Heart Valve Technologies 2011-2012 Facility and Physician Billing Guide

2011-2012 Facility and Physician Billing Guide

Heart Valve Technologies

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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’ Heart Valve 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
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
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	Contractor priced

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’ Heart Valve technologies.

ICD-9-CM⁴ Procedure Code	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
88.72	Diagnostic ultrasound of heart

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	FY2010 Average National Medicare Payment5	FY2011 Average National Medicare Payment6
216	Cardiac valve procedures and other major cardiothoracic procedures with cardiac catheterization with MCC	$55,974	$54,578
217	Cardiac valve procedures and other major cardiothoracic procedures with cardiac catheterization with CC	$37,993	$36,595
218	Cardiac valve procedures and other major cardiothoracic procedures with cardiac catheterization without MCC or CC	$29,759	$29,132
219	Cardiac valve procedures and other major cardiothoracic procedures without cardiac catheterization with MCC	$45,137	$45,508
220	Cardiac valve procedures and other major cardiothoracic procedures without cardiac catheterization with CC	$30,035	$29,621
221	Cardiac valve procedures and other major cardiothoracic procedures without cardiac catheterization without MCC or CC	$25,017	$24,587

REVENUE CODES⁷ 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.

References
1 Current Procedural Terminology (CPT) copyright 2010 American Medical Association (AMA). All rights reserved. CPT® is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use.
2 Not all codes provided are applicable for the clinical scenarios in which Edwards Lifesciences’ ThruPort systems technologies are used. The provider is responsible for selecting the most appropriate code(s) for the patient’s clinical presentation. When diagnostic services are performed, it may be appropriate to add applicable codes according to the service provided following correct coding guidelines. Services that are considered a component of another procedure may not always be coded and billed separately.
3 For all Medicare Payments for physician, hospital outpatient, and ASC services, the multiple procedure reduction rule may apply. Consult with coding and billing staff, and payer policy for further guidance. National average Medicare payment is calculated using the Conversion Factor of $33.9764. Federal Register Volume 75, Number 228, November 29, 2010.
4 For Minimal Incision Valve Surgery procedures, multiple catheters and/or cannulae are typically used; therefore, the use of modifier -59 may be required. Check with internal billing staff and payer policies for clarification.
5 Diagnostic procedures performed in the facility setting may require the use of modifier -26 to reflect the professional component of the service only. Check with internal billing staff and payer policies for clarification. Intraoperative Transesophageal echocardiography (TEE) is a non-covered service for many payers. Providers may wish to review Medicare’s Correct Coding Initiative when providing anesthesia services in conjunction with TEE. Consult payer policies and contracts for clarification.
6 International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2011 ICD-9-CM for hospitals, volume 1, 2, & 3
7 CMS Federal Register, Volume 74; Number 165, August 27, 2009, Number 193, October 7, 2009, and the Patient Protection and Affordable Health Care Act as modified in the Health Care and Education Reconciliation Act of 2010. Payments are effective April 1, 2010- September 30, 2010.
8 CMS Federal Register, Volume 75; Number 157, August 16, 2010. Payments are effective October 1, 2010 - September 30, 2011.
9 National Uniform Billing Committee, American Hospital Association.

2011-2012 Facility and Physician Billing GuideHeart Valve Technologies

2011-2012 Facility and Physician Billing Guide

Heart Valve Technologies