2015 Facility and Physician Billing Guide
PHYSICIAN AND OUTPATIENT BILLING CODES
Clinicians and outpatient facilities 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 and Medicaid Services (CMS) and other payers. Some commonly billed CPT codes used to describe procedures related to Edwards Lifesciences’ Vascular technologies (e.g. Fogarty catheters) are listed below. 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. This rule does not normally apply to radiologic procedures..
Procedures related to the use of Edwards Lifesciences’ technologies (e.g. Fogarty catheters) are often performed in a facility setting. Procedures performed in an outpatient department would require a place of service (POS) code 22. Edwards Lifesciences technologies can also be used in an ambulatory surgery center (ASC), which would require a POS code 24, as well as a vascular access center (VAC) which depending on how it is licensed, would require a POS code 11 (physician office), 22 or 24). Reimbursement is determined based upon services rendered and varies by place of service. The following are commonly billed codes and associated national average Medicare payment amounts. This list may not be comprehensive and complete.
Medicare National Average Physician Payment4
|CPT Code||Description||Facility Setting |
|Non-Facility Setting |
(Including POS 11)
|Ambulatory Payment Classification |
|35301||Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision||$1,197||Facility Only||n/a||n/a||n/a|
|35390||Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (list separately in addition to code for primary procedure)||$169||Facility Only||n/a||n/a||n/a|
|361476||Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)||$195||$850||APC
|361487||Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (List separately in addition to code for primary procedure)||$51||$266||n/a||n/a||n/a|
|36831||Thrombectomy, open, arteriovenous fistula without revision, autogenous or non-autogenous dialysis graft (separate procedure)||$653||Facility Only||APC
|36833||Revision, open, arteriovenous fistula; with thrombectomy, autogenous or non-autogenous dialysis graft (separate procedure)||$856||Facility Only||APC
|36870||Thrombectomy, percutaneous, arteriovenous fistula; autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis)||$314||$1,865||APC
|37211||Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day||$419||Facility Only||APC
|37212||Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day||$368||Facility Only||APC
|37213||Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed||$259||Facility Only||APC
|37214||Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method||$143||Facility Only||APC
INPATIENT HOSPITAL BILLING CODES
Medicare inpatient hospital reimbursement is based upon the Medicare Severity-Diagnosis Related Group (MS-DRG) classification system, which assigns MS-DRGs based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. The following codes generally describe procedures associated with the use of Edwards Lifesciences’ Vascular technologies (e.g. Fogarty catheters).
|ICD9-CM Procedure Code8||Description|
|38.12||Endarterectomy of other vessels of head and neck|
|38.32||Resection of other vessels of head and neck with anastomosis|
|38.42||Resection of other vessel of head and neck replacement; carotid artery (common) (external) (internal), jugular vein (external) (internal)|
|38.93||Venous catheterization, not elsewhere classified|
|39.42||Revision of arteriovenous shunt for renal dialysis|
|39.49||Other revisions of vascular procedure|
|39.94||Replacement of vessel-to-vessel cannula|
REVENUE CODES 9 AND HCPCS CODES
Revenue codes help hospitals categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting purposes. It may be appropriate for hospitals to capture the cost of products used for these procedures for payer reporting or cost accounting purposes as expenses within Revenue Code 0278 (Medical/Surgical Supply – Other Implants) on the hospital UB-04 billing form. CMS uses C-codes under the Outpatient Prospective Payment System (OPPS) to track device cost information for future APC rate-setting purposes. No additional facility payment is associated with these codes. CMS may reject hospital claims if the appropriate C codes used to report device costs are not identified on the claim. Edwards Lifesciences’ Vascular technologies can be used in both the inpatient and outpatient setting. C codes which may apply to the use of these products in the outpatient setting are listed below. Procedure codes associated with these products are not necessarily included within this document.
|C Code||Description||Edwards Product Examples|
|C1751||Thrombectomy/Embolectomy Catheter||Fogarty and Fogarty Fortis thrombectomy and embolectomy catheters: 120403F-120807F, 12A0403F-12A1004F, NL2EMB40-NL7EMB80, 12TLW403F-12TLW807F, 140806-1408010, 160245F, 160245F, 160246F, 320806F-32080810F|
|C2628||Catheter, occlusion||Fogarty occlusion catheters: 620403F, 620404F, 620405F, 62080814F, 62080822F|
- Current Procedural Terminology (CPT) copyright 2015, 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.
- Not all codes provided are applicable for the clinical scenarios in which Edwards Lifesciences’ Vascular technologies are used. The provider is responsible for selecting the most appropriate code(s) for the patient’s clinical presentation. When radiologic guidance is used for catheter placement, 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.
- Where applicable, a physician may be required to report CPT codes for radiological supervision and interpretation with CPT codes for interventional procedures. The use of modifier-26 may be required with various radiological supervision and interpretation CPT codes unless radiological equipment is owned by the physician performing these services. Radiological services are often packaged and do not qualify for separate payment by Medicare when performed in conjunction with interventional procedures. Consult with coding and billing staff, as well as payer policy for further guidance.
- 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 $35.7547, It is likely that Congress will pass another temporary physician payment fix in order to avert the Sustainable Growth Rate (SGR) payment cut for when these rates expire on March 31, 2015. Federal Register Volume 79, Number 219, November 13, 2014. National average is based on factors such as geography, teaching vs. non-teaching hospital, rural vs. urban area, etc. and your payment may be different based on these factors. This payment will differ for commercial payers. Payments are effective January 1, 2015-March 31, 2015.
- Various radiological services are often packaged in APC payments and do not qualify for separate payment by Medicare when performed in conjunction with the interventional procedure. For Medicare claims submission and processing, applicable device-related C codes must also be reported.
- CPT code 36147 should not be used in conjunction with 75791.
- CPT code 36148 may be used in conjunction with 36147.
- International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2014 ICD-9-CM for hospitals, volume 1, 2, & 3.
- National Uniform Billing Committee, American Hospital Association.
Reimbursement information provided by Edwards Lifesciences is gathered from third-party sources and is presented for informational purposes only. Edwards makes no representation, warranty or guarantee as to the timeliness, accuracy or completeness of the information and such information is not, and should not be construed as reimbursement, coding or legal advice. Any and all references to reimbursement codes are provided as examples only and are not intended to be a recommendation or advice as to the appropriate code for the a particular patient, diagnosis, product or procedure or a guarantee or promise of coverage or payment, nor does Edwards Lifesciences warranty that codes listed are appropriate in all related clinical scenarios. It is the responsibility of the provider to determine if coverage exists and what requirements are necessary for submitting a proper claim for reimbursement to a health plan or payer, including the appropriate code(s) for products provided or services rendered. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently; service providers are responsible for all decisions relating to coding and reimbursement submissions. Medicare’s Correct Coding Initiative and commercial payer policies are reviewed and updated several times each year. Accordingly, Edwards strongly recommends consultation with payers, reimbursement specialists and/or legal counsel regarding appropriate product or procedure codes, coverage, and reimbursement matters.