncology Med/Rad: Plan of Care for Pain
||Oncology: Radiation Dose Limits to Normal Tissues
||Oncology Recording of Clinical Stage for Lung and Esophageal Cancer
2009 Measures Groups
There are 7 measures groups in 2009; none of the groups are specific to oncology.
- Chronic Kidney Disease (CKD)
- Diabetes Mellitus
- Preventative Care
- Rheumatoid Arthritis
- Coronary Artery Bypass Graft (CABG) Registry Only
- Perioperative Care
- Back Pain
Claims Based Reporting
Through the claims based reporting option Quality Data Codes (QDCs) may be reported on paper-based CMS 1500 claims or electronic 837-P claims. Each PQRI measure has two major components; the denominator and the numerator.
The Measure Specification Manual on the CMS PQRI Web site contains the following information for each measure:
- Measure title
- Reporting option available for each measure (claims-based, registry, or measures group)
- Measure description
- Instructions on reporting including frequency, timeframes, and applicability
- Numerator coding
- Definitions of terms
- Coding instructions
- Use of CPT Category II exclusion modifiers, where applicable
- Denominator coding
- Rationale statement for measure
- Clinical recommendations or evidence forming the basis or supporting criteria for the measure
Review the measure specifications for each measure you are interested in reporting. The measure specification will identify the denominator and numerator codes that must be reported for each measure.
Once you have determined which measures or measure groups you will be reporting access the AMA’s 2009 PQRI Tools for step-by-step directions on patient eligibility, what you will need to report, and exactly which denominator and numerator codes are required on the claim form.
AMA 2009 Individual Measures Tools
- Measure Description:
Describes the information required to report on the measure and how frequently reporting is required. This may help users determine if it is a measure on which they would like to report.
- Data Collection Sheet:
A step-by-step tool for clinical use and office/billing staff use. It allows the physician or other eligible professional to record the clinical information required for the measure and subsequently select the corresponding billing code.
- Coding Specifications:
A complete list of ICD-9-CM and CPT® codes to identify patients eligible for the measure. A list of the quality codes (eg, CPT-II codes and/or G-codes) for each measure is also included. Should be used in conjunction with the data collection sheet to determine the appropriate code or combination of codes to be reported.
AMA 2009 PQRI Measures Group Tools
- Measure Description:
Describes the information required to report on the measures group and how frequently reporting is required. This may help users determine if it is a measures group on which they would like to report.
- Data Collection Sheet:
A step-by-step tool for clinical use and office/billing staff use. It allows the physician or other eligible professional to record the clinical information required for the measures group and subsequently select the corresponding billing codes.
Denominator = eligible patient population associated with a measure
Denominator code = 1 or more of the following:
- ICD-9 diagnosis code
- CPT procedure code
- CPT II code
Numerator = clinical action required by the measure for reporting & performance
Numerator code = Quality Data Codes (QDCs):
- CPT Category II or temporary G-codes - used to report that the service was performed or not performed
CPT II Modifiers
CPT II Modifiers are unique to CPT II codes and may be appended to the QDC code. These modifiers are used to report why a service was not performed. Performance exclusion modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record.
There are three exclusion modifiers:
- 1P - Performance exclusion modifier due to Medical Reasons
- 2P - Performance exclusion modifier used due to Patient Reasons
- 3P - Performance exclusion modifier used due to System Reasons
One or more exclusions may apply for a given measure. Not every measure has an applicable exclusion modifier. The measure specifications list the appropriate exclusion modifiers.
There is one reporting modifier used to report a patient is eligible but the measure is not performed and the reason is not specified or documented:
- 8P action not performed - reason not otherwise specified
Claims Based Reporting Principals
- The QDCs (numerator) for PQRI measures must be reported:
- On the same claim form as the payment codes (denominator), usually ICD-9-CM and CPT Category I codes
- For the same beneficiary
- For the same date of service
- For the same EP
- QDCs must be submitted with a line item charge of zero dollars ($0.00) at the time the associated covered service is performed
- The submitted charge field cannot be blank
- The line item charge should be $0.00
- If a system does not allow a $0.00 line item charge, use a small amount such as $0.01
- Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00.)
- Quality-data code line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. EPs will receive a Remittance Advice (N365) as confirmation that the QDC(s) passed into the National Claims History file.
- All diagnoses reported on the claim will be included in the PQRI analysis.
- Multiple eligible professionals’ QDCs can be reported on the same claim using their individual NPI.
- Some measures require the submission of more than one QDC in order to properly report the measure.
- Eligible professionals may submit multiple codes for more than one measure on a single claim.
- Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim.
- The individual NPI of the participating eligible professional(s) must be properly used on the claim.
- Claims may not be resubmitted simply to add QDC(s).
Beginning in 2008 practices also have the option of reporting PQRI Quality Measures through qualified registries. To date thirty-two registries have been selected as “qualified” for 2009. However, the qualified registry must be successful in reporting PQRI in 2008 in order to qualify in 2009.
Registries extract the necessary PQRI data from the provider’s EMR or practice management billing system. In certain instances the practice does not need to select the QDC (CPT II code) as the registry performs the measure calculations based on the information in the EMR and the performance data is determined and submitted by the registry.
If you are considering registry reporting be aware that the services and processes may differ from one registry to another. Contact the specific registry for program details. CMS reports a list of qualified registries for 2009 will be posted by July 31, 2009 on the PQRI Web site.
In 2009 there are eighteen measures that are reportable only through a qualified registry:
- Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)
- Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge
- Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility
- End Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis in ESRD Patients
- End Stage Renal Disease (ESRD): Plan of Care for Inadequate Peritoneal Dialysis
- HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
- HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
- HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy
- HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
- Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)
- Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
- Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident (CVA)
- Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
- Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
- Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge
- Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
- Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling
- Pediatric End Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis
Analysis of successful reporting will be performed at the individual level. This will require the accurate and consistent use of the EPs individual National Provider Identifier (NPI) on claims. As in previous years there will be no appeal process.
Learn From Past Mistakes! In 2007 only 52% of participants successfully reported. CMS reports the most common reporting errors involved:
- Incorrect HCPCS, denominator codes (18.9 %)
- Incorrect Diagnosis codes (13.9 %)
- No NPI on QDC line item (12.2%)
- Both incorrect HCPCS and DX code (7.2%)
- Missing denominator codes - all line items were QDCs only (5%)
- Age/Gender on claim was incorrect for measure
Is It Too Late To Participate in 2009?
It may not be too late to begin participating in the 2009 PQRI.
How Do I Get Started?
Carefully review the 2009 Quality Measures and Measures Groups to identify those that are most applicable to your practice and your patients. Review the Measure Specifications Manual on the CMS PQRI Web site. This manual contains two authoritative documents describing:
- The 2009 measure specifications (including codes and reporting instructions) for the 153 individual PQRI quality measures for claims or registry-based reporting and
- The changes from the 2008 PQRI Measure Specifications (in the form of release notes delineated by measure number).
Determine whether you will implement claims based reporting or registry reporting. Review your reporting options based on the measures you will report and the reporting period.
Review the Measure Specifications Manual and the Individual and Group Measure Tools available on the American Medical Association’s (AMA) Web site.
And finally, review the PQRI 2007 Reporting Experience and develop and implement a plan to identify eligible patients and accurately report the PQRI codes.
PQRI THE 2007 EXPERIENCE
On December 3, 2008 CMS published the Physician Quality Reporting Initiative: 2007 Reporting Experience. In this document CMS reports only 16 percent of eligible providers participated in the 2007 PQRI and just over half of those who participated successfully reported and received an incentive payment.
Perhaps to explain the low rate of participation and success in reporting, CMS reminds us that TRHCA required them to implement the PQRI program by the start of the first reporting period on July 1, 2007. This allowed CMS less than seven months to develop and launch the program. Indeed when the 2007 PQRI reporting period began there were many unanswered questions and this certainly contributed to the high percentage of participating providers who ultimately did not successfully report in 2007.
Based on the 2007 PQRI results, CMS developed a list of the most frequent problems that physicians experience and what your practice can do to address each:
Claim contained a procedure or diagnosis code that wasn’t valid for the indicator.
Carefully review the 2009 Quality Measure Specifications for each indicator you intend to submit. Remember the quality data code must be submitted on a claim with an appropriate CPT® code and diagnosis code. Detailed specifications are available on CMS web site at cms.gov/PQRI, click on Measures/Codes in left hand column.
ACRO has a summary of indicators that may be suitable for radiation oncology in an ACRO companion article on PQRI entitled “PQRI Summary of Upcoming Changes for 2009.”
Claim was submitted appropriately but carrier or MAC split the claims, separating quality indicator from valid CPT code.
No action required by physician. CMS will reprocess 2007 to re-integrate claims. Bonuses that should have been paid on 2007 claims will be released in Fall of 2009. New process will be used for 2008 and future claims processing.
Claim was submitted using proper diagnosis code, but diagnosis code was not listed as the primary reason for the service.
No action required by physician. CMS will reprocess 2007 look at all diagnoses codes on each claim. Bonuses that should have been paid on 2007 claims will be released in Fall of 2009. New process will be used for 2008 and future claims processing.
No NPI on claim
Should not be a problem for 2008 and subsequent years, since NPI is now a required element on the claim.
IMPORTANT CHANGES IN 2009
Section 131 of the Medicare Improvements for Patients and Providers Act (MIPPA) requires CMS to post on their Web site the names of EPs who satisfactorily report quality measures for 2009 PQRI.
And section131 (d) requires the Secretary of the Department of Health and Human Services to develop a plan to transition to a value-based purchasing program for Medicare payment for physician and other professional services, a report on this plan is due to Congress May 1, 2010. Watch for more on this subject in upcoming future issues of this newsletter.
CMS PQRI Resources
Reporting Decision Tree
2007 PQRI Report
2009 PQRI Measures List
FAQs from CMS on 2007 PQRI payments and feedback reports:
click on 2007 in left hand column
CMS guide to the 2007 incentive payment:
scroll down to bottom of the page and select 2007 PQRI Incentive Payment Guides.
Link to register through CMS security system
To report problems registering with the CMS security system:
Phone 866-484-8049 or email: Eusupport@cqi.com
For problems once you are registered:
QualityNet Help Desk 866-288-8912 or email@example.com
View your practice’s report
2007 PQRI Reporting Experience Document
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 President 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.hhs.gov.
CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2009 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.
Copyright ©2009 Oplinc, Inc.
Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided that it is forwarded unedited and in its entirety.