2014 Facility and Physician Billing Guide

Transcatheter Heart Valve Replacement Technologies

This guide is intended to support diagnostic and procedural coding for transcatheter aortic valve replacement (TAVR) procedures.
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PHYSICIAN INPATIENT CODING
Clinicians use Current Procedural Terminology (CPT1) Category III codes to track the use of emerging technology, services, and procedures for clinical efficacy, utilization and outcomes, and to facilitate billing. Category III codes are temporary and do not have relative value units (RVUs) assigned to them unlike the “permanent” CPT Category I codes. Payment has not been established and is therefore based on the payers’ policies rather than a yearly fee schedule.
The below procedures have an effective date of January 1, 2013.


Procedure

CPT Code1,2

Description

TAVR - endovascular approach 33361* TAVR with prosthetic valve; percutaneous femoral artery approach
  33362* TAVR with prosthetic valve; open femoral artery approach
  33363* TAVR with prosthetic valve; open axillary artery approach
  33364* TAVR with prosthetic valve; open iliac artery approach
  33365* TAVR with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
  33366* TAVR with prosthetic valve; transapical approach (eg, left thoractomy)
  33367* TAVR with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure)
  33368* TAVR with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (List separately in addition to code for primary procedure)
  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)

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 requiresreporting 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 Study is CT01314313. Medicare will return all other claims as unprocessable.

* Codes 33361-33369 have a 0 day global period:  Codes 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369 and 0318T 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 transcatheter heart valve technologies.

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

Cardiac Catheterization

The cardiac catheterization may be coded when performed for specific evaluation beyond the approach during the procedure.

MS-DRG5

Description

216

Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC

217

Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC

218

Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without MCC or CC

219

Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC

220

Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with CC

221

Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization without MCC or CC

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.


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, 30th Edition, 2014.
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 12-12-2013.

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.
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