Please email your completed survey to: JNagle@facs.org
For 2015, the CPT Editorial Panel has approved new and revised codes to report negative pressure wound therapy. These new / revised
CPT codes require review of physician work. The American College of Surgeons, American Academy of Orthopaedic Surgeons, American
Orthopaedic Foot & Ankle Society, American Society of Plastic Surgeons, and American Podiatric Medical Association need your help to complete this survey to assure relative values will be accurately and fairly presented to CMS during this review process.
Survey Codes
976A1 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME) , including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
976A2 total wound(s) surface area greater than 50 square centimeters
976A3 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable , non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters
976A4 total wounds(s) surface area greater than 50 square centimeters
Financial Disclosure: Do you or a family member have a direct financial interest in the procedure(s) shown above, other than providing these procedure(s) in the course of patient care?
For purposes of this survey “direct financial interest” means:
For each question
Check Yes or No
1.
A financial ownership interest in an organization of 5% or more?
2.
A financial ownership interest in an organization which contributes materially to your income?
3.
Ownership of stock options in an organization?
Yes
Yes
No
No
Yes No
4.
A position as proprietor, director, managing partner, or key employee in an organization? Yes No
5.
Serve as a consultant, researcher, expert witness (excluding professional liability testimony), speaker or writer for an organization, where payment contributes materially to your income?
Yes No



Family member means spouse, domestic partner, parent, child, brother, or sister. Disclosure of family member’s interest applies to the extent known by you.
Organization means any entity that makes or distributes the product that is utilized in performing the procedure/service and NOT the physician group or facility in which you work or perform the procedure/service.
Materially means income of $10,000 or more (excluding any reimbursement for expenses) for the past 24 months.
CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 1

Physician's NAME Last: First:
Office ( STATE )
E-mail address
General Surgery
SPECIALTY
(check all that apply)
Orthopaedic Surgery
Plastic Surgery
Podiatry
Other ( specify ) 
Number of YEARS Practicing Specialty
Primary Geographic Practice Setting:
(check one)
Primary Type of Practice:
(check one)
Rural
Suburban
Urban
Solo Practice
Single Specialty Group
Multispecialty Group
Medical School Faculty Practice Plan
(Demographic information is kept confidential.)
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 2

Please consider the “ typical patients ” shown below when completing this survey
Survey
Codes
976A1
DME
≤ 50 cm2
2015 Descriptor
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment ( DME ), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
Typical Patients
A : The patient is a male with a Stage III pressure ulcer of the sacrum that measures 8.5 x 5.0 x 3.2 cm. The base of the wound is clean and red, but with significant serous drainage. Negative pressure wound therapy using an electrically powered vacuum assisted closure device (eg, VAC TM ) is applied.
B: The patient is a male with a diabetic foot ulcer of the heel that measures 3.5 x
3.8 x 1.2 cm. The base of the wound is clean and red, but with significant serous drainage. Negative pressure wound therapy using an electrically powered vacuum assisted closure device (eg, VAC TM ) is applied.
976A2
DME
> 50 cm2
976A3
Disposable
≤ 50 cm2
976A4
Disposable
> 50 cm2
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment ( DME ), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
A: The patient is a female who underwent major abdominal surgery. The incision showed signs suspicious of infection on post-op day two and was opened creating a wound that measured 25.0 x 3.0 x 3.0 cm. On post-op day four, negative pressure wound therapy using an electrically powered vacuum assisted closure device (eg, VAC TM ) is applied.
B: The patient is a male who sustains a crush injury to his lower leg and develops an acute anterior and lateral compartment syndrome requiring compartment releases. The resulting wound is 14.0 x 6.0 x 2.0 cm. Negative pressure wound therapy using an electrically powered vacuum assisted closure device (eg, VAC TM ) is applied.
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable , non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable , non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 square centimeters
The patient is a male with a diabetic foot ulcer of the heel that measures 2.0 x
1.8 x 0.8 cm. The base of the wound is clean and red and has minimal necrotic tissue. Negative pressure wound therapy using a disposable mechanical wound care system (eg, SNaP TM ) is applied.
The patient is a female with a venous ulcer of the right anterior leg that measures 10.2 x 6.8 x 1.2 cm. The base of the wound is clean and red and has minimal necrotic tissue. Negative pressure wound therapy using a disposable mechanical wound care system (eg, SNaP TM ) is applied.
Global
XXX
XXX
XXX
XXX
CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 3

"Physician work" includes the following elements:

Physician time it takes to perform the service

Physician mental effort and judgment

Physician technical skill and physical effort, and

Physician psychological stress that occurs when an adverse outcome has serious consequences
All of these elements will be explained in greater detail as you complete this survey.
"Physician work" does not include the services provided by support staff who are employed by your practice and cannot bill separately, including registered nurses, licensed practical nurses, medical secretaries, receptionists, and technicians; these services are included in the practice expense relative values, a different component of the RBRVS.
The Table in Question 1 presents reference services that have been selected for use as comparison services for this survey because their relative values are sufficiently accurate and stable to compare with other services. The “work RVU” column presents current Medicare fee schedule work RVUs (relative value units). In Question 1 you will be asked to select one code from this list which is most similar to the survey code descriptor and typical patient/service.
It is very important to consider the global period when you are comparing the survey code to the reference services.
XXX A global period does not apply to the code and evaluation and management and other diagnostic tests or minor services performed, may be reported separately on the same day
000 0 days of post-service care are included in the work RVU:
 visits and other physician services provided within 24 hours prior to the service;
 provision of the service; and
 visits and other physician services on the day of the service
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 4

Which Reference Service below is most similar to each procedure and patient described above? You may choose one code for all procedures being surveyed or a different code for each procedure. Please put only one "X" in each column.
SURVEY CODES
Please put only one "X" in each column.
976A1
DME ≤50cm2
976A2
DME >50cm2
976A3
Disp ≤50cm2
976A4
Disp >50cm2
CPT
Code DESCRIPTOR
73620 Radiologic examination, foot; 2 views
11720 Debridement of nail(s) by any method(s); 1 to 5
11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
99212
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history;
A problem focused examination; Straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-toface with the patient and/or family.
17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)
97597
Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
29580 Strapping; Unna boot work
RVU
0.16
0.32
0.35
0.48
0.50
0.51
0.55 global period
XXX
000
000
XXX
000
000
000
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
16020
99231
0.66 000
Dressings and/or debridement of partial-thickness burns, initial or subsequent; small
(less than 5% total body surface area)
0.71 000
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history;
A problem focused examination; Medical decision making that is straightforward or of low complexity. Usually, the patient is stable, recovering or improving. Typically, 15
0.76 XXX minutes are spent at the bedside and on the patient's hospital floor or unit.
Table continues on next page
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 5

976A1
DME ≤50cm2
976A2
DME >50cm2
976A3
Disp ≤50cm2
976A4
Disp >50cm2
- CONTINUED
CPT
Code DESCRIPTOR
12001
99213
11042
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.
Typically, 15 minutes are spent face-to-face with the patient and/or family.
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first
20 sq cm or less work
RVU
0.84
0.97
1.01 global period
000
XXX
000
95908 Nerve conduction studies; 3-4 studies 1.25 XXX
99214
16025
99221
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium
(eg, whole face or whole extremity, or 5% to 10% total body surface area)
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Usually, the problem(s) requiring admission are of low severity.
Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.
1.50
1.74
1.92
XXX
000
XXX
CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright by the American Medical Association. No payment schedules, fee schedules, relative value units, scales, conversion factors, or components thereof are included in CPT. The AMA is not recommending that any specific relative values, fees, payment schedules, or related listings be attached to CPT. Any relative value scales or relative listings assigned to CPT codes are not those of the AMA, and the AMA is not recommending use of these relative values.
CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 6

Pre-service period
Preparing to see the patient, reviewing records, and communicating with other professionals.
Intra-service period
Intra-service period includes treatment / therapy.
Post-service period
Post-service period includes arranging for further services communicating (written or verbal) with the patient, family and other professionals.
How much of your own time in minutes is required per patient treated for each of the following steps in patient care related to the surveyed code and typical patient?
PRE-service time:
INTRA-service time:
POST-service time:
976A1
DME
≤50cm2
976A2
DME >50cm2
976A3
Disp
≤50cm2
976A4
Disp >50cm2 minutes minutes minutes
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 7

For the Survey codes and for the Reference codes you chose in Question 1, RATE the average pre-, intra-, and post service complexity/intensity on a scale of 1 to 5 (1 = low; 3 =medium; 5 = high). Please base your rankings on the universe of codes your specialty performs. (Your reference code was chosen in Question 1 above.)
INSERT Complexity Rating of 1, 2, 3, 4, or 5 in each green cell
(rating scale: 1=low; 5=high)
PRE-service complexity
INTRA-service complexity
POST-service complexity
RATE
976A1
DME
≤50cm2
RATE
Your
Ref Code
RATE
976A2
DME
>50cm2
RATE
Your
RATE
976A3
Ref Code Disposable
≤50cm2
RATE
Your
RATE
976A4
Ref Code Disposable
>50cm2
RATE
Your
Ref Code
In evaluating the work of a service, it is helpful to identify and think about each of the components of a particular service. Focus only on the work that you perform during each of the identified components. The descriptions below are general in nature. Within the broad outlines presented, please think about the specific services that you provide.
Physician work includes the following:

Time it takes to perform the service.

Mental Effort and Judgment necessary with respect to the amount of clinical data that needs to be considered, the fund of knowledge required, the range of possible decisions, the number of factors considered in making a decision, and the degree of complexity of the interaction of these factors.

Technical Skill required with respect to knowledge, training and actual experience necessary to perform the service.

Physical Effort can be compared by dividing services into tasks and making the direct comparison of tasks. In making the comparison, it is necessary to show that the differences in physical effort are not reflected accurately by differences in the time involved; if they are, considerations of physical effort amount to double counting of physician work in the service.

Psychological Stress – Two kinds of psychological stress are usually associated with physician work. The first is the pressure involved when the outcome is heavily dependent upon skill and judgment and an adverse outcome has serious consequences. The second is related to unpleasant conditions connected with the work that are not affected by skill or judgment. These circumstances would include situations with high rates of mortality or morbidity regardless of the physician’s skill or judgment, difficult patients or families, or physician physical discomfort. Of the two forms of stress, only the former is fully accepted as an aspect of work; many consider the latter to be a highly variable function of physician personality.
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 8

For the Survey codes and for the Reference codes you chose in Question 1, RATE the average pre-, intra-, and post service complexity/intensity on a scale of 1 to 5 (1 = low; 3 =medium; 5 = high). Please base your rankings on the universe of codes your specialty performs. (Your reference code was chosen in Question 1 above.)
RATE
976A1
DME
≤50cm2
INSERT Complexity Rating of 1, 2, 3, 4, or 5 in each green cell
(rating scale: 1=low; 5=high)
RATE
Your
Ref Code
RATE
976A2
DME
>50cm2
RATE
Your
Ref Code
RATE
976A3
Disposable
≤50cm2
RATE
Your
Ref Code
RATE
976A4
Disposable
>50cm2
RATE
Your
Ref Code
Mental Effort and Judgment
The range of possible diagnoses and/or management options that must be considered
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be analyzed
Urgency of medical decision making
Technical Skill/Physical Effort
Technical skill required
Physical effort required
Psychological Stress
The risk of significant complications, morbidity and/or mortality
Outcome depends on skill and judgment of physician
Estimated risk of malpractice suit with poor outcome
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 9

What is your experience with each code in the past 12 months?
In the past 12 months , how many times have you performed each survey code and how many times have you performed each reference code that you chose in Question 1?
976A1
DME
≤50cm2
Your
Ref Code
976A2
DME
>50cm2
Your
Ref Code
976A3
Disposable
≤50cm2
Your
Ref Code
976A4
Disposable
>50cm2
Your
Ref Code
Is your typical patient for each code similar to the typical patient described on Page 3 at the beginning of the survey?
YES? NO? If No , please describe your typical patient below:
976A1
DME
≤50cm2
976A2
DME
>50cm2
YES? NO? If No , please describe your typical patient below:
976A3
Disposable
≤50cm2
YES? NO? If No , please describe your typical patient below:
976A4
Disposable
>50cm2
YES? NO? If No , please describe your typical patient below:
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CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 10

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Based on your review of all previous steps, please provide your estimated work RVU for each survey code.
Please indicate value to two decimal places (eg, 0.25, 0.64, 1.12)
Please keep in mind the range of work RVUs for the reference codes listed in Question 1 above when providing your estimate. For example , if the new/revised code involves the same amount of physician work as the reference service you choose in Question 1, you would assign the same work RVU. If the new or revised code involves less work than the reference service you would estimate a work
RVU that is less than the work RVU of the reference service and vice-versa. This methodology attempts to set the work RVU of the new/revised service “relative” to the work RVU of comparable and established reference services.
976A1 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment
(DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
976A2 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment
(DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
976A3 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable , non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters
976X4 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable , non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 square centimeters
CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 11