2014 FACILITY AND PHYSICIAN BILLING GUIDE

TRANSCATHETER AORTIC VALVE REPLACEMENT

This guide is intended to support diagnostic and procedural coding for Transcatheter Aortic Valve Replacement (TAVR) procedures.
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PHYSICIAN INPATIENT CODING
Facilities and Physicians 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).
All the CPT codes used to bill for TAVR procedures are listed below.


Procedure

CPT Code1,2

Description

2014 National
Avg. Physician
Payment

Each Physician
Payment
(Modifier-62)*

2014 Facility
RVUs

TAVR 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach $1,403 $877 39.18
  33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach $1,535 $959 42.85
  33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach $1,588 $993 44.35
  33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach $1,671 $1,044 46.66
  33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (e.g., median sternotomy, mediastinotomy) $1,843 $1,152 51.46
  33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) $1,994 $1,246 55.69
 
 

Add-on Codes

     
  33367* Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (e.g., femoral vessels) (list separately in addition to code for primary procedure) $643 NA 17.97
  33368* TAVR with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (List separately in addition to code for primary procedure) $780 NA 21.78
  33369* TAVR with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) $1,029 NA 28.74

Note: *As per the CMS’s NCD for TAVR, TAVR is a two-physician (IC & CS) procedure. Medicare payment for each physician is 62.5% of the established national average payment 8. +33367,33368 and 33369 are add-on codes which does not require modifier 62 hence each physician payment of 62.5% does not apply.

Note: Medicare will only pay TAVR physician claims with these CPT codes when billed with the Place of Service (POS) code 21 (Inpatient Hospital), modifier 62 (two surgeons/ co-surgeons), modifier Q0 (zero) signifying CED participation (qualifying registry or qualified clinical study) and ICD-9 secondary diagnosis code V70.7 (Examination of participant in clinical trial). Medicare requires reporting of the Clinical Trial (CT) number on the claim form. For example, the CT number for the TVT Registry is CT01737528 and the PARTNER II Trial is CT01314313. Medicare may return other claims as unprocessable. * Codes 33361-33369 have a 0 day global period; Codes 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368 and 33369 do not include cardiac catheterization [93451-93572] when performed at the time of the procedure for diagnostic purposes prior to aortic valve replacement. Codes 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368 and 33369 include all other catheterization[s], temporary pacing, intraprocedural contrast injection[s], fluoroscopic radiological supervision and interpretation, and imaging guidance, which are not reported separately when performed to complete the aortic valve procedure.



HOSPITAL INPATIENT DIAGNOSIS AND PROCEDURE CODING
Medicare inpatient hospital reimbursement is based upon the Medicare Severity Diagnostic-Related Group (MSDRG) classification system, which assigns MS-DRGs based on ICD-9-CM diagnosis and procedure codes. The following codes generally describe diagnosis and procedures associated with the use of the Edwards SAPIEN XT transcatheter heart valve.

ICD9-CM3 Diagnosis Code

Description

424.1

Aortic valve disorders

ICD9-CM3 Procedure Code

Description

35.054

Endovascular replacement of aortic valve

35.064

Transapical replacement of aortic valve

Pursuant to the final rule for the FY 2015 hospital Inpatient Prospective Payment System (IPPS), CMS created new MS-DRGs for endovascular cardiac valve replacements, effective October 1, 2014.

CPT Code1,2

Description

FY 2015
Relative Weight

FY 2015
National Average
Payment7

FY 2015
Geometric
Mean-LOS

266 Endovascular Cardiac Valve Replacement with MCC 8.9920 $52,742 8.4
267 Endovascular Cardiac Valve Replacement without MCC 6.7517 $39,602 5.0

Note: Medicare will only pay TAVR facility claims with these ICD-9-CM codes when billed with the ICD-9 secondary diagnosis code V70.7 (Examination of participant in clinical trial) and condition code 30 (qualifying clinical trial). Medicare will return all other claims as unprocessable.


Additional Notes
Diagnostic left heart catheterization codes (93452, 93453, 93458-93461) and the supravalvular aortography code (93567) should not be used with TAVR/TAVI services (33361-33366) to report:
   1. Contrast injections, angiography, roadmapping, and/or fluoroscopic guidelines for the TAVR/TAVI,
   2. Aorta/left ventricular outflow tract measurement for the TAVR/TAVI, or
   3. Post-TAVR/TAVI aortic or left ventricular angiography, as this work is captured in the TAVR/TAVI services codes (33361-33366).
    Diagnostic coronary angiography performed at the time of TAVR/TAVI may be separately reportable if:
       1. No prior catheter-based coronary angiography study is available and a full diagnostic study is performed, or
       2. A prior study is available, but as documented in the medical record:
         a. The patient’s condition with respect to the clinical indication has changed since the prior study, or
         b. There is inadequate visualization of the anatomy and/or pathology, or
         c. There is a clinical change during the procedure that requires new evaluation.
         d. For same session/same day diagnostic coronary angiography services, report the appropriate diagnostic cardiac catheterization codes(s) appended with modifier 59 indicating separate and distinct procedural service from TAVR/TAVI
    Diagnostic coronary angiography performed at a separate session from an interventional procedure may be separately reportable.
    Other cardiac catheterization services are reported separately when performed for diagnostic purposes not intrinsic to TAVR/TAVI.
    Percutaneous coronary interventional procedures are reported separately, when performed.


    Reimbursement Hotline: 1-800-471-9387

    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.

        References
        1. Current Procedure Terminology (CPT) copyright 2013, 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’ Transcatheter 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. International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2014 ICD-9-CM for hospitals, volume 1, 2, & 3.
        4. Centers for Medicare & Medicaid Services (CMS). Updates and Revisions to ICD-9-CM Procedure Codes (Addendum). FY 2012 Medicare Addendum, ICD-9-CM Volume 3, Procedures. 26 October 2011. and . CMS MLN Matters MM7897, National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR), Revised 25 September, 2012 CMS MLN Matters MM8255, NCD for TAVR- Implementation of Mandatory Reporting of Clinical Trial Number. Revised July, 2013
        5. DRG Expert: A Comprehensive Guidebook to the DRG Classification System, 31st Edition, 2015.
        6. Centers for Medicare and Medicaid Services, Physician Fee Schedule Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFee- Sched/PFS-Relative-Value-Files.html. Accessed 8-13-2014
        7. CMS Federal Register, Volume 79; Number 163, August 22, 2014/Rules and Regulations. The FY2015 Final Average standardized amount is $5865.48
        8. CMS Federal Register, Volume 77; Number 222, November 16, 2012/Rules and Regulations
        Accessed 12-12-2013.
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