2021 Procedural Payment Guide

INSIDE THIS GUIDE Cardiovascular • Hospital Inpatient Codes and 2021 Payments • Outpatient Codes and 2021 Payments (Hospital, OBL, ASC) • Physician 2021 Payment and RVUs

FOR MORE PROCEDURE PAYMENT GUIDES, CLICK HERE Procedural Payment Guide - CY2021 FY2021 Hospital Inpatient, CY2021 Hospital Outpatient, Ambulatory Surgery Center (ASC) and Physician Reimbursement Information

Contents Introduction Important—Please Note (print page 2) Description of Payment Methods (print page 3) Rhythm Management Procedures (print page range: 4-18)

Interventional Cardiology Select Coronary Interventions (print page range: 19-29)

Peripheral Interventions (print page range: 30-50) Appendices Appendix A: APC Reference Table (print page 51-52) Appendix B: Category Codes (C-Codes) Reference Guide 2020 (print page range: 53-54) Appendix C: ICD-10-PCS Reference Table (print page range: 55-70)

This document is formatted to print in a landscape orientation on letter (8.5 x 11) or legal (8.5 x 14) paper.

See pages 2 and 3 for important information about the uses and limitations of this document. CRV-732305-AD | JAN 2021 | 1 of 71 Pages IMPORTANT—Please Note: This Procedural Payment Guide for rhythm management, interventional cardiology and peripheral intervention procedures provides coding and reimbursement information for physicians and healthcare facilities.

The codes included in this guide are intended to represent typical rhythm management, cardiology and peripheral intervention procedures where there is: 1) at least one product approved by the U.S. Food and Drug Administration (FDA) for use in the listed procedure; and 2) specific procedural coding guidance provided by a recognized coding or reimbursement authority such as the American Medical Association (AMA) or the Centers for Medicare and Medicaid Services (CMS). This guide is in no way intended to promote the off‐label use of medical devices.

Please note that while these materials are intended to provide coding information for a range of cardiology, rhythm, and vascular peripheral intervention procedures, the FDA‐ approved/cleared labeling for all products may not be consistent with all uses described in these materials. Some payers, including some Medicare contractors, may treat a procedure which is not specifically covered by a product’s FDA‐approved labeling as a non‐covered service.

The Medicare reimbursement amounts shown are currently published national average payments. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic differences in labor and non‐labor costs, hospital teaching status, proportion of low‐income patients, coverage, and/or payment rules. Please feel free to contact the Boston Scientific reimbursement departments: For Rhythm Management ([email protected]) or call 1‐800‐CARDIAC and request ext. 24114, for Peripheral Interventions ([email protected]), and for Intervention Cardiology ([email protected]) or call 1‐877‐786‐1050 and select option 2. if you have any questions about the information in these materials. You can also find reimbursement updates on our website: www.bostonscientific.com/reimbursement Disclaimer

Please note: this coding information may include codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved.

Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third‐party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. It is always the provider’s responsibility to understand and comply with national coverage determinations (NCD), local coverage determinations (LCD) and any other coverage requirements established by relevant payers which can be updated frequently.

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐ inclusive list. We recommend consulting your relevant manuals for appropriate coding options. CPT® Disclaimer CPT® Copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. 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. Boston Scientific does not promote the use of its products outside their FDA‐approved label.

See pages 2 and 3 for important information about the uses and limitations of this document. CRV-732305-AD | JAN 2021 | 2 of 71 Pages Physician Billing and Payment: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to Current Procedural Terminology1 (CPT®) codes. CPT codes are published by the AMA and used to report medical services and procedures performed by or under the direction of physicians. Physician payment for procedures performed in an outpatient or inpatient hospital or Ambulatory Surgical Center (ASC) setting is described as an in‐facility fee payment (listed as In‐Hospital in document) while payment for procedures performed in the physician office is described as an in‐office payment. In‐facility payments reflect modifier ‐26 as applicable.

Hospital Outpatient Billing and Payment: Medicare reimburses hospitals for outpatient stays (typically stays that do not span 2 midnights) under Ambulatory Payment Classification (APC) groups. Medicare assigns an APC to a procedure based on the billed CPT/HCPCS (Healthcare Common Procedural Coding System) code. (Note that private insurers may require other procedure codes for outpatient payment.) While it is possible that separate APC payments may be deemed appropriate where more than one procedure is done during the same outpatient visit, many APCs are subject to reduced payment when multiple procedures are performed on the same day. Comprehensive APCs (J1 status indicator) can impact total payment received for outpatient services.

Hospitals report device category codes (C‐codes) on claims when such devices are used in conjunction with procedure(s) billed and paid for under the OPPS. This reporting provides claims data used annually to update the OPPS payment rates. Although separate payment is not typically available for C‐Codes, denials may result if applicable C‐ Codes are not included with associated procedure codes CMS has an established cost center for “Implantable Devices Charged to Patients”, available for cost reporting periods since May 1, 2009. As CMS uses data from this cost center to establish OPPS payments, it is important for providers to document device costs in this cost center to help ensure appropriate payment amounts.

Hospital Inpatient Billing and Payment: Medicare reimburses hospital inpatient procedures based on the Medicare Severity Diagnosis Related Group (MS‐DRG). The MS‐DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS‐DRGs closely calibrate payment to the severity of a patient’s illness. One single MS‐DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of “professional” (e.g., physician) charges associated with performing medical procedures. Private payers may also use MS‐DRG‐ based systems or other payer‐specific system to pay hospitals for providing inpatient services.

ICD‐10‐PCS: Potential procedure codes are included within this guide. Due to the number of potential codes within the ICD‐10‐PCS system, the codes included in this document do not fully account for all procedure code options. Some codes outlined in this guide include an " _" symbol. For example, 027_3_Z is listed as a potential code for reporting a coronary drug‐eluting stent procedure. In this example, the "_" character could be 0, 1, 2, 3, 4, 5, 6, or 7 depending on the number of arteries treated. The "_" symbol is not a recognized character within the ICD‐10‐PCS system.

Note: Effective October 1, 2016 coronary arteries are specified by the number of arteries (formerly sites) treated. (AHA Coding Clinic 4 th Qtr 2016)

ASC Billing and Payment: Many elective procedures are performed outside of the hospital in Medicare certified facilities also known as Ambulatory Surgical Centers (ASCs). Not all procedures that Medicare covers in the hospital setting are eligible for payment in an ASC. Medicare has a list of all services (as defined by CPT/HCPCs codes), generally non‐surgical, that it covers when offered in an ASC. ASC allowed procedures can be found at http://www.cms.hhs.gov/ASCPayment/. Payments made to ASCs from private insurers depend on the contract the facility has with the payer.

See pages 2 and 3 for important information about the uses and limitations of this document. CRV-732305-AD | JAN 2021 | 3 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

In‐Office CPT® In‐Hospital Work RVU ASC APC APC Possible Possible CPT Descriptions Non Facility MS‐DRG Payment6 Code¹ (‐26) Total RVU7 Payment³ Category Payment4 ICD‐10‐PCS Codes5 MS‐DRG Assignment Fee

Rhythm Management Device Implant Procedures go to APC list go to ICD‐10‐PCS list 33206 Insertion of new or replacement of permanent pacemaker with transvenous $468 NA 7.14 $7,635 APC 5223 $10,400 02H63JZ Permanent cardiac pacemaker implant electrode(s); atrial 13.41 0JH604Z MS‐DRG 244 without CC/MCC $13,277 X2A0T or MS‐DRG 243 with CC $16,278 0JH605Z MS‐DRG 242 with MCC $23,926 33207 Insertion of new or replacement of permanent pacemaker with transvenous $492 7.80 $7,742 02HK3JZ electrode(s); ventricular 14.10 0JH605Z or 0JH604Z

33208 Insertion of new or replacement of permanent pacemaker with transvenous $534 8.52 $7,897 02H63JZ electrode(s); atrial and ventricular 15.31 02HK3JZ 0JH606Z

33212 Insertion of pacemaker pulse generator only; with existing single lead $331 5.01 $6,729 APC 5222 $8,153 0JH604Z Cardiac pacemaker replacement 9.50 MS‐DRG 259 without MCC $13,627 MS‐DRG 258 with MCC $20,576 33213 Insertion of pacemaker pulse generator only; with existing dual leads $345 5.28 $7,881 APC 5223 $10,400 0JH606Z 9.89 33221 Insertion of pacemaker pulse generator only; with existing multiple leads $372 5.55 $12,075 APC 5224 $18,611 0JH607Z 10.66 33214 Upgrade of implanted pacemaker system, conversion of single chamber $493 7.59 $7,771 APC 5223 $10,400 0JH606Z Permanent cardiac pacemaker implant system to dual chamber system (includes removal of previously placed pulse 14.12 0JPT0PZ MS‐DRG 244 without CC/MCC $13,277 generator, testing of existing lead, insertion of new lead, insertion of new 02H63JZ RA MS‐DRG 243 with CC $16,278 pulse generation) or MS‐DRG 242 with MCC $23,926 02HK3KZ RV 33215 Repositioning of previously implanted transvenous pacemaker or $318 4.92 $1,372 APC 5183 $2,862 02WA3MZ Cardiac pacemaker revision except device implant implantable defibrillator (right atrial or right ventricular) electrode 9.11 MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 MS‐DRG 260 with MCC $23,037

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 4 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Implant Procedures continued go to APC list go to ICD‐10‐PCS list 33216 Insertion of a single transvenous electrode, permanent pacemaker or $382 NA 5.62 $5,556 APC 5222 $8,153 02H63JZ Cardiac pacemaker revision except device implant cardioverter‐defibrillator 10.96 02H43KZ MS‐DRG 262 without CC/MCC $10,979 02H73JZ MS‐DRG 261 with CC $12,799 02HK3JZ MS‐DRG 260 with MCC $23,037 02HL3JZ 02HK3KZ ICD lead procedures 02H73KZ MS‐DRG 265 $21,613 02HL3KZ 33217 Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter‐ $379 5.59 $7,151 02H63KZ defibrillator 10.85 33218 Repair of single transvenous electrode, permanent pacemaker or pacing $400 5.82 $1,747 APC 5221 $3,440 02WA3MZ Cardiac pacemaker revision except device replacement cardioverter‐defibrillator 11.45 MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 MS‐DRG 260 with MCC $23,037 33220 Repair of 2 transvenous electrodes for permanent pacemaker or pacing $386 5.90 $2,332 APC 5221 $3,440 02WA3MZ Cardiac pacemaker revision except device replacement cardioverter‐defibrillator 11.07 MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 33222 Relocation of skin pocket for pacemaker $352 4.85 $871 APC 5054 $1,715 0JWT0PZ MS‐DRG 260 with MCC $23,037 10.08 33223 Relocation of skin pocket for implantable‐defibrillator $422 6.30 12.10 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular $527 9.04 $7,656 APC 5223 $10,400 02H43JZ ICD lead procedures pacing, with attachment to previously placed pacemaker or implantable 15.11 MS‐DRG 265 $21,613 defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 5 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

26 Rhythm Management Device Implant Procedures continued go to APC list go to ICD‐10‐PCS list +33225 Insertion of pacing electrode, cardiac venous system, for left ventricular $479 NA 8.33 NA Status N, items and 02H43JZ Cardiac defibrillator implant with cardiac catheterization with acute 3322526 pacing, at time of insertion of implantable defibrillator or pacemaker pulse 13.72 services packaged into MI/HF/Shock 33225 generator (eg, for upgrade to dual chamber system) (List separately in primary procedure APC MS‐DRG 222 with MCC $54,126 addition to code for primary procedure) rate. No separate MS‐DRG 223 without MCC $39,928 payment. Cardiac defibrillator implant with cardiac catheterization without acute MI/HF/Shock MS‐DRG 224 with MCC $47,320 MS‐DRG 225 without MCC $36,166

Cardiac defibrillator implant without cardiac catheterization

MS‐DRG 226 with MCC $42,497 MS‐DRG 227 without MCC $33,756 Permanent cardiac pacemaker implant MS‐DRG 242 with MCC $23,926 MS‐DRG 243 with CC $16,278 MS‐DRG 244 without CC/MCC $13,277 33226 Repositioning of previously implanted cardiac venous system (left $505 8.68 $1,372 APC 5183 $2,862 02WA3MZ Cardiac pacemaker revision except device replacement ventricular) electrode (including removal, insertion and/or replacement of 14.46 existing generator) MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 33233 Removal of permanent pacemaker pulse generator only $239 3.14 $5,758 APC 5222 $8,153 0JPT0PZ MS‐DRG 260 with MCC $23,037 6.86 33227 Removal of permanent pacemaker pulse generator with replacement of $348 5.25 $6,436 0JH604Z Cardiac pacemaker device replacement pacemaker pulse generator; single lead system 9.98 or 0JH605Z 0JPT0PZ MS‐DRG 258 with MCC $10,561 33228 Removal of permanent pacemaker pulse generator with replacement of $365 5.52 $7,701 APC 5223 $10,400 0JPT0PZ MS‐DRG 259 without MCC $7,462 pacemaker pulse generator; dual lead system 10.45 0JH606Z

33229 Removal of permanent pacemaker pulse generator with replacement of $386 5.79 $12,026 APC 5224 $18,611 0JPT0PZ pacemaker pulse generator; multiple lead system 11.05 0JH607Z

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 6 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Implant Procedures continued go to APC list go to ICD‐10‐PCS list 33234 Removal of transvenous pacemaker electrode(s); single lead system, atrial or $500 NA 7.66 $2,335 APC 5221 $3,440 02PA3MZ Cardiac pacemaker revision except device replacement ventricular 14.32 MS‐DRG 262 without CC/MCC $10,979 33235 Removal of transvenous pacemaker electrode(s); dual lead system $655 9.90 MS‐DRG 261 with CC $12,799 18.78 MS‐DRG 260 with MCC $23,037 33240 Insertion of implantable defibrillator pulse generator only; with existing $375 5.80 $20,375 APC 5231 $23,040 0JH608Z AICD Generator Procedures single lead 10.75 MS‐DRG 245 $34,798 33230 Insertion of implantable defibrillator pulse generator only; with existing dual $394 6.07 leads 11.30 33231 Insertion of implantable defibrillator pulse generator only; with existing $412 6.34 $26,748 APC 5232 $32,839 multiple leads 11.81 33241 Removal of implantable defibrillator pulse generator only $221 3.04 $1,286 APC 5221 $3,440 0JPT0PZ Cardiac pacemaker revision except device replacement 6.34 MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 MS‐DRG 260 with MCC $23,037 33262 Removal of implantable defibrillator pulse generator with replacement of $384 5.81 $19,793 APC 5231 $23,040 0JH608Z AICD Generator Procedures implantable defibrillator pulse generator; single lead system 11.01 0JPT0PZ MS‐DRG 245 with MCC $34,798

33263 Removal of implantable defibrillator pulse generator with replacement of $400 6.08 implantable defibrillator pulse generator; dual lead system 11.45

33264 Removal of implantable defibrillator pulse generator with replacement of $417 6.35 $26,629 APC 5232 $32,839 implantable defibrillator pulse generator; multiple lead system 11.96

33244 Removal of single or dual chamber implantable defibrillator electrode(s); by $890 13.74 Not covered APC 5221 $3,440 02PA3MZ Cardiac pacemaker revision except device replacement transvenous extraction 25.51 for ASC payment MS‐DRG 262 without CC/MCC $10,979 MS‐DRG 261 with CC $12,799 MS‐DRG 260 with MCC $23,037

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 7 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Implant Procedures continued go to APC list go to ICD‐10‐PCS list 33249 Insertion or replacement of permanent implantable defibrillator system with $942 NA 14.92 $26,733 APC 5232 $32,839 02H63KZ Cardiac defibrillator implant with cardiac catheterization with acute transvenous lead(s), single or dual chamber 26.99 02HK3KZ MI/HF/Shock 0JH608Z MS‐DRG 222 with MCC $54,126 MS‐DRG 223 without MCC $39,928

Cardiac defibrillator implant with cardiac catheterization without acute MI/HF/Shock 33270 Insertion or replacement of permanent subcutaneous implantable $579 9.10 $26,844 0JH608Z defibrillator system, with subcutaneous electrode including defibrillation 16.59 0JH60FZ MS‐DRG 224 with MCC $47,320 threshold evaluation, induction of arrhythmia evaluation of sensing for MS‐DRG 225 without MCC $36,166 arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Cardiac defibrillator implant without cardiac catheterization MS‐DRG 226 with MCC $42,497 MS‐DRG 227 without MCC $33,756 33271 Insertion of subcutaneous implantable defibrillator electrode $464 7.50 $7,431 APC 5222 $8,153 0JH60FZ ICD lead procedures 13.30 MS‐DRG 265 $21,613 33272 Removal of subcutaneous implantable defibrillator electrode $356 5.42 NA APC 5221 $3,440 0JPT0FZ 10.20

33273 Reposition of previously implanted subcutaneous implantable defibrillator $409 6.50 $1,747 0JWT0FZ electrode 11.71 Subcutaneous Cardiac Rhythm Monitor SCRM 33285 Insertion, subcutaneous cardiac rhythm monitor, including programming $90 $5,200 In Facilty $7,046 APC 5222 $8,153 0JH632Z Cardiac pacemaker revision except device replacement 1.53 MS‐DRG 262 without CC/MCC $10,979 2.58 MS‐DRG 261 with CC $12,799 In office MS‐DRG 260 with MCC $23,037 147.16 Peripheral, Cranial Nerve and Other Nervous System Procedures 149.03 MS‐DRG 40 without CC/MCC $25,438 MS‐DRG 41 without CC $15,110 MS‐DRG 42 with MCC $12,115 33286 Removal, subcutaneous cardiac rhythm monitor $89 $141 In Facilty $316 APC 5071 $622 0JPT32Z NA 1.50 2.55

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 8 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

26 Rhythm Management Device Evaluation Codes go to APC list go to ICD‐10‐PCS list 93279 Programming device evaluation (in person) with iterative adjustment of the $32 $67 0.65 Not covered APC 5741 $37 4B02XSZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9327926 implantable device to test the function of the device and select optimal 0.92 for ASC permanent programmed values with analysis, review and report by a physician or payment. other qualified health care professional; single lead pacemaker system or leadless pacemaker system in one cardiac chamber

93280 Programming device evaluation (in person) with iterative adjustment of the $39 $80 0.77 9328026 implantable device to test the function of the device and select optimal 1.11 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead pacemaker system

93281 Programming device evaluation (in person) with iterative adjustment of the $43 $85 0.85 9328126 implantable device to test the function of the device and select optimal 1.24 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; multiple lead pacemaker system

93282 Programming device evaluation (in person) with iterative adjustment of the $43 $81 0.85 4B02XTZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9328226 implantable device to test the function of the device and select optimal 1.23 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead transvenous implantable defibrillator system

93283 Programming device evaluation (in person) with iterative adjustment of the $58 $99 1.15 9328326 implantable device to test the function of the device and select optimal 1.65 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead transvenous implantable defibrillator system

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 9 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Evaluation Codes continued go to APC list go to ICD‐10‐PCS list 93284 Programming device evaluation (in person) with iterative adjustment of the $63 $107 1.25 Not covered APC 5741 $37 4B02XTZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9328426 implantable device to test the function of the device and select optimal 1.80 for ASC permanent programmed values with analysis, review and report by a payment physician or other qualified health care professional; multiple lead transvenous implantable defibrillator system

93260 Programming device evaluation (in person) with iterative adjustment of the $43 $77 0.85 9326026 implantable device to test the function of the device and select optimal 1.24 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system

93285 Programming device evaluation (in person) with iterative adjustment of the $26 $60 0.52 4A12X4Z 9328526 implantable device to test the function of the device and select optimal 0.75 permanent programmed values with analysis, review and report by a physician or other qualified health care professional; subcutaneous cardiac rhythm monitor system

93286 Peri‐procedural device evaluation (in person) and programming of device $15 $46 0.30 NA 4B02XSZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9328626 system parameters before or after a surgery, procedure, or test with 0.44 analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead pacemaker system, or leadless pacemaker system

93287 Peri‐procedural device evaluation (in person) and programming of device $23 $54 0.45 4B02XTZ 9328726 system parameters before or after a surgery, procedure, or test with 0.66 analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 10 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Evaluation Codes continued go to APC list go to ICD‐10‐PCS list 93288 Interrogation device evaluation (in person) with analysis, review and report $21 $56 0.43 Not covered APC 5741 $37 4B02XSZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9328826 by a physician or other qualified health care professional, includes 0.60 for ASC connection, recording and disconnection per patient encounter; single, dual, payment or multiple lead pacemaker system, or leadless pacemaker system

93289 Interrogation device evaluation (in person) with analysis, review and report $38 $73 0.75 4B02XTZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9328926 by a physician or other qualified health care professional, includes 1.08 connection, recording and disconnection per patient encounter; single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements

93261 Interrogation device evaluation (in person) with analysis, review and report $37 $70 0.74 4B02XTZ 9326126 by a physician or other qualified health care professional, includes 1.06 connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system

93290 Interrogation device evaluation (in person) with analysis, review and report $22 $53 0.43 4A02XFZ 9329026 by a physician or other qualified health care professional, includes 0.62 connection, recording and disconnection per patient encounter; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors

93291 Interrogation device evaluation (in person) with analysis, review and report by a $18 $49 0.37 APC 5731 $25 9329126 physician or other qualified health care professional, includes connection, 0.53 recording and disconnection per patient encounter; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 11 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Evaluation Codes continued go to APC list go to ICD‐10‐PCS list 93292 Interrogation device evaluation (in person) with analysis, review and report $21 $50 0.43 Not covered APC 5741 $37 4B02XTZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9329226 by a physician or other qualified health care professional, includes 0.61 for ASC connection, recording and disconnection per patient encounter; wearable payment defibrillator system

93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual or $15 $52 0.31 9329326 multiple lead pacemaker system, includes recording with and without 0.43 magnet application with analysis, review and report(s) by a physician or other qualified health care professional, up to 90 days

93294 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or $31 $31 0.60 NA 4B02XSZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9329426 multiple lead pacemaker system, or leadless pacemaker system with interim 0.88 analysis, review(s) and report(s) by a physician or other qualified health care professional 93295 Interrogation device evaluation(s) (remote), up to 90 days single, dual, or $38 $38 0.74 4B02XTZ 9329526 multiple lead implantable defibrillator system with interim analysis, 1.09 review(s) and report(s) by a physician or other qualified health care professional

93296 Interrogation device evaluation(s) (remote), up to 90 days single, dual, or NA $26 0.00 APC 5741 $37 4B02XSZ 9329626 multiple lead pacemaker system, leadless pacemaker system or implantable NA 4B02XTZ defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

93297 Interrogation device evaluation(s), (remote) up to 30 days; implantable $27 $27 0.52 NA 4A02X9Z 93297 cardiovascular physiologic monitor system, including analysis of 1 or more 0.77 recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 12 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Rhythm Management Device Evaluation Codes continued go to APC list go to ICD‐10‐PCS list 93298 Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac $27 $27 0.52 Not covered NA 4A02X9Z ICD‐10‐PCS procedure code does not impact MS‐DRG 93298 rhythm monitor system, including analysis of recorded heart rhythm data, 0.77 for ASC analysis, review(s) and report(s) by a physician or other qualified health care payment professional

G2066 Interrogation device evaluation(s), (remote) up to 30 days; implantable Contractor Contractor 0.00 APC 5741 $37 93299 cardiovascular monitor system or subcutaneous cardiac rhythm monitor system, Priced Priced 0.00 remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

Intracardiac Electrophysiology Procedures/Studies Modifier 26 93318 Echocardiography, transesophageal (TEE) for monitoring purposes, including $104 $104 2.15 B244ZZ4 ICD‐10‐PCS procedure code does not impact MS‐DRG 9331826 probe placement, real time 2‐dimensional image acquisition and interpretation 2.99 B246ZZ4 leading to ongoing (continuous) assessment of (dynamically changing) cardiac B24BZZ4 B24CZZ4 pumping function and to therapeutic measures on an immediate time basis Status N, items and services Not covered B24DZZ4 packaged into primary for ASC procedure APC rate. No payment. +93462 Left heart catheterization by transseptal puncture through intact septum or by $215 $215 3.73 separate payment. 4A023N7 Percutaneous Intracardiac Procedures 93462 transapical puncture (List separately in addition to code for primary procedure) 6.15 MS‐DRG 273 with MCC $24,663 93462 MS‐DRG 274 without MCC $21,117

93600 Bundle of His recording $121 $121 0.00 APC 5212 $6,078 4A023FZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9360026 N/A 93602 Intra‐atrial recording $119 $119 0.00 9360226 N/A 93603 Right ventricular recording $119 $119 0.00 APC 5211 $1,113 9360326 N/A +93609 Intraventricular and/or intra‐atrial mapping of tachycardia site(s) with catheter $283 $283 4.99 Status N, items and services 02K83ZZ Percutaneous Intracardiac Procedures 9360926 manipulation to record from multiple sites to identify origin of tachycardia (list 8.10 Not covered packaged into primary MS‐DRG 273 with MCC $24,663 93609 separately in addition to code for primary procedure) for ASC procedure APC rate. No MS‐DRG 274 without MCC $21,117 payment. separate payment.

93610 Intra‐atrial pacing $167 $167 3.02 APC 5212 $6,078 4A0234Z ICD‐10‐PCS procedure code does not impact MS‐DRG 9361026 4.80 93612 Intraventricular pacing $166 $166 3.02 9361226 4.76

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 13 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Intracardiac Electrophysiology Procedures/Studies Modier 26 go to APC list go to ICD‐10‐PCS list +93613 Intracardiac electrophysiologic 3‐dimensional mapping (List separately in $303 NA 5.23 Status N, items and 02K83ZZ Percutaneous Intracardiac Procedures 93613 addition to code for primary procedure) 8.67 Not covered services packaged into MS‐DRG 273 with MCC $24,663 93613 for ASC primary procedure APC MS‐DRG 274 without MCC $21,117 payment. rate. No separate payment. 93615 Esophageal recording of atrial electrogram with or without ventricular $38 $38 0.74 APC 5211 $1,113 4A02X4Z ICD‐10‐PCS procedure code does not impact MS‐DRG 9361526 electrogram(s) 1.09 93616 Esophageal recording of atrial electrogram with or without ventricular $60 $60 1.24 9361626 electrogram(s); with pacing 1.71 93618 Induction of arrhythmia by electrical pacing $224 $224 4.00 9361826 6.41 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and $399 $399 7.06 APC 5212 $6,078 4A0234Z Percutaneous Intracardiac Procedures 9361926 recording, right ventricular pacing and recording, His bundle recording, 11.43 MS‐DRG 273 with MCC $24,663 including insertion and repositioning of multiple electrode catheters, MS‐DRG 274 without MCC $21,117 without induction or attempted induction of arrhythmia

93620 Comprehensive electrophysiologic evaluation including insertion and $639 $639 11.32 9362026 repositioning of multiple electrode catheters with induction or attempted 18.31 induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording

+93621 Comprehensive electrophysiologic evaluation including insertion and $119 $119 2.10 Percutaneous Intracardiac Procedures 9362126 repositioning of multiple electrode catheters with induction or attempted 3.42 Status N, items and MS‐DRG 273 with MCC $24,663 93621 induction of arrhythmia; with left atrial pacing and recording from coronary Not covered services packaged into MS‐DRG 274 without MCC $21,117 sinus or left atrium (List separately in addition to code for primary for ASC primary procedure APC procedure) payment. rate. No separate payment.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 14 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Intracardiac Electrophysiology Procedures/Studies continued Modifier 26 go to APC list go to ICD‐10‐PCS list Percutaneous Intracardiac Procedures +93622 Comprehensive electrophysiologic evaluation including insertion and $175 $175 3.10 Status N, items and 4A0234Z 9362226 5.02 MS‐DRG 273 with MCC $24,663 repositioning of multiple electrode catheters with induction or attempted Not covered services packaged into 93622 MS‐DRG 274 without MCC $21,117 induction of arrhythmia; with left ventricular pacing and recording (List for ASC primary procedure APC separately in addition to code for primary procedure) payment. rate. No separate payment. +93623 Programmed stimulation and pacing after intravenous drug infusion (List $130 $130 0.98 4A023FZ 9362326 separately in addition to code for primary procedure) 3.72 3E043KZ 93623 3E033KZ 93624 Electrophysiologic follow‐up study with pacing and recording to test $244 $244 4.55 APC 5212 $6,078 4A023FZ 9362426 effectiveness of therapy, including induction or attempted induction of 6.98 arrhythmia Electrophysiologic evaluation of single or dual chamber pacing cardioverter‐ 4A02XFZ ICD‐10‐PCS procedure code does not impact MS‐DRG 93640 $182 $182 3.26 Status N, items and 9364026 defibrillator leads including defibrillation threshold evaluation (induction of 5.23 Not covered services packaged into arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at for ASC primary procedure APC time of initial implantation or replacement payment. rate. No separate payment. 93641 Electrophysiologic evaluation of single or dual chamber pacing cardioverter $318 $318 5.67 4A02XFZ 9364126 defibrillator leads including defibrillation threshold evaluation (induction of 9.10 arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter‐ defibrillator pulse generator

93642 Electrophysiologic evaluation of single or dual chamber transvenous pacing $259 $259 4.63 APC 5211 $1,113 4A02XFZ 9364226 cardioverter‐defibrillator (includes defibrillation threshold evaluation, induction 7.42 of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 15 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

26 Intracardiac Electrophysiology Procedures/Studies continued go to APC list go to ICD‐10‐PCS list 93644 Electrophysical evaluation of subcutaneous implantable defibrillator (includes $146 $201 3.04 NA 4B02XTZ ICD‐10‐PCS procedure code does not impact MS‐DRG 9364426 defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing 4.19 for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters

93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular $603 NA 10.24 APC 5212 $6,078 02583ZZ Percutaneous Intracardiac Procedures 9365026 conduction for creation of completer heart block, with or without temporary 17.28 0JH636Z MS‐DRG 273 with MCC $24,663 pacemaker placement 0JH634Z MS‐DRG 274 without MCC $21,117

93653 Comprehensive electrophysiologic evaluation including insertion and $853 NA 14.75 APC 5213 $21,464 02583ZZ repositioning of multiple electrode catheters with induction or attempted 24.44 4A0234Z induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary) and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow Not covered atrioventricular pathway, accessory atrioventricular connection, cavo‐tricuspid for ASC isthmus or other single atrial focus or source of atrial re‐entry payment.

93654 Comprehensive electrophysiologic evaluation including insertion and $1,141 NA 19.75 9365426 repositioning of multiple electrode catheters with induction or attempted 32.71 induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary) and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 16 of 71 Pages Rhythm Management 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ 4 6 + Signifies Add‐on Code OUTPATIENT INPATIENT

Intracardiac Electrophysiology Procedures/Studies continued go to APC list go to ICD‐10‐PCS list +93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which $434 NA 7.50 02583ZZ Percutaneous Intracardiac Procedures Status N, items and 9365526 is distinct from the primary ablated mechanism, including repeat diagnostic 12.44 4A0234Z MS‐DRG 273 with MCC $24,663 Not covered services packaged into 93655 maneuvers, to treat a spontaneous or induced arrhythmia (List separately in MS‐DRG 274 without MCC $21,117 for ASC primary procedure APC addition to code for primary procedure) payment. rate. No separate payment.

93656 Comprehensive electrophysiologic evaluation including transseptal $1,145 NA 19.77 APC 5213 $21,464 9365626 catheterizations, insertion and repositioning of multiple electrode catheters 32.82 with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation

+93657 Additional linear or focal intracardiac catheter ablation of the left or right $434 NA 7.50 NA 02563ZZ 93657 atrium for treatment of atrial fibrillation remaining after completion of 12.43 02573ZZ pulmonary vein isolation (List separately in addition to code for primary procedure)

93660 Evaluation of cardiovascular function with tilt table evaluation, with $93 $93 1.89 APC 5723 $488 3E033KZ 9366026 continuous ECG monitoring and intermittent blood pressure monitoring, 2.66 3E043KZ with or without pharmacological intervention 4A12XFZ

+93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, $115 $115 1.44 NA B244ZZ3 ICD‐10‐PCS procedure code does not impact MS‐DRG 9366226 including imaging supervision and interpretation (list separately in addition 3.30 B245ZZ3 93662 to code for primary procedure) B246ZZ3 B24BZZ3 B24DZZ3

Note: Some of the codes presented above may be used to code for a variety of procedures (diagnostic and therapeutic) employed in the field of electrophysiology, including atrial fibrillation, atrial flutter, AV Node, SVT and VT ablations.

1 Current Procedural Terminology (CPT) © 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. https://www.cms.gov/medicaremedicare‐fee‐service‐paymentphysicianfeeschedpfs‐federal‐regulation‐ 2 Source: CMS website. Physician Fee Schedule – 2021 National Physician Fee Schedule Relative Value File: notices/cms‐1734‐f https://www.cms.gov/medicaremedicare‐fee‐service‐paymentascpaymentasc‐regulations‐and‐ 3 Source: CMS website. ASC Addenda Updates: notices/cms‐1736‐fc https://www.cms.gov/medicaremedicare‐fee‐service‐paymenthospitaloutpatientppshospital‐outpatient‐ 4 Source: CMS website. 2021 OPPS Addendum B: regulations‐and‐notices/cms‐1736‐fc

Peripheral Interventions (print page range: 30‐50) https://www.cms.gov/icd10m/version38‐fullcode‐cms/fullcode_cms/P0001.html https://www.cms.gov/medicare/acute‐inpatient‐pps/fy‐2021‐ipps‐final‐rule‐home‐page 6 Source: Data tables (FY2021 IPPS Final Rule). CMS Website. National average (wage index greater than one) MS‐ DRG rates calculated using the national adjusted full update standardized labor, non‐labor and capital amounts. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic differences in labor and non‐labor costs, hospital teaching status, and/or proportion of low‐income patients).

7 Total RVU is the relative value unit total for In‐Facility calculation. For codes 93279‐93284, 93260, 93285‐93289, 93261, and 93290‐93299 Total RVUs represent In‐office total RVUs.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 18 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment 26 Diagnostic Cardiac Catheterization (Use physician modifier -26 as appropriate) go to APC list go to ICD‐10‐PCS list 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac $133 #N/A $1,411 APC 5191 $2,899 4A023N6 Cardiac valve and other major cardiothoracic procedures with cardiac right output, when performed 3.81 4A020N6 catheterization 9345126 X4A0T MS‐DRG 216 with MCC $67,039 93530 Right heart catheterization, for congenital cardiac anomalies $204 3.97 MS‐DRG 217 with CC $41,732 right 5.85 MS‐DRG 218 without CC/MCC $33,057 9353026 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, $240 4.50 $1,411 4A023N7 Cardiac defibrillator implant with cardiac catheterization with left imaging supervision and interpretation, when performed 6.88 4A020N7 AMI/HF/Shock 9345226 MS‐DRG 222 with MCC6 $54,126 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical $215 3.73 $0 Status N, items and 6 $39,928 puncture (List separately in addition to code for primary procedure) services packaged into MS‐DRG 223 without MCC left 6.15 primary procedure APC rate. No separate 9346226 Cardiac defibrillator implant with cardiac catheterization without payment. AMI/HF/Shock 93453 Combined right heart catheterization and left heart catheterization including $322 5.99 $1,411 APC 5191 $2,899 4A023N8 6 combined intraprocedural injection(s) for left ventriculography, imaging supervision and 9.22 4A020N8 MS‐DRG 224 with MCC $47,320 9345326 interpretation, when performed 6 MS‐DRG 225 without MCC $36,166 93531 Combined right heart catheterization and retrograde left heart catheterization, for $427 8.34 combined congenital cardiac anomalies 12.23 Coronary bypass with cardiac catheterization 9353126 MS‐DRG 233 with MCC $50,087 93532 Combined right heart catheterization and transseptal left heart catheterization through $536 9.99 MS‐DRG 234 without MCC $34,177 combined intact septum, with or without retrograde left heart catheterization, for congenital cardiac 15.35 9353226 anomalies Circulatory disorders except AMI with cardiac catheterization 93533 Combined right heart catheterization and transseptal left heart catheterization through $358 6.69 combined existing septal opening, with or without retrograde left heart catheterization, for 10.27 MS‐DRG 286 with MCC $14,231 9353326 congenital cardiac anomalies) MS‐DRG 287 without MCC $7,392

Atherosclerosis MS‐DRG 302 with MCC $7,028 MS‐DRG 303 without MCC $4,348

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 19 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment 26 Diagnostic Cardiac Catheterization (Use physician modifier -26 as appropriate) go to APC list go to ICD‐10‐PCS list 93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $243 4.54 $1,411 APC 5191 $2,899 B21 _ _ ZZ Cardiac valve and other major cardiothoracic procedures with cardiac placement injection(s) for coronary angiography, imaging S&I 6.97 catheterization 93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $283 5.29 $1,411 MS‐DRG 216 with MCC $67,039 placement injection(s) for coronary angiography, imaging supervision and interpretation; with catheter 8.12 MS‐DRG 217 with CC $41,732 9345526 placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including MS‐DRG 218 without CC/MCC $33,057 intraprocedural injection(s) for bypass graft angiography Cardiac defibrillator implant with cardiac catheterization with 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $316 5.90 $1,411 AMI/HF/Shock 6 placement injection(s) for coronary angiography, imaging supervision and interpretation; with right heart 9.07 MS‐DRG 222 with MCC $54,126 9345626 catheterization MS‐DRG 223 without MCC6 $39,928 93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $356 6.64 $1,411 placement injection(s) for coronary angiography, imaging supervision and interpretation; with catheter 10.21 9345726 placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including Cardiac defibrillator implant with cardiac catheterization without intraprocedural injection(s) for bypass graft angiography and right heart catheterization AMI/HF/Shock MS‐DRG 224 with MCC6 $47,320 93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $299 5.60 $1,411 MS‐DRG 225 without MCC6 $36,166 placement injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 8.58 9345826 catheterization including intraprocedural injection(s) for left ventriculography, when performed Coronary bypass with cardiac catheterization

93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $340 6.35 $1,411 MS‐DRG 233 with MCC $50,087 placement injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 9.74 MS‐DRG 234 without MCC $34,177 9345926 catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with Circulatory disorders except AMI with cardiac catheterization bypass graft angiography MS‐DRG 286 with MCC $14,231 MS‐DRG 287 without MCC $7,392 93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $381 7.10 $1,411 placement injection(s) for coronary angiography, imaging supervision and interpretation; with right and left 10.91 Atherosclerosis heart catheterization including intraprocedural injection(s) for left ventriculography, when MS‐DRG 302 with MCC $7,028 performed MS‐DRG 303 without MCC $4,348 9346026 93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural $420 7.85 $1,411 placement injection(s) for coronary angiography, imaging supervision and interpretation; with right and left 12.04 heart catheterization including intraprocedural injection(s) for left ventriculography, when 9346126 performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 20 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Injection Diagnostic Cardiac Catheterization (Each site may be injected multiple times, only report each code once) go to APC list go to ICD‐10‐PCS list +93563 Injection procedure during cardiac catheterization including imaging supervision, interpretation, $58 1.11 3E053KZ and report; for selective coronary angiography during congenital heart catheterization (List 93563 1.67 3E063KZ separately in addition to code for primary procedure)

+93564 Injection procedure during cardiac catheterization including imaging supervision and $62 1.13 3E053KZ 93564 interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass 1.77 3E063KZ graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure) Status N, items and services packaged into Injection procedure during cardiac catheterization including imaging supervision and 7 +93565 $45 0.86 primary procedure APC 3E073KZ NA 93565 interpretation, and report; for selective left ventricular or left arterial angiography (List 1.3rate. No separate 3E083KZ separately in addition to code for primary procedure) payment. +93566 Injection procedure during cardiac catheterization including imaging supervision and $46 0.86 93566 interpretation, and report; for selective right ventricular or right atrial angiography (List 1.32 separately in addition to code for primary procedure)

+93567 Injection procedure during cardiac catheterization including imaging supervision and $53 0.97 3E053KZ 93567 interpretation, and report; for supravalvular aortography (List separately in addition to code for 1.52 3E063KZ primary procedure) +93568 Injection procedure during cardiac catheterization including imaging supervision and $49 0.88 93568 interpretation, and report; for pulmonary angiography (List separately in addition to code for 1.39 primary procedure) 26 Miscellaneous +93463 Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of $99 2.00 3E073KZ 93463 nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic 2.85Status N, items and 3E083KZ measurements before, during, after and repeat pharmacologic agent administration, when services packaged into performed (List separately in addition to code for primary procedure) primary procedure APC NA8 rate. No separate +93464 Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic $89 1.80 4A1335C payment. 9346426 measurements before and after (List separately in addition to code for primary procedure) 2.55 93464

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 21 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Coronary Angioplasty (PTCA), without stent go to APC list go to ICD‐10‐PCS list 92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch $539 9.85 $3,067 APC 5192 $4,957 027_3ZZ Percutaneous cardiovascular procedures without coronary artery stent 15.45 027_3Z6 +92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major $0 0.00 $0 NA MS‐DRG 250 with MCC $16,215 92921 coronary artery (list separately in addition to code for primary procedure) 0.00 MS‐DRG 251 without MCC $10,668

Coronary Atherectomy, without stent 92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when $643 11.74 APC 5193 $10,043 02C_3ZZ Percutaneous cardiovascular procedures without coronary artery stent performed; single major coronary artery or branch 18.42 02C_3Z6 +92925 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when $0 0.00 NA MS‐DRG 250 with MCC $16,215 92925 performed; each additional branch of a major coronary artery (list separately in addition to 0.00 MS‐DRG 251 without MCC $10,668 code for primary procedure) Bare Metal Coronary Stent with Angioplasty 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty $600 10.96 $5,997 APC 5193 $10,043 027_3_Z when performed; single major coronary artery or branch 17.19 027_3_6 Percutaneous cardiovascular procedures with non‐drug‐eluting stent MS‐DRG 248 with MCC $20,400 +92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty $0 0.00 $0 NA MS‐DRG 249 without MCC $12,079 92929 when performed; each additional branch of a major coronary artery (list separately in 0.00 addition to code for primary procedure) Drug-Eluting Coronary Stent with Angioplasty C9600 Percutaneous transcatheter placement of drug‐eluting intracoronary stent(s), with $6,276 APC 5193 $10,043 027_3_Z Percutaneous cardiovascular procedures with drug‐ eluting stent coronary angioplasty when performed; single major coronary artery or branch 027_3_6 NA MS‐DRG 246 with MCC $20,090 Physicians use codes +C9601 Percutaneous transcatheter placement of drug‐eluting intracoronary stent(s), with $0 NA MS‐DRG 247 without MCC $12,779 92928/+92929 C9601 coronary angioplasty when performed; each additional branch of major coronary artery

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 22 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Bare Metal Coronary Stent with Atherectomy go to APC list go to ICD‐10‐PCS list 92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary $673 12.29 APC 5194 $16,064 027_3_Z angioplasty when performed; single major coronary artery or branch 19.30 027_3_6 Percutaneous cardiovascular procedures with non‐drug‐ eluting stent 02C_3Z_ MS‐DRG 248 with MCC $20,400 +92934 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary $0 0.00 NA MS‐DRG 249 without MCC $12,079 92934 angioplasty when performed; each additional branch of a major coronary artery (list 0.00 separately in addition to code for primary procedure

Drug-Eluting Coronary Stent with Atherectomy C9602 Percutaneous transluminal coronary atherectomy, with drug‐eluting intracoronary stent, $11,371 APC 5194 $16,064 027_3_Z Percutaneous cardiovascular procedures with drug‐ eluting stent 027_3_6 with coronary angioplasty when performed; single major coronary artery or branch NA 02C_3Z_ MS‐DRG 246 with MCC $20,090 Physicians use codes +C9603 Percutaneous transluminal coronary atherectomy, with drug‐eluting intracoronary stent, $0 NA MS‐DRG 247 without MCC $12,779 92933/+92934 with coronary angioplasty when performed; each additional branch of a major coronary artery Bare Metal Stent - Bypass Graft Revascularization 92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft $599 10.95 APC 5193 $10,043 027_3_Z (internal mammary, free arterial, venous), any combination of intracoronary stent, 17.17 027_3_6 Percutaneous cardiovascular procedures with non‐drug‐ eluting stent atherectomy and angioplasty, including distal protection when performed; single vessel 02C_3Z_ MS‐DRG 248 with MCC $20,400 MS‐DRG 249 without MCC $12,079 +92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft $0 0.00 NA 92938 (internal mammary, free arterial, venous), any combination of intracoronary stent, 0.00 atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) Drug-Eluting Stent - Bypass Graft Revascularization C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal $6,398 APC 5193 $10,043 027_3_Z Percutaneous cardiovascular procedures with drug‐ eluting stent mammary, free arterial, venous), any combination of drug‐eluting intracoronary stent, 027_3_6 atherectomy and angioplasty, including distal protection when performed; single vessel 02C_3Z_ MS‐DRG 246 with MCC $20,090 NA MS‐DRG 247 without MCC $12,779 +C9605 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal Physicians use codes $0 NA mammary, free arterial, venous), any combination of drug‐eluting intracoronary stent, 92937/+92938 atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 23 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment

Bare Metal Stent - Chronic Total Occlusion Revascularization go to APC list go to ICD‐10‐PCS list 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, $674 12.31 027_3_Z coronary artery branch, or coronary artery bypass graft, any combination of intracoronary APC 5193 $10,043 stent, atherectomy and angioplasty; single vessel 19.33 027_3_6 Percutaneous cardiovascular procedures with non‐drug‐eluting stent 02C_3Z_ MS‐DRG 248 with MCC $20,400 MS‐DRG 249 without MCC $12,079 +92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, $0 0.00 NA 92944 coronary artery branch, or coronary artery bypass graft, any combination of intracoronary 0.00 stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure)

Drug-Eluting Stent - Chronic Total Occlusion Revascularization C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, $11,286 APC 5194 $16,064 027_3_Z coronary artery branch, or coronary artery bypass graft, any combination of drug‐eluting 027_3_6 Percutaneous cardiovascular procedures with drug‐eluting stent intracoronary stent, atherectomy and angioplasty; single vessel 02C_3Z_ MS‐DRG 246 with MCC $20,090 NA MS‐DRG 247 without MCC $12,779 +C9608 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, Physicians use codes $0 NA coronary artery branch, or coronary artery bypass graft, any combination of drug‐eluting 92943/+92944 intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft

BSC currently has no stents FDA‐approved for CTOs

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 24 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment 26 Intravascular Ultrasound (Use physician modifier -26 as appropriate) go to APC list go to ICD‐10‐PCS list +92978 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical $97 1.80 B240ZZ3 Coronary bypass with PTCA coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention MS‐DRG 231 with MCC $54,570 92978 2.77Status N, items and B241ZZ3 9297826 including imaging supervision, interpretation and report; initial vessel (List separately in addition MS‐DRG 232 without MCC $37,911 services packaged into to code for primary procedure) primary procedure APC +92979 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or $77 1.44 rate. No separate 92979 optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic 2.20 Percutaneous cardiovascular procedure with drug‐eluting stent payment. 9297926 intervention including imaging supervision, interpretation and report; each additional MS‐DRG 246 with MCC or 4+ vessels/stents vessel (List separately in addition to code for primary procedure) $20,090 Fractional Flow Reserve (FFR) (Use physician modifier -26 as appropriate) MS‐DRG 247 without MCC $12,779 +93571 Intravascular Doppler velocity and/or pressure derived coronary flow reserve $74 1.38 $0 4A033BC 93571 measurement (coronary vessel or graft) during coronary angiography including 2.12 Percutaneous cardiovascular procedure with non‐drug‐ eluting stent 9357126 pharmacologically induced stress; initial vessel (List separately in addition to code for Status N, items and primary procedure) services packaged into +93572 Intravascular Doppler velocity and/or pressure derived coronary flow reserve $54 1.00 $0 primary procedure APC MS‐DRG 248 with MCC or 4+ vessels/stents $20,400 93572 measurement (coronary vessel or graft) during coronary angiography including 1.54 rate. No separate MS‐DRG 249 without MCC $12,079 9357226 pharmacologically induced stress; each additional vessel (List separately in addition to payment. code for primary procedure) Percutaneous cardiovascular procedure without coronary artery stent MS‐DRG 250 with MCC $16,215 MS‐DRG 251 without MCC $10,668

Circulatory disorders except AMI, with cardiac catheterization

MS‐DRG 286 with MCC $14,231 MS‐DRG 287 without MCC $7,392 Thrombectomy go to APC list go to ICD‐10‐PCS list +92973 Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition $180 3.28 NA 02C_3Z_ Percutaneous cardiovascular procedure with drug‐eluting stent 92973 to code for primary procedure) 5.16 92973 MS‐DRG 246 with MCC or 4+ vessels/stents $20,090 MS‐DRG 247 without MCC $12,779

Percutaneous cardiovascular procedure with non‐drug‐ eluting stent

MS‐DRG 248 with MCC or 4+ vessels/stents $20,400 MS‐DRG 249 without MCC $12,079

Percutaneous cardiovascular procedure without coronary artery stent

MS‐DRG 250 with MCC $16,215 MS‐DRG 251 without MCC $10,668 CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 25 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Moderate (Conscious) Sedation go to APC list go to ICD‐10‐PCS list 99151 Moderate sedation service performed by the same Physician or other qualified health care $25 0.50 99151 professional performing the diagnostic or therapeutic service that the sedition supports, 0.73 requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of 99152 Moderate sedation service performedh by the samef Physician or other qualified health care $13 0.25 99152 professional performing the diagnostic or therapeutic service that the sedation supports, 0.36 requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient 5 years or older

99153 Moderate sedation service performed by the same Physician or other qualified health care NA 0.00 99153 professional performing the diagnostic or therapeutic service that the sedation supports, NA requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time (List separately in addition to code for primary service) NA NA7

99155 Moderate sedation service provided by a physician or other qualified health care $85 1.90 professional other than the physician or other qualified health care professional 99155 2.43 performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age

99156 Moderate sedation service provided by a physician or other qualified health care $77 1.65 99156 professional other than the physician or other qualified health care professional 2.22 performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older

99157 Moderate sedation service provided by a physician or other qualified health care $64 1.25 99157 professional other than the physician or other qualified health care professional 1.83 performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time (List separately in addition to code for primary service)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 26 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Percutaneous Balloon Valvuloplasty; Aortic Valve go to APC list go to ICD‐10‐PCS list 92986 Percutaneous balloon valvuloplasty; aortic valve $1,342 22.60 5192 $4,957 027F3ZZ Percutaneous Intracardiac Procedures 92986 39.04 027F4ZZ MS‐DRG 273 with MCC $24,663 92987 Percutaneous balloon valvuloplasty; mitral valve $1,387 23.38 5193 $10,043 027G3ZZ MS‐DRG 274 without MCC $21,117 92987 40.32 027G4ZZ 92990 Percutaneous balloon valvuloplasty; pulmonary valve $1,107 18.27 5193 $10,043 027H3ZZ 92990 32.21 027H4ZZ Endovascular or Transthoracic Valves go to APC list go to ICD‐10‐PCS list 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous $1,233 22.47 02RF37Z Endovascular Cardiac Valve Replacement Aortic femoral artery approach 35.34 02RF38Z MS‐DRG 266 with MCC $45,617 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral $1,343 24.54 02RF3JZ MS‐DRG 267 without MCC $35,999 Aortic artery approach 38.50 02RF3KZ 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary $1,393 25.47 Aortic artery approach 39.93 33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery $1,394 25.97 Aortic approach 39.95 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic $1,452 26.59 Aortic approach (e.g., median sternotomy, mediastinotomy) 41.62 33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical $1,602 29.35 NA 02RF3JH Aortic exposure (eg, left thoracotomy) 45.90 Inpatient Only +33367 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $640 11.88 Procedure. 02RF3_Z Aortic cardiopulmonary bypass support with percutaneous peripheral arterial and venous 18.35 5A1221Z 33367 cannulation (e.g., femoral vessels) (list separately in addition to code for primary procedure) +33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $756 14.39 02RF0_Z Aortic cardiopulmonary bypass support with open peripheral arterial and venous cannulation 21.66 5A1221Z 33368 (e.g., femoral, iliac, axillary vessels) (list separately in addition to code for primary procedure) +33369 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $998 19.00 02RF3JZ Aortic cardiopulmonary bypass support with central arterial and venous cannulation (e.g., aorta, 28.60 5A1221Z 33369 right atrium, pulmonary artery) (list separately in addition to code for primary procedure)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 27 of 71 Pages Select Coronary Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │ Outpatient and ASC information effective through December 31, 2021 │ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the 2021 conversion factor of $34.89 HOSPITAL HOSPITAL *PHYSICIAN² ASC³ OUTPATIENT INPATIENT CPT® Work RVU ASC APC APC Possible Possible CPT Descriptions In‐Hospital2 MS‐DRG Payment5,6 Code¹ Total RVU9 Payment³ Category Payment3 ICD‐10‐PCS Codes4 MS‐DRG Assignment Endovascular or Transthoracic Valves continued go to APC list go to ICD‐10‐PCS list 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre‐ $1,381 25.00 02RH3_Z Endovascular Cardiac Valve Replacement Pulmonary stenting of the valve delivery site, when performed 39.58 33999 Unlisted procedure, cardiac surgery Carrier 0.00 02RH3_H MS‐DRG 266 with MCC $45,617 priced 0.00 NA MS‐DRG 267 without MCC $35,999 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture $1,832 32.25 Inpatient Only 02UG3JZ Percutaneous Intracardiac Procedures when performed; initial prosthesis 52.51 Procedure. MS‐DRG 228 with MCC $39,948 +33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture $433 7.93 MS‐DRG 229 without MCC $25,633 when performed; additional prosthesis(es) during same session (List separately in addition 12.40 33419 to code for primary procedure) TM WATCHMAN Left Atrial Appendage Closure (LAAC) Procedure go to APC list 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, $805 14.00 02L73DK Percutaneous Intracardiac Procedures NA including fluoroscopy, transseptal puncture, catheter placement(s),left atrial angiography, 23.06 MS‐DRG 273 with MCC $24,663 Inpatient Only 33340 left atrial appendage angiography, when performed, and radiological supervision and MS‐DRG 274 without MCC $21,117 Procedure. interpretation WATCHMAN is a registered or unregistered trademark of Boston Scientific Corporation. All other trademarks are the property of their respective owners.

1 Current Procedural Terminology (CPT) © 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. https://www.cms.gov/medicaremedicare‐fee‐service‐paymentphysicianfeeschedpfs‐federal‐regulation‐ 2 Source: CMS website. Physician Fee Schedule – 2021 National Physician Fee Schedule Relative Value File: notices/cms‐1734‐f https://www.cms.gov/medicaremedicare‐fee‐service‐paymentascpaymentasc‐regulations‐and‐notices/cms‐1736‐ 3 Source: CMS website. ASC Addenda Updates: fc https://www.cms.gov/medicaremedicare‐fee‐service‐paymenthospitaloutpatientppshospital‐outpatient‐ 4 Source: CMS website. 2021 OPPS Addendum B: regulations‐and‐notices/cms‐1736‐fc https://www.cms.gov/icd10m/version38‐fullcode‐cms/fullcode_cms/P0001.html 5 Source: CMS ICD‐10‐CM/PCS MS‐DRG v38 Definitions Manual https://www.cms.gov/medicare/acute‐inpatient‐pps/fy‐2021‐ipps‐final‐rule‐home‐page

6 Source: Data tables (FY2021 IPPS Final Rule). CMS Website. National average (wage index greater than one) MS‐ DRG rates calculated using the national adjusted full update standardized labor, non‐labor and capital amounts. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic differences in labor and non‐labor costs, hospital teaching status, and/or proportion of low‐income patients).

9 Total RVU is the relative value unit total for In‐Facility calculation

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 29 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

Transluminal Balloon Angioplasty go to APC list go to ICD‐10‐PCS list 37246 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, $352 $2,078 7.00 $2,167 APC 5192 $4,957 027_3ZZ Other vascular procedures intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and X6A0T 10.08 037_3ZZ MS‐DRG 252 w MCC 252 $21,344 radiological supervision and interpretation necessary to perform the angioplasty within the same 037_3Z6 MS‐DRG 253 w CC 253 $17,056 artery; initial artery 047_3ZZ MS‐DRG 254 wo CC 254 $11,630 37247 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, $172 $647 3.50 047_3Z6 Status N, items and services intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and 4.93 Status N1 packaged into primary radiological supervision and interpretation necessary to perform the angioplasty within the same No separate procedure APC rate. No artery; each additional artery (List separately in addition to code for primary procedure) payment. separate payment.

37248 Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging $300 $1,540 6.00 $2,167 APC 5192 $4,957 and radiological supervision and interpretation necessary to perform the angioplasty within the same 8.61 vein; initial vein 027_3ZZ 37249 Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging $147 $516 2.97 Status N, items and services 057_3ZZ and radiological supervision and interpretation necessary to perform the angioplasty within the same 4.21 Status N1 packaged into primary 067_3ZZ vein; each additional vein (List separately in addition to code for primary procedure) No separate procedure APC rate. No payment. separate payment. Iliac Artery Revascularization 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with $407 $2,925 7.90 $2,167 APC 5192 $4,957 047_3ZZ Other vascular procedures transluminal angioplasty 11.65 047_3Z6 MS‐DRG 252 w MCC 252 $21,344 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with $501 $3,793 9.75 $6,247 APC 5193 $10,043 047_3DZ MS‐DRG 253 w CC 253 $17,056 transluminal stent placement(s), includes angioplasty within same vessel, when performed 14.37 047_3D6 MS‐DRG 254 wo CC 254 $11,630

37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac $188 $722 3.73 047_3ZZ vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) 5.38 047_3Z6 Status N, items and services Status N1 packaged into primary No separate 37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac $216 $1,718 4.25 procedure APC rate. No 047_3DZ payment. vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 6.19separate payment. 047_3D6 performed (List separately in addition to code for primary procedure)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 30 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Femoral/Popliteal Artery Revascularization go to APC list go to ICD‐10‐PCS list 37224 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with $452 $3,459 8.75 $3,081 APC 5192 $4,957 047_3ZZ Other vascular procedures transluminal angioplasty 12.94 047_3Z6 MS‐DRG 252 w MCC 252 $21,344 047_3Z1 MS‐DRG 253 w CC 253 $17,056 37225 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with $611 $10,957 11.75 $6,763 APC 5193 $10,043 047_3ZZ MS‐DRG 254 wo CC 254 $11,630 atherectomy, includes angioplasty within the same vessel, when performed 17.52 047_3Z6 047_3Z1 37226 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with $528 $9,969 10.24 $6,540 APC 5193 $10,043 047_3_1 transluminal stent placement(s), includes angioplasty within the same vessel, when performed 15.13 047_3_6 047_3_Z X27_3_5 37227 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with $732 $14,044 14.25 $11,301 APC 5194 $16,064 047_3_1 transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when 20.99 047_3_6 performed 047_3_Z 04C_3ZZ

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 31 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Tibial/Peroneal Artery Revascularization go to APC list go to ICD‐10‐PCS list 37228 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial $550 $4,953 10.75 $5,822 APC 5193 $10,043 047_3ZZ Other vascular procedures vessel; with transluminal angioplasty 15.75 047_3Z6 MS‐DRG 252 w MCC 252 $21,344 047_3Z1 MS‐DRG 253 w CC 253 $17,056 37229 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial $708 $11,021 13.80 $10,556 APC 5194 $16,064 04C_3ZZ MS‐DRG 254 wo CC 254 $11,630 vessel; with atherectomy, includes angioplasty within the same vessel, when performed 20.29 047_3Z6 047_3Z1 37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial $707 $10,485 13.55 $10,408 APC 5194 $16,064 047_3_1 vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 20.27 047_3_6 performed 047_3_Z

37231 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial $761 $14,091 14.75 $10,592 APC 5194 $16,064 047_3_1 vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same 21.81 047_3_6 vessel, when performed 047_3_Z 04C_3Z6 37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each $202 $989 4.00 047_3ZZ Other vascular procedures additional vessel; with transluminal angioplasty. (List separately in addition to code for primary 5.80 047_3Z6 MS‐DRG 252 w MCC 252 $21,344 procedure) 047_3Z1 MS‐DRG 253 w CC 253 $17,056 047_3Z6 MS‐DRG 254 wo CC 254 $11,630 37233 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each $330 $1,220 6.50 047_3ZZ additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed. 9.46 047_3Z6 (List separately in addition to code for primary procedure) 047_3Z1 Status N, items and services 047_3Z6 Status N1 packaged into primary 047_3ZZ No separate 37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each $290 $4,132 5.50 procedure APC rate. No 047_3_1 payment. additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, 8.30separate payment. 047_3_6 when performed. (List separately in addition to code for primary procedure) 047_3_Z

37235 Revascularization, endovascular, open or percutaneous, tibial\peroneal artery, unilateral, each $400 $4,391 7.80 047_3_1 additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within 11.46 047_3_6 the same vessel, when performed. (List separately in addition to code for primary procedure 047_3_Z 04C_3Z6 04C_3ZZ

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 32 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Transcatheter Placement of Intravascular Stents (Peripheral stenting is covered at local Medicare contractor discretion. Payment amounts assume procedure is covered) go to APC list go to ICD‐10‐PCS list 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, $449 $3,318 8.75 $6,133 APC 5193 $10,043 027_3_Z Other vascular procedures extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, 12.88 027_3_6 MS‐DRG 252 w MCC 252 $21,344 including radiological supervision and interpretation and including all angioplasty within the same 037_3_Z MS‐DRG 253 w CC 253 $17,056 vessel, when performed; initial artery 037_3_6 MS‐DRG 254 wo CC 254 $11,630 047_3_Z 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, $214 $1,691 4.25 027_3_Z extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, 6.13Status N, items and services 027_3_6 Status N1 including radiological supervision and interpretation and including all angioplasty within the same packaged into primary 037_3_Z No separate 037_3_6 vessel, when performed; each additional artery (List separately in addition to code for primary procedure APC rate. No payment. 047_3_Z procedure) separate payment. 047_3_6

37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological $312 $3,977 6.04 $6,267 APC 5193 $10,043 supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein 8.93

027_3DZ 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological $154 $1,990 2.97 057_3DZ supervision and interpretation and including angioplasty within the same vessel, when performed; Status N, items and services 067_3DZ 4.42 Status N1 each additional vein (List separately in addition to code for primary procedure) packaged into primary No separate procedure APC rate. No payment. separate payment.

BSC currently has no stent approved for use in the veins of the lower extremities Transcatheter Placement of Carotid Stents with embolic protection (Boston Scientific's carotid WALLSTENT® Monorail® Endoprosthesis device is indicated for carotid artery stenting with embolic protection only. Medicare will not consider payment for the procedure when performed without embolic protection.) 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, $1,014 N/A 17.75 Carotid artery stent procedure NA including angioplasty, when performed, and radiological supervision and interpretation; with distal 29.07 MS‐DRG 034 w MCC 34 $25,546 embolic protection. Inpatient only procedure. 037_3_Z MS‐DRG 035 w CC 35 $15,021 NA 37216 Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, $994 N/A 17.98 037_3_6 MS‐DRG 036 wo CC/MCC 36 $11,898 including angioplasty, when performed, and radiological supervision and interpretation; without NA distal embolic protection 28.49 Not covered by Medicare.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 33 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

Embolization go to APC list go to ICD‐10‐PCS list 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $438 $5,159 8.75 $4,285 APC 5193 $10,043 05L_3DZ Other major cardiovascular procedures intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, 12.55 06L_3DZ MS‐DRG 270 w MCC 270 $33,304 other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary MS‐DRG 271 w CC 271 $22,911 hemangiomas, varices, varicoceles) MS‐DRG 272 wo CC/MCC 272 $17,282

37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $481 $8,070 9.80 $6,366 APC 5193 $10,043 03L_3DZ Other vascular procedures intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, 13.79 04L_3DZ MS‐DRG 252 w MCC 252 $21,344 other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous MS‐DRG 253 w CC 253 $17,056 malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) MS‐DRG 254 wo CC 254 $11,630

37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $563 $9,933 11.74 $4,285 APC 5193 $10,043 03L_3DZ intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 16.14 04L_3DZ tumors, organ ischemia, or infarction 04LE3DT 04LF3DU 37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $668 $7,444 13.75 APC 5193 $10,043 03L_3DZ intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 19.15 04L_3DZ NA arterial or venous hemorrhage or lymphatic extravasation

Ultrasound Guidance 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, $14 $39 0.30 documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular Status N, items and services 7693726 needle entry, with permanent recording and reporting (List separately in addition to code for primary 0.40 Status N1 procedure) packaged into primary 7 No separate B_4_ZZA NA 76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation $103 NA 0.00 procedure APC rate. No payment. 7694026 2.94 separate payment. 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), $31 $59 0.67 7694226 imaging supervision and interpretation 0.90

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 34 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Catheter Access go to APC list go to ICD‐10‐PCS list 36005 Injection procedure for extremity venography (including introduction of needle or intracatheter) $49 $299 0.95 05H_33Z 1.40 06H_33Z 36010 Introduction of catheter, superior or inferior vena cava $111 $582 2.18 02HV33Z 3.19 06H033Z 36013 Introduction of catheter, right heart or main pulmonary artery $125 $862 2.52 Status N, items and services Status N1 02H_33Z 3.58 packaged into primary No separate NA 7 36140 Introduction of needle or intracatheter; extremity artery $91 $540 1.76 procedure APC rate. No 03H_33Z payment. 2.61 separate payment. 04H_33Z 36160 Introduction of needle or intracatheter, aortic, translumbar $125 $599 2.52 02H_33Z 3.58 36200 Introduction of catheter, aorta $141 $643 2.77 02HW33Z 4.05 02HX33Z Catheter Placement 36011 Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) $160 $912 3.14 4.59 05H_33Z 36012 Selective catheter placement, venous system; second order, or more selective, branch (eg, left $176 $927 3.51 06H_33Z adrenal vein, petrosal sinus) 5.04 36014 Selective catheter placement, left or right pulmonary artery $154 $883 3.02 4.41 02H_33Z 36015 Selective catheter placement, segmental or subsegmental pulmonary artery $173 $950 3.51 4.96 36215 Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, $215 $1,143 4.17 within a vascular family 6.15 36216 Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, $275 $1,193 5.27 Status N, items and services within a vascular family 7.88 Status N1 36217 Selective catheter placement, arterial system; initial third order or more selective thoracic or $332 $1,979 6.29 packaged into primary 03H_33Z 7 No separate NA procedure APC rate. No brachiocephalic branch, within a vascular family 9.52 payment. 36218 Selective catheter placement, arterial system; additional second order, third order, and beyond, $51 $227 1.01 separate payment. thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second 1.46 or third order vessel as appropriate) 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity $239 $1,400 4.65 artery branch, within a vascular family 6.84 36246 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower $257 $912 5.02 extremity artery branch, within a vascular family 7.36 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, $304 $1,589 6.04 04H_33Z or lower extremity artery branch, within a vascular family 8.72 36248 Selective catheter placement, arterial system; additional second order, third order, and beyond, $50 $134 1.01 abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code 1.42 for initial second or third order vessel)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 35 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

Catheter Placement (continued ) go to APC list go to ICD‐10‐PCS list 36251 Selective catheter placement (first‐order), main renal artery and any accessory renal artery(s) for $261 $1,452 5.10 APC 5183 $2,862 renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast 7.47 injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram when performed; unilateral

36252 Selective catheter placement (first‐order), main renal artery and any accessory renal artery(s) for $365 $1,566 6.74 APC 5183 $2,862 renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast 10.45 injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram 04H933Z when performed; bilateral Status N1 04HA33Z No separate B416_ZZ NA 7 36253 Superselective catheter placement (one or more second order or higher renal artery branches), renal $358 $2,277 7.30 payment. APC 5184 $4,770 B417_ZZ artery and any accessory renal artery(s) for renal angiography, including arterial puncture and 10.26 B418_ZZ catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram when performed; unilateral

36254 Superselective catheter placement (one or more second order or higher renal artery branches), renal $417 $2,236 7.90 APC 5183 $2,862 artery and any accessory renal artery(s) for renal angiography, including arterial puncture and 11.96 catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram when performed; bilateral

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 36 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

26 Angiography (Use physician modifier ‐26 as appropriate) go to APC list go to ICD‐10‐PCS list 73706 Computed tomographic angiography, lower extremity, with contrast material(s), including $92 $360 1.90 $91 APC 5571 $179 B42F_ZZ 7370626 noncontrast images, if performed, and image postprocessing 2.64 75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, $97 $169 2.00 APC 5183 $2,862 B4_D_ZZ 7563026 radiological supervision and interpretation 2.78 75710 Angiography, extremity, unilateral, radiological supervision and interpretation $85 $162 1.75 Status N1 APC 5183 $2,862 B3_ _ _ZZ 2.44 B4_ _ _ZZ 7571026 No separate 75716 Angiography, extremity, bilateral, radiological supervision and interpretation $95 $174 1.97 APC 5183 $2,862 B3_ _ _ZZ payment. 7571626 2.73 B4_ _ _ZZ 75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological $96 $181 2.05 APC 5184 $4,770 B40_ _ZZ 7572626 supervision and interpretation 2.76 B41_ _ZZ 75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation $56 $161 1.14 $99 APC 5183 $2,862 B40_ _ZZ 7573126 1.60 B41_ _ZZ 75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation $63 $177 1.31 APC 5183 $2,862 B40_ _ZZ NA 7 7573326 1.80 B41_ _ZZ 75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation $54 $149 1.14 APC 5184 $4,770 B40C_ZZ 7573626 1.54 B41C_ZZ 75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation $62 $140 1.31 APC 5183 $2,862 B30S_ZZ 7574126 1.78 Status N1 B31S_ZZ 75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation $79 $158 1.66 No separate APC 5183 $2,862 B30T_ZZ 7574326 2.26 payment. B31T_ZZ 75774 Angiography, selective, each additional vessel studied after basic examination, radiological $48 $106 1.01 B3_ _ _ZZ Status N, items and services supervision and interpretation (List separately in addition to code for primary procedure) 7577426 1.37packaged into primary B4_ _ _ZZ procedure APC rate. No separate payment.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 37 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment 26 Venography (Use physician modifier ‐26 as appropriate) go to APC list go to ICD‐10‐PCS list 75820 Venography, extremity, unilateral, radiological supervision and interpretation $52 $120 1.05 Status N1 APC 5182 $1,406 B50_ _ZZ 7582026 1.48 B51_ _ZZ 75822 Venography, extremity, bilateral, radiological supervision and interpretation $71 $144 1.48 $70 APC 5182 $1,406 B50_ _ZZ 7582226 2.04 B51_ _ZZ 75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation $55 $124 1.14 APC 5183 $2,862 B50_ _ZZ 7582526 1.58 B51_ _ZZ 75827 Venography, caval, superior, with serialography, radiological supervision and interpretation $55 $129 1.14 APC 5182 $1,406 B50_ _ZZ 7582726 1.59 B51_ _ZZ 75831 Venography, renal, unilateral, selective, radiological supervision and interpretation $53 $128 1.14 APC 5183 $2,862 B50J_ZZ B50K_ZZ 7583126 1.52 Status N1 75833 Venography, renal, bilateral, selective, radiological supervision and interpretation $71 $155 1.49 APC 5183 $2,862 B51J_ZZ No separate 2.04 B51K_ZZ 7583326 payment. 75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation $56 $138 1.14 APC 5183 $2,862 B50_ _ZZ 1.60 B51_ _ZZ 7584026 NA 7 75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation $73 $168 1.49 APC 5184 $4,770 B50_ _ZZ 7584226 2.09 B51_ _ZZ 75860 Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological $55 $136 1.14 APC 5183 $2,862 B50_ _ZZ 7586026 supervision and interpretation 1.59 B51_ _ZZ 75870 Venography, superior sagittal sinus, radiological supervision and interpretation $62 $177 1.14 $109 APC 5183 $2,862 B50_ _ZZ 7587026 1.78 B51_ _ZZ 75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and $67 $146 1.44 Status N1 APC 5183 $2,862 B50T_ZZ 7588526 interpretation 1.91 B51T_ _Z 75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision $67 $147 1.44 $76 APC 5183 $2,862 B50T_ZZ 7588726 and interpretation 1.93 B51T_ _Z 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and $52 $132 1.14 APC 5183 $2,862 Status N1 interpretation 1.50 7588926 No separate B51T_ _Z 75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and $53 $133 1.14 APC 5183 $2,862 payment. 7589126 interpretation 1.52 Vascular Imaging 78445 Non‐cardiac vascular flow imaging (ie, angiography, venography) $25 $210 0.49 $192 APC 5591 $377 C713YZZ 7844526 0.72 78456 Acute venous thrombosis imaging, peptide $49 $322 1.00 $663 APC 5593 $1,306 1.39 7845626 NA 7 78457 Venous thrombosis imaging, venogram; unilateral $38 $184 0.77 $249 APC 5592 $489 C51__ZZ 7845726 1.08 78458 Venous thrombosis imaging, venogram; bilateral $44 $211 0.90 $192 APC 5591 $377 7845826 1.27

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 38 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

Transhepatic Shunts (TIPS) go to APC list go to ICD‐10‐PCS list 37182 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic $822 N/A 16.97 06H43DZ Other vascular procedures 23.57NA 06H83DZ MS‐DRG 252 w MCC 252 $21,344 and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract NA Inpatient only 06183DY MS‐DRG 253 w CC 253 $17,056 formation/dilatation, stent placement and all associated imaging guidance and documentation) Inpatient only procedure. procedure. MS‐DRG 254 wo CC 254 $11,630

37183 Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic $376 $6,592 7.74 $2,929 APC 5192 $4,957 06H43DZ Pancreas, liver and shunt procedures and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract 10.79 06H83DZ MS‐DRG 405 w MCC 405 $36,832 recanulization/dilatation, stent placement and all associated imaging guidance and documentation) 06PY3DZ MS‐DRG 406 w CC 406 $18,492 06WY3DZ MS‐DRG 407 wo CC/MCC 407 $13,600 06183DY Dialysis Circuit 36901 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the $171 $756 3.36 $548 APC 5182 $1,406 Other vascular procedures dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all 4.89 necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow B30_ _ZZ MS‐DRG 252 w MCC 252 $21,344 including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and B31_ _ZZ MS‐DRG 253 w CC 253 $17,056 interpretation and image documentation and report MS‐DRG 254 wo CC 254 $11,630 36902 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the $243 $1,359 4.83 $2,167 APC 5192 $4,957 Other kidney and urinary tract procedures dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all 6.96 necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow MS‐DRG 673 w MCC 673 $22,259 including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and 037_3ZZ interpretation and image documentation and report; with transluminal balloon angioplasty, 067_3ZZ MS‐DRG 674 w CC 674 $15,300 peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty MS‐DRG 675 wo CC/MCC 675 $11,261

36903 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the $320 $5,152 6.39 $6,458 APC 5193 $10,043 Other vascular procedures 9.17 dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all MS‐DRG 252 w MCC 252 $21,344 necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and 037_3_Z MS‐DRG 253 w CC 253 $17,056 interpretation and image documentation and report; with transcatheter placement of intravascular 067_3DZ stent(s) peripheral dialysis segment, including all imaging and radiological supervision and MS‐DRG 254 wo CC 254 $11,630 interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 39 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Dialysis Circuit (continued ) go to APC list go to ICD‐10‐PCS list 36904 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis $373 $1,998 7.50 $2,167 APC 5192 $4,957 circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic 3E0_317 angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological 10.69 03C_3ZZ thrombolytic injection(s)

36905 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis $450 $2,553 9.00 $4,285 APC 5193 $10,043 circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic Other kidney and urinary tract procedures angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological 12.89 3E0_317 MS‐DRG 673 w MCC 673 $22,259 thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, 03C_3ZZ including all imaging and radiological supervision and interpretation necessary to perform the MS‐DRG 674 w CC 674 $15,300 angioplasty MS‐DRG 675 wo CC/MCC 675 $11,261 36906 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis $518 $6,456 10.42 $10,679 APC 5194 $16,064 circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological 3E0_317 thrombolytic injection(s); with transcatheter placement of an intravascular stent(s), peripheral 14.85 03C_3ZZ dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit

36907 Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, $149 $690 3.00 Other vascular procedures including all imaging and radiological supervision and interpretation required to perform the 4.26 037_3ZZ MS‐DRG 252 w MCC 252 $21,344 angioplasty (List separately in addition to code for primary procedure) 067_3ZZ MS‐DRG 253 w CC 253 $17,056 MS‐DRG 254 wo CC 254 $11,630 Status N, items and services 36908 Transcatheter placement of an intravascular stent(s), central dialysis segment, performed through $210 $1,898 4.25 Status N1 packaged into primary Other kidney and urinary tract procedures dialysis circuit, including all imaging radiological supervision and interpretation required to perform No separate 037_3_Z 6.02 procedure APC rate. No the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for payment. 067_3DZ separate payment. MS‐DRG 673 w MCC 673 $22,259 primary procedure) 36909 Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory $204 $2,155 4.12 MS‐DRG 674 w CC 674 $15,300 veins), endovascular, including all imaging and radiological supervision and interpretation necessary 05L_3DZ 5.86 to complete the intervention (List separately in addition to code for primary procedure) 06L_3DZ MS‐DRG 675 wo CC/MCC 675 $11,261

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 40 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Arterial Mechanical Thrombectomy go to APC list go to ICD‐10‐PCS list 37184 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non‐intracranial, $437 $1,978 8.41 $6,652 APC 5193 $10,043 Other major cardiovascular procedures arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological 12.53 MS‐DRG 270 w MCC 270 $33,304 thrombolytic injection(s); initial vessel MS‐DRG 271 w CC 271 $22,911 MS‐DRG 272 wo CC/MCC 272 $17,282 37185 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non‐intracranial, $165 $566 3.28 arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological 4.74 3E0_317 thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List 03C_3ZZ separately in addition to code for primary mechanical thrombectomy procedure) Other vascular procedures Status N, items and services 03C_3Z6 04C_3ZZ MS‐DRG 252 w MCC 252 $21,344 Status N1 packaged into primary 04C_3Z6 MS‐DRG 253 w CC 253 $17,056 37186 Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, $248 $1,369 4.92 No separate procedure APC rate. No MS‐DRG 254 wo CC 254 $11,630 05C_3ZZ suction technique), noncoronary, non‐intracranial, arterial or arterial bypass graft, including 7.10 payment. separate payment. fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure)

Venous Mechanical Thrombectomy 37187 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural $397 $1,974 7.78 $6,553 APC 5193 $10,043 Other major cardiovascular procedures pharmacological thrombolytic injections and fluoroscopic guidance 11.39 MS‐DRG 270 w MCC 270 $33,304 MS‐DRG 271 w CC 271 $22,911 MS‐DRG 272 wo CC/MCC 272 $17,282 37188 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural $281 $1,693 5.46 $1,372 APC 5183 $2,862 05C_3ZZ pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent 8.06 Other vascular procedures day during course of thrombolytic therapy MS‐DRG 252 w MCC 252 $21,344 MS‐DRG 253 w CC 253 $17,056 MS‐DRG 254 wo CC 254 $11,630

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 41 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Ultrasound Assisted Thrombolysis go to APC list go to ICD‐10‐PCS list 37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary or intracranial, any $391 N/A 7.75 $2,381 APC 5184 $4,770 02F_3Z0 Other respiratory system O.R. procedures method, including radiological supervision and interpretation, initial treatment day 11.21 03F_3Z0 MS‐DRG 166 w MCC 166 $24,358 04F_3Z0 MS‐DRG 167 w CC 167 $11,961 3E05317 MS‐DRG 168 wo CC/MCC 168 $8,802 3E06317 37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological $342 N/A 6.81 $1,372 APC 5183 $2,862 02F_3Z0 supervision and interpretation, initial treatment day 9.80 05F_3Z0 06F_3Z0 Other vascular procedures 3E03317 MS‐DRG 252 w MCC 252 $21,344 3E04317 MS‐DRG 253 w CC 253 $17,056 37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, $235 N/A 4.75 $1,372 APC 5183 $2,862 02F_3Z0 MS‐DRG 254 wo CC 254 $11,630 including radiological supervision and interpretation, continued treatment on subsequent day during 6.74 03F_3Z0 course of thrombolytic therapy, including follow‐up catheter contrast injection, position change, or 04F_3Z0 exchange, when performed 05F_3Z0 37214 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, $124 N/A 2.49 $1,372 APC 5183 $2,862 06F_3Z0 including radiological supervision and interpretation, continued treatment on subsequent day during 3.56 3E0[2/3/4/5/6]317 course of thrombolytic therapy, including follow‐up catheter contrast injection, position change, or 0[2/3/4][P/Q]33Z exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method

Vena Cava Filters 37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel $225 $2,409 4.46 $3,384 APC 5184 $4,770 Other vascular procedures selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging 6.45 MS‐DRG 252 w MCC 252 $21,344 06H03DZ guidance (ultrasound and fluoroscopy), when performed MS‐DRG 253 w CC 253 $17,056 MS‐DRG 254 wo CC 254 $11,630 37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, $350 $1,410 7.10 $1,929 APC 5183 $2,862 10.02 vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and 06WY3DZ imaging guidance (ultrasound and fluoroscopy), when performed

37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, $351 $1,662 7.10 $1,372 APC 5183 $2,862 vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and 10.07 06PY3DZ imaging guidance (ultrasound and fluoroscopy), when performed

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 42 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Intravascular Ultrasound go to APC list go to ICD‐10‐PCS list 37252 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic $91 $1,151 1.80 Other vascular procedures intervention, including radiological supervision and interpretation; initial noncoronary vessel (List 2.61 MS‐DRG 252 w MCC 252 $21,344 Status N, items and services separately in addition to code for primary procedure) Status N1 B34_ZZ3 MS‐DRG 253 w CC 253 $17,056 packaged into primary No separate B44_ZZ3 37253 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic $72 $187 1.44 procedure APC rate. No MS‐DRG 254 wo CC 254 $11,630 intervention, including radiological supervision and interpretation; each additional noncoronary payment. B54_ZZ3 2.07 separate payment. vessel (List separately in addition to code for primary procedure)

Superficial Venous Disease 36465 Injection of non‐compounded foam sclerosant with ultrasound compression maneuvers to guide $121 $1,545 2.35 $871 APC 5054 $1,715 dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent Vein ligation & stripping 3.47 extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) MS‐DRG 263 263 $14,817 36466 Injection of non‐compounded foam sclerosant with ultrasound compression maneuvers to guide $157 $1,724 3.00 $871 APC 5054 $1,715 dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent 065_3ZZ truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg 4.49

36470 Injection of sclerosant; single incompetent vein (other than telangiectasia) $39 $118 0.75 $83 APC 5052 $346 1.12 36471 Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg $77 $207 1.50 $139 APC 5052 $346 2.20 Biliary Procedures Diagnostic 47531 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including $72 $443 1.30 APC 5341 $3,183 BF0_ _ZZ Disorders of the biliary tract imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and 2.05 BF1_ _ZZ MS‐DRG 444 w MCC 444 $10,726 interpretation; existing access Status N1 MS‐DRG 445 w CC 445 $6,921 MS‐DRG 446 wo CC 446 $5,246 No separate 47532 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including $215 $909 4.25 APC 5341 $3,183 BF0_ _ZZ payment. imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and 6.16 BF1_ _ZZ interpretation; new access (eg, percutaneous transhepatic cholangiogram)

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 43 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Drainage (Internal Stent/External Catheter) go to APC list go to ICD‐10‐PCS list 47533 Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when $267 $1,304 5.38 $1,413 APC 5341 $3,183 0F9_30Z Disorders of the biliary tract performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological 7.65 MS‐DRG 444 w MCC 444 $10,726 supervision and interpretation; external MS‐DRG 445 w CC 445 $6,921 MS‐DRG 446 wo CC 446 $5,246 47534 Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when $372 $1,446 7.60 $1,413 APC 5341 $3,183 0F9_30Z performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological 10.67 supervision and interpretation; internal‐external

47535 Conversion of external biliary drainage catheter to internal‐external biliary drainage catheter, $197 $1,008 3.95 $1,413 APC 5341 $3,183 0F2BX0Z percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, 5.64 fluoroscopy), and all associated radiological supervision and interpretation

47536 Exchange of biliary drainage catheter (eg, external, internal‐external, or conversion of internal‐ $133 $720 2.61 $1,413 APC 5341 $3,183 0F2BX0Z external to external only), percutaneous, including diagnostic cholangiography when performed, 3.80 imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

47537 Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (eg, with $97 $513 1.84 $411 APC 5301 $810 0FP_30Z concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging 2.77 guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

47538 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging $237 $4,398 4.75 $3,502 APC 5361 $5,060 0F7_3DZ guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter 6.80 removal(s) when performed, and all associated radiological supervision and interpretation; existing access 47539 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging $423 $4,824 8.75 $2,318 APC 5361 $5,060 0F7_3DZ guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter 12.12 removal(s) when performed, and all associated radiological supervision and interpretation; new access, without placement of separate biliary drainage catheter

47540 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging $442 $4,932 9.03 $3,415 APC 5361 $5,060 0F7_3DZ guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter 12.67 0F9_30Z removal(s) when performed, and all associated radiological supervision and interpretation; new access, with placement of separate biliary drainage catheter (eg, external or internal‐external)

47541 Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary $335 $1,277 6.75 $1,413 APC 5341 $3,183 0F7_3DZ procedure (eg, rendezvous procedure), percutaneous, including diagnostic cholangiography when 9.61 0F9_30Z performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation, new access

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 44 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment 26 Biliary Procedures Drainage (Internal Stent/External Catheter) continued go to APC list go to ICD‐10‐PCS list 47542 Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including imaging $137 $545 2.85 Disorders of the biliary tract guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, each duct 3.92 MS‐DRG 444 w MCC 444 $10,726 0F7_3DZ (List separately in addition to code for primary procedure) MS‐DRG 445 w CC 445 $6,921 MS‐DRG 446 wo CC 446 $5,246 47543 Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (eg, brush, forceps, and/or $145 $452 3.00 Status N, items and services needle), including imaging guidance (eg, fluoroscopy), and all associated radiological supervision and 4.15 Status N1 packaged into primary 0FB_3ZX interpretation, single or multiple (List separately in addition to code for primary procedure) No separate procedure APC rate. No payment. separate payment. 47544 Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction $157 $985 3.28 of calculi by any method (eg, mechanical, electrohydraulic, lithotripsy) when performed, imaging 4.51 guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation (List 0FC_3ZZ separately in addition to code for primary procedure)

49421 Insertion of tunneled intraperitoneal catheter for dialysis, open $234 N/A 4.21 $1,413 APC 5341 $3,183 0WHG03Z 6.70 49423 Exchange of previously placed abscess or cyst drainage catheter under radiological guidance $72 $650 1.46 $693 APC 5302 $1,625 0D2_X0Z (separate procedure) 2.05 0W2_X0Z 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary $39 $106 0.83 Status N, items and services system, abscess), radiological supervision and interpretation 7598426 1.11 packaged into primary BF1_ _ZZ N/A 7 procedure APC rate. No separate payment. Biliary Stenting 47556 Biliary endoscopy, percutaneous via T‐tube or other tract; with dilation of biliary duct stricture(s) $376 N/A 8.55 $3,454 APC 5361 $5,060 Disorders of the biliary tract 10.77 MS‐DRG 444 w MCC 444 $10,726 4755626 with stent 0F7_4DZ MS‐DRG 445 w CC 445 $6,921 MS‐DRG 446 wo CC 446 $5,246 26 Radiological S&I Codes – Billed in Conjunction with Procedure Code (Use physician modifier ‐26 as appropriate) 74363 Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, $43 $0 0.00 NA Status N, items and services BF00_ZZ 7436326 radiological supervision and interpretation 1.23packaged into primary BF10_ZZ procedure APC BF12_ZZ N/A 7 rate. No separate payment.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 45 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Ablation Procedures go to APC list go to ICD‐10‐PCS list Renal 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy $462 $4,414 8.88 $5,686 APC 5362 $8,908 0T5_3ZZ Kidney and ureter procedures for neoplasm 13.23 MS‐DRG 656 w MCC 656 $21,093 50542 Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance $1,187 N/A 21.36 $3,813 APC 5362 $8,908 0T5_4ZZ MS‐DRG 657 w CC 657 $12,431 and monitoring, when performed 34.01 MS‐DRG 658 wo CC/MCC 658 $10,150 50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound $1,236 N/A 22.22 NA Only paid as inpatient 0T5_0ZZ guidance and monitoring, if performed 35.43 procedure. 50592 Ablation, 1 or more renal tumor(s), unilateral, percutaneous, radiofrequency $346 $3,287 6.55 $2,318 APC 5361 $5,060 0T5_3ZZ 9.92 50200 Renal biopsy; percutaneous, by trocar or needle $129 $569 2.38 $597 APC 5072 $1,407 0TB_3ZZ 3.69 Liver 47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation $450 $6,882 8.88 $3,447 APC 5361 $5,060 0F5_3ZZ Pancreas, liver and shunt procedures 12.91 MS‐DRG 405 w MCC 405 $36,832 47371 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical $1,300 N/A 20.80 $3,813 APC 5362 $8,908 0F5_4ZZ MS‐DRG 406 w CC 406 $18,492 37.25 MS‐DRG 407 wo CC/MCC 407 $13,600 47381 Ablation, open, of 1 or more liver tumor(s); cryosurgical $1,530 N/A 24.88 NA Only paid as inpatient 0F5_0ZZ 43.85 procedure. 47382 Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency $745 $4,348 14.97 $2,318 APC 5361 $5,060 0F5_3ZZ 21.35 47370 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency $1,290 N/A 20.80 $3,813 APC 5362 $8,908 0F5_4ZZ 36.97 47380 Ablation, open, of 1 or more liver tumor(s); radiofrequency $1,488 N/A 24.56 NA Only paid as inpatient 0F5_0ZZ 42.65 procedure. 47000 Biopsy of liver, needle; percutaneous $89 $325 1.65 $597 APC 5072 $1,407 0FB_3ZZ 2.56 Lung 32994 Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, $443 $5,657 9.03 $3,378 APC 5361 $5,060 0F5_3ZZ Major chest procedures percutaneous, cryoablation, unilateral, includes imaging guidance 12.69 MS‐DRG 163 w MCC 163 $31,877 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or $442 $3,581 9.03 $2,318 APC 5361 $5,060 0F5_4ZZ MS‐DRG 164 w CC 164 $16,941 chest wall when involved by tumor extension, percutaneous, including imaging guidance when 12.67 performed, unilateral; radiofrequency MS‐DRG 165 wo CC/MCC 165 $12,267 32408 Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when $155 $967 3.18 $597 APC 5072 $1,407 0F5_0ZZ performed 4.44 0FB_3ZZ

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 46 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Nerve go to APC list go to ICD‐10‐PCS list 0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral $0 $0 0.00 $809 APC 5431 $1,754 Cranial & peripheral nerve disorders nerve 0.00 MS‐DRG 073 w MCC 73 $9,316 0441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral $0 $0 0.00 $809 APC 5431 $1,754 MS‐DRG 074 wo MCC 74 $6,546 015_3ZZ nerve 0.00 0442T Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve $0 $0 0.00 $4,116 APC 5432 $5,700 (eg, brachial plexus, pudendal nerve) 0.00 Breast 19105 Ablation, cryosurgical, breast fibroadenoma, includes ultrasound guidance, each fibroadenoma $217 $2,791 3.69 $1,711 APC 5091 $3,158 Breast biopsy, local exc & oth breast procs 6.22 0H5_3ZZ MS‐DRG 584 w MCC 584 $11,726 MS‐DRG 585 wo MCC 585 $11,162 Prostate 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) $777 $6,514 13.60 $6,321 APC 5376 $8,258 Major male pelvic procedures 22.28 MS‐DRG 707 w MCC 707 $12,344 0V5_3ZZ 55700 Biopsy, prostate; needle or punch, single or multiple, any approach $132 $256 2.50 $801 APC 5373 $1,793 MS‐DRG 708 wo MCC 708 $9,586 3.78 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy $385 $1,567 5.93 $1,315 APC 5374 $3,076 11.04 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy $360 $1,613 5.42 $1,380 APC 5374 $3,076 0V5_7ZZ 5385026 10.31 53854 Transurethral destruction of prostate tissue; by radiofrequency generated water vapor $386 $1,888 5.93 $801 APC 5373 $1,793 5385426 thermotherapy 11.05 26 Radiological S&I Codes – Billed in Conjunction with Procedure Code (Use physician modifier ‐26 as appropriate) 76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation $103 $0 0.00 B_4_ZZA 7694026 2.94 77013 Computed tomography guidance for, and monitoring of, parenchymal tissue ablation $187 $0 0.00 B_2_ _ZZ 7701326 5.37 77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation $211 $0 0.00 Status N, items and services B_3_ _ _Z 7702226 6.06 Status N1 packaged into primary 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), $31 $59 0.67 No separate procedure APC B_4_ZZA N/A 7 imaging supervision and interpretation 0.90 7694226 payment. rate. No separate payment. 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) $28 $119 0.54 B_1_ _ZZ 7700226 (List separately in addition to code for primary procedure) 0.80 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization $73 $151 1.50 B_2_ _ZZ 7701226 device), radiological supervision and interpretation 2.08 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or $72 $471 1.50 B_3_ _ _Z 7702126 placement of localization device) radiological supervision and interpretation 2.05

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 47 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment TheraSphere Radioembolization (SIRT/TARE) Procedures go to APC list go to ICD‐10‐PCS list Simulation Planning & Simulation 77263 Therapeutic Radiology Simulation Treatment Planning, Complex $170 $170 3.14 NA Status B, payment always NA 4.87 bundled. 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, $304 $1,589 6.04 or lower extremity artery branch, within a vascular family Status N, items and services 8.72 Status N1 packaged into primary 36248 $50 $134 1.01 No separate 04H_33Z Selective catheter placement, arterial system; additional second order, third order, and beyond, procedure APC payment. abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code 1.42 rate. No separate payment. for initial second or third order vessel) 7 75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological $96 $181 2.05 APC 5184 $4,770 N/A 2.76 7572626 supervision and interpretation B40_0ZZ 75774 Angiography, selective, each additional vessel studied after basic examination, radiological $48 $106 1.01 Status N1 Status N, items and services B40_1ZZ supervision and interpretation (List separately in addition to code for primary procedure) No separate packaged into primary B40_YZZ 7577426 1.37 payment. procedure APC rate. No B41_ _ZZ separate payment.

77290 Therapeutic Radiology Simulation, Complex $82 $501 1.56 $172 APC 5612 $339 NA 7729026 2.36 37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $481 $8,070 9.80 $6,366 APC 5193 $10,043 03L_3DZ Other vascular procedures intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, 13.79 04L_3DZ MS‐DRG 252 w MCC 252 $21,344 other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous 04LE3DT MS‐DRG 253 w CC 253 $17,056 malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) 04LF3DU MS‐DRG 254 wo CC 254 $11,630

Simulation Nuclear Imaging 78201 Liver Imaging; static only $21 $196 0.44 $249 APC 5592 $489 CF151ZZ 7820126 0.60 CF15YZZ 78202 Liver Imaging w/ vascular flow; static only $24 $215 0.51 $249 APC 5592 $489 CF151ZZ 7820226 0.69 CF15YZZ 78800 Rp localization tumor/distribution Rp agent, incl vasc flow, planar, 1 area, 1 day $32 $263 0.64 $192 APC 5591 $377 CF151ZZ N/A 7 7880026 0.91 CF15YZZ 78803 Rp localization tumor/distribution Rp agent, incl vasc flow, (SPECT), 1 area, 1 day $51 $397 1.09 $663 APC 5593 $1,306 CF251ZZ 7880326 1.47 CF25YZZ 78830 Rp localization tumor/distribution Rp agent, incl vasc flow, (SPECT) w/concurrent CT, 1 area, 1 day $70 $505 1.49 $663 APC 5593 $1,306 CF25_ZZ 7883026 2.01 BF25_ _Z

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV-732305-AD | JAN 2021 | 48 of 71 Pages Select Peripheral Interventions 2021 Procedural Payment Guide Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Inpatient information effective through September 30, 2021 │Outpatient and ASC information effective through December 31, 2021│ Physician fee information effective through December 31, 2021 *National Average Medicare physician payment rates calculated using the revised 2021 conversion factor of $34.8931. HOSPITAL HOSPITAL *PHYSICIAN 2 ASC 3 OUTPATIENT 4 INPATIENT 6

CPT® In‐Hospital In‐Office Work RVU ASC APC APC Possible Possible CPT Descriptions MS‐DRG Payment 6,7 Code 1 (‐26) (Global) Total RVU 8 Payment 3 Category Payment 4 ICD‐10‐PCS Codes 5 MS‐DRG Assignment Brachytherapy Clinical Treatment Planning & Dosimetry go to APC list go to ICD‐10‐PCS list 77300 Basic dosimetry calc, CADD calc, TDF, NSD, Gap calc, OAF, TIF, NIRSDD calc (req Rx treat phys) $33 $67 0.62 $32 APC 5611 $127 7730026 0.94 77316 Brachytherapy Isodose Plan, 1‐4 Sources, Incl Basic Dosimetry Calc $74 $237 1.40 $153 APC 5612 $339 7731626 2.12 77317 Brachytherapy Isodose Plan, 5‐10 Sources, Incl Basic Dosimetry Calc $97 $311 1.83 $172 APC 5612 $339 2.77 7731726 NA N/A 7 77295 3‐dimensional radiotherapy plan, including dose‐volume histograms $226 $491 4.29 $249 APC 5613 $1,262 7729526 6.49 77370 Special Medical Radiation Physics Consult N/A $131 0.00 $64 APC 5611 $127 7737026 3.75 77470 Special Treatment Procedure $108 $135 2.03 $25 APC 5623 $543 7747026 3.10 TheraSphere Delivery 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, $304 $1,589 6.04 or lower extremity artery branch, within a vascular family Status N, items and services 8.72 Status N1 packaged into primary 36248 $50 $134 1.01 No separate 04H_33Z N/A 7 Selective catheter placement, arterial system; additional second order, third order, and beyond, procedure APC payment. abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code 1.42 rate. No separate payment. for initial second or third order vessel) 37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, $563 $9,933 11.74 $4,285 APC 5193 $10,043 03L_3DZ Pancreas, liver and shunt procedures intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 16.14 04L_3DZ MS‐DRG 405 w MCC 405 $36,832 tumors, organ ischemia, or infarction 04LE3DT MS‐DRG 406 w CC 406 $18,492 04LF3DU MS‐DRG 407 wo CC/MCC 407 $13,600 79445 Radiopharmaceutical Therapy (intra‐arterial) $112 $112 2.40 $127 APC 5661 $250 3.22 7944526 3E0_3HZ N/A 7 77778 Interstitial Radiation Source Application, Complex [only when IR is NOT the AU] $463 $900 8.78 $360 APC 5624 $708 7777826 13.28 TheraSphere Y‐90 Brachytherapy Source C2616 Brachytherapy Source, Non‐Stranded, Yttrium‐90 (per source) NA NA NA $17,398 APC 2616 $17,398 C261626 NA S2095 Transcatheter Occlusion or Embolization, Tumor Destruction, Percutaneous, Y‐90 Microspheres NA Payer NA NA Status E, not paid by DF109YZ N/A 7 S209526 Determined NA Medicare. Q3001 Brachytherapy Radioelements, Each NA MAC NA NA Status B, not paid under Q300126 Determined NA OPPS. Post‐TheraSphere Implantation (only if required) 76145 Medical physics dose evaluation for radiation exposure that exceeds institutional review threshold, N/A $848 0.00 $64 APC 5611 $127 NA N/A 7 7614526 including report 24.31

2 Source: CMS website. Physician Fee Schedule – 2021 National Physician Fee Schedule Relative Value File: https://www.cms.gov/medicaremedicare‐fee‐service‐paymentphysicianfeeschedpfs‐federal‐regulation‐notices/cms‐1734‐f

3 Source: CMS website. ASC Addenda Updates: https://www.cms.gov/medicaremedicare‐fee‐service‐paymentascpaymentasc‐regulations‐and‐notices/cms‐1736‐fc

4 Source: CMS website. 2021 OPPS Addendum B: https://www.cms.gov/medicaremedicare‐fee‐service‐paymenthospitaloutpatientppshospital‐outpatient‐regulations‐and‐notices/cms‐1736‐fc

5 Source: CMS ICD‐10‐CM/PCS MS‐DRG v38 Definitions Manual https://www.cms.gov/icd10m/version38‐fullcode‐cms/fullcode_cms/P0001.html

6 Source: Data tables (FY2021 IPPS Final Rule). CMS Website. National average (wage index greater than one) MS‐DRG rates calculated using the national adjusted full update standardized labor, non‐labor and capital amounts. Actual reimbursement will https://www.cms.gov/medicare/acute‐inpatient‐pps/fy‐2021‐ipps‐final‐rule‐home‐page vary for each provider and institution for a variety of reasons including geographic differences in labor and non‐labor costs, hospital teaching status, and/or proportion of low‐income patients).

7 MS‐DRG grouping is driven by other primary procedures that are performed in conjunction with this procedure. 8 Total RVU is the relative value unit total for In‐Facility calculation.

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 50 of 71 Pages X8A0T APPENDIX A APC Reference Table APC Category APC Payment APC Description 2616 $17,398 Brachytx, non‐str,Yttrium‐90 5052 $346 Level 2 Skin Procedures 5054 $1,715 Level 4 Skin Procedures 5072 $1,407 Level 2 Excision/ Biopsy/ Incision and Drainage 5091 $3,158 Level 1 Breast/Lymphatic Surgery and Related Procedures 5181 $542 Level 1 Vascular Procedures 5182 $1,406 Level 2 Vascular Procedures 5183 $2,862 Level 3 Vascular Procedures 5184 $4,770 Level 4 Vascular Procedures 5191 $2,899 Level 1 Endovascular Procedures 5192 $4,957 Level 2 Endovascular Procedures 5193 $10,043 Level 3 Endovascular Procedures 5194 $16,064 Level 4 Endovascular Procedures 5211 $1,113 Level 1 Electrophysiologic Procedures 5212 $6,078 Level 2 Electrophysiologic Procedures 5213 $21,464 Level 3 Electrophysiologic Procedures 5221 $3,440 Level1 Pacemaker and Similar Procedures 5222 $8,153 Level 2 Pacemaker and Similar Procedures 5223 $10,400 Level 3 Pacemaker and Similar Procedures 5224 $18,611 Level 4 Pacemaker and Similar Procedures 5231 $23,040 Level 1 ICD and Similar Procedures 5232 $32,839 Level 2 ICD and Similar Procedures 5301 $810 Level 1 Upper GI Procedures 5302 $1,625 Level 2 Upper GI Procedures

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 51 of 71 Pages APC Category APC Payment APC Description 5341 $3,183 Abdominal/Peritoneal/Biliary and Related Procedures 5361 $5,060 Level 1 Laparoscopy and Related Services 5362 $8,908 Level 2 Laparoscopy and Related Services 5373 $1,793 Level 3 Urology and Related Services 5374 $3,076 Level 4 Urology and Related Services 5376 $8,258 Level 6 Urology and Related Services 5431 $1,754 Level 1 Nerve Procedures 5432 $5,700 Level 2 Nerve Procedures 5571 $179 Level 1 Imaging with Contrast 5591 $377 Level 1 Nuclear Medicine and Related Services 5593 $1,306 Level 3 Nuclear Medicine and Related Services 5611 $127 Level 1 Therapeutic Radiation Treatment Preparation 5612 $339 Level 2 Therapeutic Radiation Treatment Preparation 5613 $1,262 Level 3 Therapeutic Radiation Treatment Preparation 5623 $543 Level 3 Radiation Therapy 5624 $708 Level 4 Radiation Therapy 5661 $250 Therapeutic Nuclear Medicine 5723 $488 Level 3 Diagnostic Tests and Related Services 5732 $34 Level 2 Minor Procedures 5741 $37 Level 1 Electronic Analysis of Devices

BSC C‐Code Finder Website C‐Codes are important to future reimbursement. Use of all applicable C‐Codes on a claim allows identification of device(s) utilized in a procedure and may affect future payment rates. Rhythm Management Category Codes Category Code Description C1721 Peripheral Interventions (print page range: 30‐50) C1729 Catheter, drainage C1730 Catheter, electrophysiology, diagnostic, other than 3‐D mapping (19 or fewer electrodes) C1731 Catheter, electrophysiology, diagnostic, other than 3‐D mapping (20 or more electrodes) C1732 Catheter, electrophysiology, diagnostic/ablation, 3‐D or vector mapping C1733 Catheter, electrophysiology, diagnostic/ablation, other than 3‐D or vector mapping, other than cool‐tip C1766 Introducer/sheath, guiding, intracardiac electrophysiological, steerable, other than peel‐away C1769 Guide Wire C1772 Cardioverter‐defibrillator, single chamber (implantable) C1777 Lead, cardioverter‐defibrillator, endocardial single coil (implantable) C1779 Lead, pacemaker, transveneous VDD Single pass C1785 Pacemaker, dual chamber, rate‐responsive (implantable) C1786 Pacemaker, single chamber, rate‐responsive (implantable) C1882 Cardioverter‐defibrillator, other than single or dual chamber (implantable) C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) C1887 Catheter, guiding (may include infusion/perfusion capability) C1893 Introducer/sheath, guiding, intracardiac electrophysiological, fixed curve, other than peel‐away C1894 Introducer/sheath, other than guiding, intracardiac electrophysiological, non‐laser C1895 Lead, cardioverter‐defibrillator, endocardial dual coil (implantable) C1896 Lead, cardioverter‐defibrillator, other than endocardial single or dual coil (implantable) C1898 Lead, pacemaker, other than transvenous VDD single pass C1900 Lead, coronary venous C2621 Pacemaker, other than single or dual chamber (implantable) C2628 Catheter, occlusion C2630 Catheter, electrophysiology, diagnostic/ablation, other than 3‐D or vector mapping cool‐tip

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 53 of 71 Pages Interventional Cardiology Category Codes Category Code Description C1724 Catheter, transluminal atherectomy, rotational C1725 Catheter, transluminal angioplasty, non‐laser (may include guidance, infusion/perfusion capability) C1753 Catheter, intravascular ultrasound C1757 Catheter, embolectomy/thrombectomy C1769 Guide wire C1874 Stent, coated/covered, with delivery system C1876 Stent, noncoated/noncovered, with delivery system C1884 Embolization protective system C1887 Catheter, guiding (may include infusion/perfusion capability) C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, nonlaser

Peripheral Interventions Category Codes Category Code Description C1724 Catheter, transluminal atherectomy, rotational C1725 Catheter, transluminal angioplasty, non‐laser (may include guidance, infusion/perfusion capability) C1729 Catheter, drainage C1753 Catheter, intravascular ultrasound C1757 Catheter, thrombectomy, embolectomy C1758 Catheter, ureteral C1769 Guide wire C1874 Stent, coated/covered, with delivery system C1876 Stent, non‐coated/non‐covered, with delivery system C1880 Vena cava filter C1884 Embolization protective system C1887 Catheter, guiding (may include infusion/perfusion capability) C1888 Catheter, ablation, non‐cardiac, endovascular (implantable) C1889 Implantable/insertable device, not otherwise classified C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non‐laser C2616 Brachytherapy source, non‐stranded, yttrium‐90, per source C2617 Stent, non‐coronary, temporary, without delivery system C2618 Probe/needle, cryoablation C2623 Catheter, transluminal angioplasty, drug‐coated, non‐laser C2628 Catheter, occlusion C2699 Brachytherapy source, non‐stranded, not otherwise specified, per source

CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 64 of 71 Pages X10AT APPENDIX C ICD‐10‐PCS Reference Table FY 2021 ‐ Note that some procedures may require multiple procedure codes to be reported ICD‐10‐PCS Description Peripheral Interventions Percutaneous Transluminal Balloon Angioplasty 0470341 Dilate Abd Aorta w Drug‐elut, Drug Blln, Perc 04703D1 Dilate Abd Aorta w Intralum Dev, Drug Blln, Perc 04703ZZ Dilation of Abdominal Aorta, Percutaneous Approach 027X34Z Dilate of Thor Aorta Asc with Drug‐elut Intra, Perc Approach 027X3DZ Dilation of Thor Aorta Asc with Intralum Dev, Perc Approach 027X3ZZ Dilation of Thoracic Aorta, Ascending/Arch, Perc Approach 027W34Z Dilate of Thor Aorta Asc with Drug‐elut Intra, Perc Approach 027W3DZ Dilation of Thor Aorta Asc with Intralum Dev, Perc Approach 027W3ZZ Dilation of Thoracic Aorta, Descending, Perc Approach 03763D1 Dilate L Axilla Art w Intralum Dev, Drug Blln, Perc 03763DZ Dilation of L Axilla Art with Intralum Dev, Perc Approach 03763Z1 Dilation of L Axilla Art using Drug Blln, Perc Approach 03763ZZ Dilation of Left Axillary Artery, Percutaneous Approach 03753D1 Dilate R Axilla Art w Intralum Dev, Drug Blln, Perc 03753DZ Dilation of R Axilla Art with Intralum Dev, Perc Approach 03753Z1 Dilation of R Axilla Art using Drug Blln, Perc Approach 03753ZZ Dilation of Right Axillary Artery, Percutaneous Approach 03783D1 Dilate L Brach Art w Intralum Dev, Drug Blln, Perc 03783DZ Dilation of L Brach Art with Intralum Dev, Perc Approach 03783Z1 Dilation of L Brach Art using Drug Blln, Perc Approach 03783ZZ Dilation of Left Brachial Artery, Percutaneous Approach 03773D1 Dilate R Brach Art w Intralum Dev, Drug Blln, Perc 03773DZ Dilation of R Brach Art with Intralum Dev, Perc Approach 03773Z1 Dilation of R Brach Art using Drug Blln, Perc Approach 03773ZZ Dilation of Right Brachial Artery, Percutaneous Approach 04713D1 Dilate Celiac Art w Intralum Dev, Drug Blln, Perc 04713DZ Dilation of Celiac Art with Intralum Dev, Perc Approach 04713Z1 Dilation of Celiac Art using Drug Blln, Perc Approach 04713ZZ Dilation of Celiac Artery, Percutaneous Approach 04773D1 Dilate L Colic Art w Intralum Dev, Drug Blln, Perc 04773DZ Dilation of L Colic Art with Intralum Dev, Perc Approach 04773Z1 Dilation of L Colic Art using Drug Blln, Perc Approach 04773ZZ Dilation of Left Colic Artery, Percutaneous Approach 04783D1 Dilate Mid Colic Art w Intralum Dev, Drug Blln, Perc 04783DZ Dilation of Mid Colic Art with Intralum Dev, Perc Approach 04783Z1 Dilation of Mid Colic Art using Drug Blln, Perc Approach 04783ZZ Dilation of Middle Colic Artery, Percutaneous Approach 04763D1 Dilate R Colic Art w Intralum Dev, Drug Blln, Perc 04763DZ Dilation of R Colic Art with Intralum Dev, Perc Approach CPT® 2020 American Medical Association. All Rights Reserved. CPT is a registered trademark. See pages 2 and 3 for important information about the uses of this document. CRV‐732305‐AD | JAN 2021 | 65 of 71 Pages X10AT APPENDIX C ICD‐10‐PCS Reference Table FY 2021 ‐ Note that some procedures may require multiple procedure codes to be reported ICD‐10‐PCS Description 04763Z1 Dilation of R Colic Art using Drug Blln, Perc Approach 04763ZZ Dilation of Right Colic Artery, Percutaneous Approach 04793ZZ Dilation of Right Renal Artery, Percutaneous Approach 047A3ZZ Dilation of Left Renal Artery, Percutaneous Approach 027W3ZZ Dilation of Thoracic Aorta, Percutaneous Approach 04703ZZ Dilation of Abdominal Aorta, Percutaneous Approach 03773ZZ Dilation of Right Brachial Artery, Percutaneous Approach 03783ZZ Dilation of Left Brachial Artery, Percutaneous Approach 03Q73ZZ Repair Right Brachial Artery, Percutaneous Approach 03Q83ZZ Repair Left Brachial Artery, Percutaneous Approach B3110ZZ Fluoroscopy of Right Brachiocephalic‐Subclavian Artery using High Osmolar Contrast B3111ZZ Fluoroscopy of Right Brachiocephalic‐Subclavian Artery using Low Osmolar Contrast B311YZZ Fluoroscopy of Right Brachiocephalic‐Subclavian Artery using Other Contrast B4120ZZ Fluoroscopy of Hepatic Artery using High Osmolar Contrast B4121ZZ Fluoroscopy of Hepatic Artery using Low Osmolar Contrast B412YZZ Fluoroscopy of Hepatic Artery using Other Contrast B51B0ZA Fluoroscopy of Right Lower Extremity Veins using High Osmolar Contrast, Guidance B51B1ZA Fluoroscopy of Right Lower Extremity Veins using Low Osmolar Contrast, Guidance B51BYZA Fluoroscopy of Right Lower Extremity Veins using Other Contrast, Guidance Iliac Artery Revascularization 047C3ZZ Dilation of Right Common Iliac Artery with Intraluminal Device, Percutaneous Approach 047F3ZZ Dilation of Left Internal Iliac Artery, Percutaneous Approach 047C3DZ Dilation of Right Common Iliac Artery with Intraluminal Device, Percutaneous Approach 047D3DZ Dilation of Left Common Iliac Artery with Intraluminal Device, Percutaneous Approach 047F3DZ Dilation of Left Internal Iliac Artery with Intraluminal Device, Percutaneous Approach Femoral/Popliteal Artery Revascularization 04CK3ZZ Extirpation of Matter from Right Femoral Artery, Percutaneous Approach 04CL3ZZ Extirpation of Matter from Left Femoral Artery, Percutaneous Approach 047K3DZ Dilation of Right Femoral Artery with Intraluminal Device, Percutaneous Approach 047L3DZ Dilation of Left Femoral Artery with Intraluminal Device, Percutaneous Approach 047M3DZ Dilation of Right Popliteal Artery with Intraluminal Device, Percutaneous Approach 047N3DZ Dilation of Left Popliteal Artery with Intraluminal Device, Percutaneous Approach 047K3Z1 Dilation of Right Femoral Artery using Drug‐Coated Balloon, Percutaneous Approach 047L3Z1 Dilation of Left Femoral Artery using Drug‐Coated Balloon, Percutaneous Approach 047M3Z1 Dilation of Right Popliteal Artery using Drug‐Coated Balloon, Percutaneous Approach 047N3Z1 Dilation of Left Popliteal Artery using Drug‐Coated Balloon, Percutaneous Approach

Please note: this coding information may include some codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.

Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third‐party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is also always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently. Boston Scientific recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA‐approved label.

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. Boston Scientific does not promote the use of its products outside their FDA‐approved label. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all‐inclusive list. We recommend consulting your relevant manuals for appropriate coding options. CPT® Disclaimer CPT® Copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. 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. 300 Boston Scientific Way Sequestration Disclaimer Marlborough, MA 01752‐1234 www.bostonscientific.com Sequestration Disclaimer: Rates referenced in these guides do not reflect Sequestration; automatic reductions in federal spending that will result in a 2% across‐the‐board reduction to ALL Medicare rates as of January 1, 2017. (Budget Control Act of 2011) Update: The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment Medical Professionals: adjustment percentage of 2% applied to all Medicare Fee‐For‐Service (FFS) claims from May 1, 2020 through December 31, 2020. The Consolidated Appropriations Act, 2021, signed Rhythm Management 1‐800‐CARDIAC (227‐3422) into law on December 27, 2020, extends the suspension period to March 31, 2021. Interventional Cardiology 1‐877‐786‐1050, Option 2 Peripheral Interventions 1‐844‐201‐2203

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