CPT Coding for CHD Catheterizations Sergio Bartakian, MD, FSCAI, FAAP Pediatric and Congenital Interventional Cardiologist Children’s Hospital of Michigan, DMC AMA CPT / RUC Advisor, SCAI Disclosures None Roadmap

• Structure • Representation / lack of • Common problems / solutions • Looking Forward • RUC Surveys AMA CPT Advisory Committee

• Total number of advisors: 156 • Panel members: 20 • Number of pediatric cardiologists: that have any experience with of CHD 1

• Job of the CPT simply stated - Create the codes and maintain the code set CPT Advisor Representation

• National Association of Social Workers (1) • American Podiatric Medical Association (2) • National Athletic Trainers Association (2) • American Massage Therapy Association (2) • American Academy of Dermatology (2) • American College of Mohs (1) • American Society of Aesthetic Plastic Surgery, Inc. (1) • American Society for Dermatologic Surgery (2) • Society of Investigative Dermatology (1)

• American Academy of Pediatrics – representing ALL SPECIALTIES (2) Relative value scale Update Committee

• RUC committee • 31 members – mostly specialists • Describe the work involved for a given code and establish an RVU recommendation • Recommendations are passed on to CMS for formal acceptance

12 of 31 panel members representing surgical specialties 1 Pediatrician (AAP) CV Surgical CPT Codes

CPT 2000 2017 33875 (DAO graft) 33.06 50.72 53% 33641 (ASD) 21.39 29.58 38% 33681 (VSD) 27.67 32.34 17% 33870 (TAO graft) 40.31 46.06 14% 33697 (TOF) 33.71 37.57 11% 33670 (AVSD) 32.73 36.63 12% 33611 (DORV) 32.30 35.57 10% 33506 (ALCAPA) 26.71 37.85 42% 33533 (CAB) 25.83 33.75 31% 33534 (CAB2) 28.82 39.88 38% 33535 (CAB3) 31.81 44.75 41% +33517 2.57 3.61 40% +33518 4.85 7.93 64% 33430 (MVR) 31.43 50.93 62% 33475 (PVR) 28.41 42.40 49% Average 35% increase Interventional CPT Codes

CPT 2000 2017 93530 (RHC) 4.23 3.97 (-6%) 93531 (R/LHC) 8.35 8.34 93565 (RV) 0.86 0.86 93568 (PA) 0.88 0.88 92992 (BAS) 0 0 37242 (Embol) 10.05 (2014) 9.80 (-2.5%) 93580 (ASD) 18.00 (2003) 17.97 37236 (Stent) 9.0 (2014) 8.75 (-3%) 92990 (P Vplasty) 17.34 18.27 5% 2017 CPT Change • Open and percutaneous transluminal angioplasty code deletions / replacements • 2016 • 35472 – Transluminal balloon angioplasty, aortic • 75966 – Transluminal balloon angioplasty, RS&I • 36200 - Introduction AO • 35472 (6.9 RVU) + 75966 (1.31 RVU) + 36200 (2.77 RVU) = 10.97 RVU • 2017 • 37246 – transluminal balloon angioplasty, 1st artery - All inclusive • 37246 – 7 RVU (instant 36% reduction) 2016-17 CPT Change

ACR - American College or Radiology SIR - Society of Interventional Radiology SVS - Society for Vascular Surgery Who Does CMS Ask?

N = 9331, 37242 93580, N = 1683 So, What Can We Do? Step 1: Build a Coalition • SCAI • ACC The House of • ASE • HRS • SIR • ACR Support from Radiology and • SVS Surgical Colleagues • STS So What Can We Do?

• Step 2: Formed PICCW • Myself, Drs. Zahid Amin, Shawn Batlivala, Jeff Delaney, Guru Hiremath, Mark Hoyer, Frank Ing, Jeremy Ringewald, Bob Vincent, SCAI staff (Dawn Gray – up to 2020) Wayne Powell • Identified the problems to be addressed • Balloon atrial septostomy • New congenital cardiac cath codes So What Are We Doing? • stenting • Ductal stenting Step 3 • Atrial septal / Fontan fenestration stenting • Coarctation angioplasty / stenting • PA angiography with device closure bundles • Modifier 63 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use Timeline for a new code

May 2020 Recommended RVUs CMS issues draft rule Decision for a new code forwarded to CMS summer 2021 made today

June 30, 2020 Deadline for prepared January 2021 CMS issues final rule application to be RUC Meeting November 2021 submitted

Nov 2020 October 2020 January 1, 2022 Application presented at (IF passes at CPT) Code available for use in CPT meeting RUC Survey goes out CPT book Multi-Pronged Attack

CPT New Code Assistant Applications Articles

Coding Needs

NCCI Editorial Revisions • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting • Coarctation angioplasty / stenting • PA angiography with device closure bundles • Modifier 63 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting • Coarctation angioplasty / stenting • PA angiography with device closure bundles • Modifier 63 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles • Modifier 63 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions • ICE • 3D Printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE • 3D printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing - category 3 CPT code issued 2019 • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing - category 3 CPT code issued 2019 • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting Drafted • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing - category 3 CPT code issued 2019 • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting Drafted • Ductal stenting • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting – To be presented October 2020 • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing - category 3 CPT code issued 2019 • Pulmonary arterial and venous angiography • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use • Identified the problems to be addressed • Balloon atrial septostomy - New code created 2019, valued 2020, Available 1/1/21 • New congenital cardiac cath codes – Presenting this week • Pulmonary artery stenting • Ductal stenting Drafted • Atrial septal / Fontan fenestration stenting – Created 2019, valued 2020, Available 1/1/21 • Coarctation angioplasty / stenting – To be presented October 2020 • PA angiography with device closure bundles – Resolved 2019 • Modifier 63 – Complete. Available 1/1/2020 • LSVC angiography – Appeal letter submitted to CMS / NCCI • Intracardiac pacing with interventions – Appeal letter submitted to CMS / NCCI • ICE – presenting this week • 3D printing - category 3 CPT code issued 2019 • Pulmonary arterial and venous angiography – To be presented October 2020 • Trans-hepatic access • RF/wire revascularlization (RF perforation of PV/PA) • Cardiac cath with biopsies • Pericardiocentesis – old codes deleted by CMS. New codes created, accepted, and in use now • Thermodilution – received significantly improved values, will be able to use with new base codes • PICC Line Placement - Stopped effort to eliminate ultrasound use Why these problems occur • Lack of involvement • No representation = gradual reduction without a fight • Ie, Pericardiocentesis and PICC lines • Lack of understanding • Coders and panel members: Catheterization ≠ catheterization • Our own community: Poor RUC survey responses • Lack of existence • In the adult world, pediatrics does not exist • Data is derived from CMS (Medicare) utilization • Examples provided: COA, LSVC, PICC lines What can YOU do?

• Respond to surveys • Ask questions • Question and audit your coders - they are NOT the experts! • Learn the RUC survey process The RUC Survey

• Pre, Intra, and Post procedure • Please refer to CCT articles published in April and May for more detail

• The survey will ask you to state how much time and intensity it takes you to perform the procedure

• VITAL that your responses pertain to the “typical patient” and work description described in the vignette, NOT YOUR TYPICAL.

• If you are not familiar with such a patient, you should not respond to the survey at all. Example

You are asked to complete a survey on PDA closure, the vignette describes a typical 2 y/o PDA procedure.

In your practice, a new Preemie PDA device closure is performed in 30% of total cases, whereas 70% continue to be the standard variety

Although the intensity of the new preemie PDA may be somewhat higher, the overall time is typically less.

Because >50% of all PDA device closure cases nationally are done using standard technique (same as your practice), you base your survey responses only on cases done with the standard technique, NOT an average of all cases.

This is an example of why it is vital to read the vignette and understand which population to consider before answering time / intensity questions. Ie, whether the vignette describes a 1-year-old PDA device procedure, vs a 1-week-old premature infant. Determining what is the “typical” case

• Your typical population for a given procedure may be different than the code proposal • Institutional preferences for surgical repair of complex cases • Referral patterns different than other centers • Answer based on the typical case described, if you are familiar with such a case, even if that is not typical for you in general • Take into account all of the steps included in the description (bundling) • Eg, angiograms, imaging, other interventions, etc • Do not assume the new code is a 1:1 replacement for the existing code • Ie, if a new ASD code was proposed, make sure to review what is included in the new code vs what was included previously. Add / remove time for any changes Thank you