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2011-2012 Facility and Physician Billing Guide
Minimal Incision Valve Surgery
Using ThruPort Systems
PHYSICIAN BILLING CODES
Clinicians use Current Procedural Terminology (CPT1) codes to bill for procedures and services. Each CPT code is assigned unique relative value units (RVUs), which are used to determine payment by the Centers for Medicare & Medicaid Services (CMS). Some commonly billed CPT codes used to describe procedures related to Edwards Lifesciences’ ThruPort systems technologies are listed below.2 This list may not be comprehensive or complete. These procedures may be subject to the CMS multiple procedure reduction rule. When applicable, a payment reduction of 50% is applied to all payment amounts except the procedure with the greatest RVUs, which is paid at 100% unless exempt by CPT instructions or payer policy.
| Surgical Services | Medicare
National Average
Physician Payment3 | | CPT Code | Description | Facility Setting | | 33400 | Valvuloplasty, aortic valve; open, with cardiopulmonary bypass | $2,396 | | 33401 | Valvuloplasty, aortic valve; open, with inflow occlusion | $1,500 | | 33403 | Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass | $1,568 | | 33405 | Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve | $2,409 | | 33406 | Replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand) | $3,017 | | 33410 | Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve | $2,671 | | 33411 | Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus | $3,516 | | 33412 | Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) | $2,590 | | 33413 | Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) | $3,393 | | 33420 | Valvotomy, mitral valve; closed heart | $1,460 | | 33422 | Valvotomy, mitral valve; open heart, with cardiopulmonary bypass | $1,770 | | 33425 | Valvuloplasty, mitral valve, with cardiopulmonary bypass | $2,840 | | 33426 | Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring | $2,511 | | 33427 | Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring | $2,585 | | 33430 | Replacement, mitral valve, with cardiopulmonary bypass | $2,940 | | 33460 | Valvectomy, tricuspid valve, with cardiopulmonary bypass | $2,528 | | 33464 | Valvuloplasty, tricuspid valve; with ring insertion | $2,556 | | 33465 | Replacement, tricuspid valve, with cardiopulmonary bypass | $2,873 | | 33468 | Tricuspid valve repositioning and plication for Ebstein anomaly | $1,956 | | 33999 | Unlisted procedure, cardiac surgery (e.g. cardioplegia) | Contractor priced |
| Anesthesia Services | Medicare
National Average
Physician Payment | | CPT Code | Description | Facility Setting | | 00560 | Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator | Total payment for anesthesia codes varies based on geography and time | | 00562 | Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator | | 36013 | Introduction of catheter, right heart or main pulmonary artery4 | $135 | | 36200 | Introduction of catheter, aorta4 | $163 | | 36620 | Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous4 | $51 | | 93318 - 26 | Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2D image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis5 | $115 | | 93503 | Insertion and placement of flow directed catheter (e.g., Swan-Ganz catheter) for monitoring purposes | $134 |
INPATIENT HOSPITAL BILLING CODES
Medicare inpatient hospital reimbursement is based upon the Medicare Severity-Diagnostic-Related Group (MS-DRG) classification system, which assigns MS-DRGs based on ICD-9-CM diagnosis and procedure codes. The following codes generally describe procedures associated with the use of Edwards Lifesciences’ ThruPort systems technologies.
| ICD9-CM Procedure Code6 | Description | | 35.00 | Closed heart valvotomy, unspecified valve | | 35.01 | Closed heart valvotomy, aortic valve | | 35.02 | Closed heart valvotomy, mitral valve | | 35.04 | Closed heart valvotomy, tricuspid valve | | 35.10 | Open heart valvuloplasty without replacement, unspecified valve | | 35.11 | Open heart valvuloplasty of aortic valve without replacement | | 35.12 | Open heart valvuloplasty of mitral valve without replacement | | 35.14 | Open heart valvuloplasty of tricuspid valve without replacement | | 35.20 | Replacement of unspecified heart valve | | 35.21 | Replacement of aortic valve with tissue graft | | 35.22 | Other replacement of aortic valve | | 35.23 | Replacement of mitral valve with tissue graft | | 35.24 | Other replacement of mitral valve | | 35.27 | Replacement of tricuspid valve with tissue graft | | 35.28 | Other replacement of tricuspid valve | | 35.99 | Other operations on valves of heart | | 38.91 | Arterial Catheterization |
INPATIENT HOSPITAL REIMBURSEMENT
Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on Medicare Severity-Diagnostic Related Groups (MS-DRGs). All services and supplies provided during the inpatient admission are bundled into a single MS-DRG payment rate for each patient regardless of the length of stay, intensity of treatments, or number of procedures performed. MS-DRG assignment is usually determined based on the patient’s primary diagnosis or procedure performed, as indicated by the ICD-9-CM codes on the billing form.
| MS-DRG | Description | FY2011 Average National Medicare Payment7 | FY2012 Average National Medicare Payment8 | | 216 | Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC | $55,974 | $54,578 | | 217 | Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC | $37,993 | $36,595 | | 218 | Cardiac valve and other major cardiothoracic procedures with cardiac catheterization without MCC or CC | $29,759 | $29,132 | | 219 | Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC | $45,137 | $45,508 | | 220 | Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC | $30,035 | $29,621 | | 221 | Cardiac valve and other major cardiothoracic procedures without cardiac catheterization without MCC or CC | $25,017 | $24,587 |
REVENUE CODES9 AND HCPCS CODES
Revenue codes help hospitals categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting purposes. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. It may be appropriate for hospitals to capture the cost of products used for the procedures described above within Revenue Code 0278 (Medical/Surgical Supply – Other Implant) or Revenue Code 0360 (Operating Room Services - General). Health Care Common Procedural Coding System (HCPCS) codes include level I codes (CPT, described above) and level II codes (other products, supplies, and services not included in CPT). Level II HCPCS codes, including C codes, are not applicable to Edwards’ products utilized in the procedures described above. C codes are used in conjunction with the Medicare prospective payment system for outpatient procedures only. |
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CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events.
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