2018 Facility and Physician Billing Guide Transcatheter Heart Valve Replacement Technologies Physician Inpatient Coding for TAVR 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. 2018 National Avg. Each Physician CPT Code1, 2 Description Physician Payment Payment 2018 Facility (Final JAN-DEC) (Modifier-62)* RVUs Transcatheter aortic valve replacement 33361 (TAVR/TAVI) with prosthetic valve; $1,421 $888 39.46 percutaneous femoral artery approach Transcatheter aortic valve replacement 33362 (TAVR/TAVI) with prosthetic valve; open $1,551 $969 43.08 femoral artery approach Transcatheter aortic valve replacement 33363 (TAVR/TAVI) with prosthetic valve; open $1,608 $1,005 44.68 axillary artery approach Transcatheter aortic valve replacement 33364 (TAVR/TAVI) with prosthetic valve; open $1,694 $1,059 47.06 iliac artery approach Transcatheter aortic valve replacement 33365 (TAVR/TAVI) with prosthetic valve; trans- $1,863 $1,164 51.76 aortic approach (e.g., median sternotomy, mediastinotomy) Transcatheter aortic valve replacement 33366 (TAVR/TAVI) with prosthetic valve; trans- $2,015 $1,259 55.98 apical exposure (e.g., left thoracotomy) Add-on Codes Transcatheter aortic valve replacement (TAVR/ TAVI) with prosthetic valve; cardio-pulmonary bypass support with percutaneous peripheral 33367+ arterial and venous cannulation (e.g., femoral $657 NA 18.26 vessels) (list separately in addition to code for primary procedure) 2018 National Avg. Each Physician 1, 2 2018 Facility CPT Code Description Payment Physician Payment RVUs (Final JAN-DEC) (Modifier-62)* Transcatheter aortic valve replacement (TAVR/ TAVI) with prosthetic valve; car-diopulmonary bypass support with open peripheral arterial 33368+ and venous cannulation (e.g., femoral, iliac, $781 NA 21.70 axillary vessels) (list separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with 33369+ central arterial and venous cannulation $1,031 NA 28.65 (e.g., aorta, right atrium, pulmonary artery) (list separately in addition to code for primary procedure) 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-10 secondary diagnosis code Z00.6 (Encounter for examination for normal comparison and control in clinical research program) 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. Additional Notes1 33361-33369 Transcatheter Aortic Valve Replacement Includes: Access and Implantation of the aortic valve (33361-33366) Access sheath placement Advancement of valve delivery system Arteriotomy closure Balloon aortic valvuloplasty Cardiac or open arterial approach Deployment of valve Percutaneous access Temporary pacemaker Valve repositioning when necessary Radiology procedures: Angiography during and after procedure Assessment of access site for closure Documentation of completion of the intervention Guidances for valve placement Supervision and interpretation Excludes: Percutaneous coronary interventional procedures Transvascular ventricular support (33967, 33970, 33973, 33975-33976, 33990-33993, 33999) Code also add-on codes for cardiopulmonary bypass, when appropriate (33367-33369) Code also cardiac catheterization services for purposes other than TAVR/TAVI Code also diagnostic coronary angiography at the same time as TAVR/TAVI when: A previous study is available, but documentation states the patient’s condition has changed since the previous study, visualization of the anatomy/pathology is inadequate, or a change occurs during the procedure warranting additional evaluation of an area outside the current target area No previous catheter-based coronary angiography study is available, and a full diagnostic study is performed, with the decision to perform the intervention based on that study Code also modifier 59 when diagnostic coronary angiography procedures are performed as separate and distinct procedural services on the same day or session as TAVR/TAVI Code also modifier 62 as well as al TAVI/TAVR procedures require the work of two physicians Do not report separately when included in the TAVR/TAVI service (93452-93453, 93458-93461, 933567) Hospital Inpatient Diagnosis and Procedure Coding Medicare inpatient hospital reimbursement is based upon the Medicare Severity Diagnostic-Related Group (MS-DRG) 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 3 transcatheter heart valve. ICD-9-CM3 ICD-10-CM Diagnosis Description Description Code Oct. 1st, 2015) 424.1 Aortic valve disorders I35.0 Nonrheumatic aortic (valve) stenosis ICD-9-CM3 ICD-10-CM Diagnosis Description Description Code Oct. 1st, 2015) Replacement of Aortic Valve with 35.05 Endovascular replacement of aortic valve 02RF38Z Zooplastic Tissue, Percutaneous Approach Replacement of Aortic Valve with Zooplastic 35.06 Transapical replacement of aortic valve 02RF38H Tissue, Transapical, Percutaneous Approach 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, eective October 1, 2014. MS-DRG5 Description FY 2018 FY 2018 National FY 2018 Geometric Relative Weight Average Payment7 Mean-LOS 266 Endovascular Cardiac Valve 7.7516 $46,727 5.0 Replacement with MCC Endovascular Cardiac Valve 267 6.1053 $36,803 2.9 Replacement without MCC Note: Medicare will only pay TAVR facility claims with these ICD-10-CM codes when billed with the ICD-10 secondary diagnosis code Z00.6 (Encounter for examination for normal comparison and control in clinical research program) and condition code 30 (qualifying clinical trial). Medicare will return all other claims as unprocessable. Principal Diagnosis for Valve-in-Valve with the Edwards SAPIEN 3 Transcatheter Heart Valve Depending on the circumstances, there are several ICD-10-CM diagnosis codes that could be used as the principal encounter from the prior surgical valve placement. From a coding perspective, the options are following. Scenario ICD-10 Diagnosis Code ICD-10 Code Description If the previously placed valve was malpositioned Displacement of biological heart or became displaced T82.222A valve graft, initial encounter If the previously placed valve developed Stenosis of cardiac prosthetic devices, stenosis prematurely T82.857A implants and grafts, initial encounter If the previously placed valve developed Leakage of biological heart valve regurgitation prematurely T82.223A graft, initial encounter If the previously placed valve developed stenosis or regurgitation as an expected occurrence as it Encounter for adjustment and Z45.09 management of other cardiac device degenerates toward valve end-of-life Reimbursement Hotline: (303) 524-3854 or [email protected] 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