2015 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) and other payers. 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 for Valve Repair/Replacement Procedures Medicare
National Average
Physician Payment3
CPT Code Description Facility Setting
33400 Valvuloplasty, aortic valve; open, with cardiopulmonary bypass $2,371
33401 Valvuloplasty, aortic valve; open, with inflow occlusion $1,504
33403 Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass $1,543
33405 Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve $2,360
33406 Replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand) $2,991
33410 Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve $2,640
33411 Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus $3,491
33412 Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) $3,309
33413 Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) $3,413
33420 Valvotomy, mitral valve; closed heart $1,498
33422 Valvotomy, mitral valve; open heart, with cardiopulmonary bypass $1,744
33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass $2,840
33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring $2,476
33427 Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring $2,542
33430 Replacement, mitral valve, with cardiopulmonary bypass $2,909
33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass $2,543
33463 Valvuloplasty, tricuspid valve; without ring insertion $3,219
33464 Valvuloplasty, tricuspid valve; with ring insertion $2,539
33465 Replacement, tricuspid valve, with cardiopulmonary bypass $2,868
33468 Tricuspid valve repositioning and plication for Ebstein anomaly $2,549
33999 Unlisted procedure, cardiac surgery Contractor priced
92986 Percutaneous balloon valvuloplasty; aortic valve $1,377
92987 Percutaneous balloon valvuloplasty; mitral valve $1,420


Surgical Services for CABG Procedures

Medicare
National Average
Physician Payment3

CPT Code Description Facility Setting
33510 Coronary artery bypass, vein only; single coronary venous graft $2,008
33511 Coronary artery bypass, vein only; 2 coronary venous grafts $2,207
33512 Coronary artery bypass, vein only; 3 coronary venous grafts $2,510
33513 Coronary artery bypass, vein only; 4 coronary venous grafts $2,584
33514 Coronary artery bypass, vein only; 5 coronary venous grafts) $2,731
33516  Coronary artery bypass, vein only; 6 or more coronary venous grafts $2,861
33517 Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) $195
33518 Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure) $429
33519 Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure) $567
33521 Coronary artery bypass, using venous graft(s) and arterial graft(s);4 venous grafts (List separately in addition to code for primary procedure) $680
33522 Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition to code for primary procedure) $764
33523 Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for primary procedure) $873
33530 Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for primary procedure) $549
33533 Coronary artery bypass, using arterial graft(s); single arterial graft  $1,943
33534 Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts $2,286
33535 Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts $2,551
33536 Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts $2,752
35600 Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure (List separately in addition to code for primary procedure) $267


Anesthesia Services Medicare
National Average
Physician Payment
CPT Code Description Facility Setting
36013 Introduction of catheter, right heart or main pulmonary artery4 $130
36200 Introduction of catheter, aorta4 $161
36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous4 $53
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 $122
93503 Insertion and placement of flow directed catheter (e.g., Swan-Ganz catheter) for monitoring purposes $132


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’ Heart Valve technologies.3

ICD9-CM Procedure Code6 Description
Valve Repair/Replacement Procedures
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
35.33 Annuloplasty
35.99 Other operations on valves of heart
38.91 Arterial Catheterization
88.72 Diagnostic ultrasound of heart
CABG Procedures
36.10 Aortocoronary bypass for heart revascularization, not otherwise specified
36.11 (Aorto)coronary bypass of one coronary artery
36.12 (Aorto)coronary bypass of two coronary artery
36.13 (Aorto)coronary bypass of three coronary artery
36.14 (Aorto)coronary bypass of four or more coronary artery
36.15 Single internal mammary-coronary artery bypass
36.16 Double internal mammary-coronary artery bypass
36.17 Abdominal-coronary artery bypass
36.19 Other bypass anastomosis for heart revascularization
38.91 Arterial catheterization
39.61 Extracorporeal circulation auxiliary to open heart surgery


INPATIENT HOSPITAL REIMBURSEMENT
Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on Medicare Severity-Diagnosis 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-DRG7 Description FY2014 Medicare National Average Payment8 FY2015 Medicare National Average Payment9
Valve Repair/Replacement Procedures
216 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC $54,981 $55,862
217 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC $36,442 $37,123
218 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization without MCC or CC $31,470 $32,667
219 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC $45,928 $45,203
220 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC $30,690 $30,533
221 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization without MCC or CC $26,924 $27,185

CABG Procedures

231 Coronary bypass with PTCA with MCC $45,328 $45,309
232 Coronary bypass with PTCA without MCC $32,562 $32,833
233 Coronary bypass with cardiac catheterization with MCC $42,851 $43,107
234 Coronary bypass with cardiac catheterization without MCC $27,955 $28,633
235 Coronary bypass without cardiac catheterization with MCC $33,915 $33,485
236 Coronary bypass without cardiac catheterization without MCC $22,045 $22,261


REVENUE CODES10 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 2015American 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’ Heart Valve 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 the 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 $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.
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, 2014. ICD-9-CM for hospitals, volume 1, 2, & 3
7 DRG Expert: A Comprehensive Guidebook to the DRG Classification System, 2014.
8 CMS Federal Register, Volume 78; Number 160, August 19, 2013. Payments are effective October 1, 2013- September 30, 2014.
9 CMS Federal Register, Volume 79; Number 163, August 22, 2014. Payments are effective October 1, 2014 - September 30, 2015.
10 National Uniform Billing Committee, American Hospital Association.
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.

DISCLAIMER
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.