Vascular Products 2009 Facility and Physician Billing Guide

2009 Facility and Physician Billing Guide

Vascular Products

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PROCEDURAL SERVICES
Clinicians and outpatient facilities use Current Procedural Terminology (CPT®1) codes to bill for their services. For clinicians, each CPT code is assigned a unique relative value unit, which is used to determine Medicare payment based on the RBRVS system. For facilities, each CPT code is assigned a payment level based on historical charge information. Some CPT codes commonly used to describe procedures related to Edwards’ products (e.g. Fogarty catheters) are listed below.2 Unless indicated in an endnote below, these procedures may be subject to the CMS multiple procedure discount. When applicable, a payment reduction of 50% is applied to all payment amounts except the highest reimbursed procedure, which is paid at 100%. This rule does not normally apply to radiologic procedures.

Procedures related to the use of Edwards’ products (e.g. Fogarty catheters) are often performed in a facility setting, including an outpatient hospital department (HOPPS, Place of Service (POS) code 22), Ambulatory Surgery Center (POS code 24), or a Vascular Access Center (which can be licensed as POS 11, 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 is not necessarily complete.

2009 Medicare National Average Payments		Physician Payment3		Facility Payment
CPT Code	Description	Facility Setting Various POSs	Non-Facility Setting Including POS 11	Outpatient Hospital4 POS 22		ASC POS 24
Interventional Procedures5
35261	Repair blood vessel with graft other than vein; neck	$1,049	Facility Only	APC 0653	$3,095	Non-covered
35266	Repair blood vessel with graft other than vein; upper extremity	$868	Facility Only	APC 0653	$3,095	Non-covered
36145⁶	Introduction of needle or intracatheter; arteriovenous shunt created for dialysis cannula, fistula, or graft	$101	$466	n/a	n/a (Packaged)	n/a (Packaged)
36831	IntrThrombectomy, open, arteriovenous fistula without revision, autogenous or non‐autogenous dialysis graft (separate procedure)	$453	Facility Only	APC 0088	$2,663	$1,466
36833	Revision, open, arteriovenous fistula; with thrombectomy, autogenous or non‐autogenous dialysis graft (separate procedure)	$654	Facility Only	APC 0088	$2,663	$1,120
36870	Thrombectomy, percutaneous, arteriovenous fistula; autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra‐graft thrombolysis)	$302	$1,770	APC 0653	$3,095	$1,598
37201	Transcatheter therapy, infusion for thrombolysis other than coronary	$281	Facility Only	APC 0103	$1,039	Non-covered

FACILITY BILLING - INPATIENT
Medicare inpatient hospital reimbursement is based upon the MS-DRG system, which assigns MS-DRGs based on ICD-9-CM diagnosis and procedure codes. The following codes generally describe procedures associated with the use of Edwards’ products (e.g. Fogarty catheters).

ICD9-CM Procedure Code⁷	Description
39.42	Revision of arteriovenous shunt for renal dialysis
39.49	Other revisions of vascular procedure, including graft declotting
39.57	Repair of blood vessel with synthetic patch graft

HCPCS CODES
Hospitals may capture the cost of products used for these procedures for payer reporting or cost accounting purposes as expenses within Revenue Code 270 (Medical/Surgical Supply) 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 payment will be provided to the facility. All appropriate C codes should be added to the hospital’s chargemaster to report device costs used in the outpatient setting. CMS rejects hospital claims if the appropriate pass‐through code is not identified on the claim. Edwards Vascular products can be used in both the inpatient and outpatient setting. C codes which 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
C1757	Thrombectomy/Embolectomy Catheter	Fogarty and Fogarty Fortis thrombectomy and embolectomy catheters: 120403F‐120807F, 12A0403F‐12A1004F, NL2EMB40‐NL7EMB80, 12TLW403F‐12TLW807F, 140806‐1408010, 160245F‐320808F
C1768	Graft, vascular	R06010‐R10080, QT47040‐QT47050, RS47050, T06020‐T10080, T3103
C2628	Catheter, occlusion	620403F, 620404F, 620405F, 62080814F, 62080822F

References
1 Current Procedural Terminology (CPT) copyright 2008 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 all clinical scenarios in which Edwards Vascular products are used. The most appropriate code(s) for the patient’s clinical presentation must be selected. When radiologic guidance is used for catheter placement, add applicable codes according to the service provided following correct coding guidelines. When performing multiple procedures, review current correct coding guidelines carefully. Services that are considered a component of another procedure cannot 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.
4 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.
5 Where applicable, 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. These 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.
6 Report CPT 36145 twice if both the arterial and venous sites are punctured, with modifier ‐59 appended to one.
7 2009 ICD‐9‐CM for Hospitals Volumes 1, 2, and 3.

2009 Facility and Physician Billing Guide Vascular Products

2009 Facility and Physician Billing Guide

Vascular Products