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2009 Facility and Physician Billing Guide
Heart Valve Products
PHYSICIAN SERVICES
Clinicians use Current Procedural Terminology (CPT1) codes to bill for procedures. Each CPT code is assigned a unique relative value unit, which is used to determine Medicare payment based on the RBRVS system. Some commonly billed codes used to describe procedures related to Edwards’ heart valve products are listed below.2 This list is not necessarily complete. Unless indicated otherwise in an endnote, 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.
| CPT Code |
Description |
Facility Relative Value Units |
2009 Average National Medicare Payment3 |
| Codes Related to Surgical Services |
| 33400 |
Valvuloplasty, aortic valve; open, with cardiopulmonary bypass |
60.59 |
$2,222 |
| 33401 |
Valvuloplasty, aortic valve; open, with inflow occlusion |
41.06 |
$1,481 |
| 33403 |
Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass |
41.24 |
$1,487 |
| 33405 |
Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve |
63.27 |
$2,282 |
| 33410 |
Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve |
68.51 |
$2,471 |
| 33411 |
Replacement, aortic valve; with aortic annulus enlargement, noncoronary cusp |
89.23 |
$3,218 |
| 33412 |
Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) |
68.51 |
$2,470 |
| 33420 |
Valvotomy, mitral valve; closed heart |
36.89 |
$1,330 |
| 33422 |
Valvotomy, mitral valve; open heart, with cardiopulmonary bypass |
46.23 |
$1,667 |
| 33425 |
Valvuloplasty, mitral valve, with cardiopulmonary bypass |
71.32 |
$2,572 |
| 33426 |
Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring |
65.19 |
$2,351 |
| 33427 |
Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring |
68.31 |
$2,463 |
| 33430 |
Replacement, mitral valve, with cardiopulmonary bypass |
75.16 |
$2,711 |
| 33999 |
Unlisted procedure, cardiac surgery |
(Carrier Priced) |
FACILITY BILLING
CMS uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify diagnoses and procedures in the hospital inpatient setting. At least one ICD-9-CM diagnosis code is required on all claim forms. Medicare may require additional clinical information specific to each patient to determine coverage and payment for the reported procedure. The following codes generally describe procedures associated with Edwards’ heart valve products.
| ICD9-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 |
| 35.10 |
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 |
| 35.20 |
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 |
| 35.99 |
Other operations on valves of heart |
Hospital Inpatient 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 reimbursement rate for each patient regardless of the length 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 ICD-9-CM coding.
| MS-DRG |
Description |
Relative Weight |
FY2009 Average National Medicare Payment5 |
| 216 |
Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC |
10.0943 |
$56,008 |
| 217 |
Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC |
6.9900 |
$38,784 |
| 218 |
Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without MCC or CC |
5.4211 |
$30,079 |
| 219 |
Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC |
8.0329 |
$44,571 |
| 220 |
Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with CC |
5.2799 |
$29,296 |
| 221 |
Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization without MCC or CC |
4.3869 |
$24,341 |
Revenue Codes6 and HCPCS Codes
Revenue codes help hospitals categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. Hospitals may capture the cost of products used for the procedures described above within Revenue Code 0278 (Medical/Surgical Supply) or Revenue Code 0360 (Medical/Surgical Supplies and Devices, Other Implant). 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, do not exist for 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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