J1 MAC: Percutaneous Endovascular Cardiac Assist Covered

It isn’t every day a Medicare administrative contractor (MAC) says it will cover a procedure that has neither a specific CPT® code describing it nor any concrete proof that the medical intervention is even useful. On July 16, however, Palmetto GBA did exactly that when it posted a policy update for percutaneous endovascular cardiac assist procedures and devices.

Effective for dates of service on or after Sept. 1, 2011, the jurisdiction 1 Part B MAC will cover the percutaneous insertion of an endovascular cardiac assist device and the device itself.

Coverage will be allowed for (but not exclusively) the following ICD-9-CM codes:

• Cardiogenic shock, reported with 785.51
• Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following:
  • 428.21 Acute systolic heart failure
  • 428.23 Acute or chronic systolic heart failure
  • 428.41 Acute combine systolic and diastolic heart failure
  • 428.43 Acute or chronic combined systolic and diastolic heart failure
  • 429.4 Functional disturbances following cardiac surgery
  • 997.1 Cardiac complications, not elsewhere classified

When submitting a claim to Palmetto for an endovascular cardiac assist procedure, report CPT® 33999 Unlisted procedure, cardiac surgery and enter “Impella” or “Tandem Heart” in item 19 of the CMS-1500 claim form or its electronic equivalent.

Source: Palmetto GBA

July 26th, 2012

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CMS Covers New Technology for Heart Valve Damage

The Centers for Medicare & Medicaid Services (CMS) now covers transcatheter aortic valve replacement (TAVR) for Medicare patients, under certain conditions.

According to CMS, coverage for TAVR is approved under Coverage with Evidence Development (CED) only for the treatment of severe symptomatic aortic valve stenosis when all of the following five conditions are met:

1. The procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval for that system’s FDA-approved indication.
2. Two cardiac surgeons have independently examined the patient face-to-face and evaluated the patient’s suitability for open aortic valve replacement (AVR) surgery; and both surgeons have documented the rationale for their clinical judgment and the rationale is available to the heart team.
3. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. TAVR must be furnished in a hospital with an appropriate infrastructure as specified in the decision memo.
4. The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR.
5. The heart team and hospital are participating in a prospective, national, audited registry that: 1) consecutively enrolls TAVR patients; 2) accepts all manufactured devices; 3) follows the patient for at least one year; and 4) complies with relevant regulations relating to protecting human research subjects, including 45 CFR Part 46 and 21 CFR Parts 50 and 56.

The following outcomes must be tracked by the registry; and the registry must be designed to permit identification and analysis of patient, practitioner and facility level variables that predict each of these outcomes:

• Stroke
• All cause mortality
• Transient Ischemic Attacks (TIAs)
• Major vascular events
• Acute kidney injury
• Repeat aortic valve procedures
• Quality of Life (QoL)

See the decision memo for further specifications about the registry requirements.

CMS is requesting public comments, specifically about the use of CED, on the proposed determination pursuant to section 1862(l) of the Social Security Act. After considering the public comments, CMS will make a final determination and issue a final decision memorandum.

You can read the tracking sheet, proposed decision memo, decision memo, and view public comments documents on the CMS website.

May 11th, 2012

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2011 Brings Wide Scale Cardiac Cath Changes

By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC

For 2011, CPT® has given cardiac catheterization (cath) coding an “extreme makeover,” to include:

• 19 deleted cardiac cath codes (93501, 93508, 93510, 93514, 93524, 93526, 93527, 93528, 93529, 93539-93545, 93555, and 93556)
• 20 new Category I codes (93451-93464 and 93563-93568)
• New injection codes and bundling issues related to congenital cath codes 93530-93533

Familiarizing yourself with the new codes and concepts will help you report these procedures accurately for correct reimbursement and compliance.

New Bundles Abound

CPT® 2011 consolidates radiological supervision and interpretation (S&I), and radiological report, into the heart cath and injection codes. Likewise, all cath codes include placement of vascular closure devices and any associated imaging, when performed. No longer are there separate codes, apart from the applicable cath and/or injection codes, to report these procedures/services.

Non-congenital caths now include left ventricular injections or ventriculography when performed: No additional code is reported for left ventriculogram (Lt. vgram) with non-congenital caths. A number of non-congenital cath codes also now include coronary angiography and bypass graft imaging.

All cardiac cath procedures include conscious sedation, sheath placement, catheter introduction and repositioning, recording of pressures, and intracoronary arterial injection of medications.

Non-Congenital Heart Caths

Now that we know what’s included, let’s review the new cath codes. We’ll start with the 11 non-congenital heart cath codes, and group them for easier understanding:

Note: For ease of understanding, we’ll use shortened code descriptors rather than the full CPT^® descriptors.

93451   Right heart cath (RHC) only

Note: No coronary angiography with 93451.

93452   Left heart cath (LHC) (+/– Lt. vgram)

93453   LHC + RHC (+/– Lt. vgram)

Note: No coronary angiography, only pressures and Lt. vgram when performed with 93452, 93453.

93454   Native coronary angiography only

93455   Native coronaries + bypass graft imaging

93456   Native coronaries + RHC

93457   Native coronaries + bypass graft imaging + RHC

Note: No LHC with 93454 – 93457.

93458   Native coronaries + LHC (+/– Lt. vgram)

93459   Native coronaries + LHC (+/– Lt. vgram) + bypass grafts

93460   Native coronaries + LHC (+/– Lt. vgram) + RHC

93461   Native coronaries + LHC (+/– Lt. vgram) + RHC + bypass grafts

Add-on Injection and Misc. Procedures

Three add-on injection procedure codes and three add-on miscellaneous codes may be used with the non-congenital cath codes. Imaging supervision is included.

+93566  Right ventricular and/or right atrial angiography

+93567  Supravalvular aortography

+93568  Pulmonary angiography

Note: Code 93566 is for right chamber injections only. Remember that left ventriculogram, when performed, is included in the appropriate non-congenital cath code.

Three miscellaneous codes also may apply:

+93462              LHC by transseptal or transapical approach

Note: Code 93462 is reported in addition to the appropriate non-congenital cath code. It also may be reported with ablations for supraventricular or ventricular tachycardia when a transseptal puncture is made to facilitate the ablation procedure (93651 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular trachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination or 93652 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia). Code 93462 is not reported with congenital heart caths.

+93463  Drug administration (e.g., nitrous oxide) with hemodynamic measurements before and after

Note: This code is not for coronary artery drug administration during interventions. Code +93463 may be reported only once per encounter.

+93464  Physiologic exercise study with hemodynamic measurements before and after

Note: This code may be reported only once per encounter.

Congenital Cath Codes

CPT® 2011 retains the four existing congenital cath codes:

93530   RHC only

93531   RHC & retrograde LHC

93532   RHC + transseptal LHC via an intact septum

93533   RHC + transseptal LHC via an existing septal opening

When reporting these codes, keep two points in mind:

1. Do not report +93462 (LHC by transseptal or transapical approach) with 93532 or 93533; the transseptal approach is included in these congenital cath codes.

2. Codes 93532 and 93533 include a retrograde LHC, if performed.

Codes describing injection procedures for congenital caths include:

+93563  Selective native coronary imaging

+93564  Selective bypass graft imaging

+93565  Selective left ventricular and/or left atrial
angiography

Note: Although 93563-93565 are to be used only with congenital cath codes, three additional codes may be used with either congenital or non-congenital cath codes:

+93566  Right ventricular and/or right atrial angiography

+93567  Supravalvular aortography

+93568  Pulmonary angiography

Related Cardiology Codes

A number of related cardiology codes may accompany cath claims:

93503  Insertion of a Swan-Ganz catheter for monitoring

Never report this code with right heart cath codes 93451, 93453, 93460, and 93461; placement of the Swan-Ganz catheter is inherent to the right heart cath. Rather, use this code for monitoring a critically ill patient in the intensive care unit (ICU), for example.

93505  Endomyocardial biopsy

Code 93505 is reported only once per session, even if more than one biopsy is obtained. A right heart cath performed for guiding the biopsy would not be reported, but if a complete RHC for separate medical necessity is performed, it may be reported.

93561  Dilution studies with cardiac output
measurement

93562  Subsequent cardiac output measurement

Never report these two codes with the right heart cath codes 93451, 93453, 93460, and 93461 because the services are inherent to the RHC. Instead, use these codes during monitoring of a critically ill patient in the ICU, when cardiac outputs are measured.

Coding Examples: 2010 vs. 2011

To illustrate how cath coding has changed, let’s use two examples to compare coding in 2010 to that in 2011.

Example 1: A patient undergoes a routine left heart cath, coronary angiography, and left ventriculogram.

This is one of the most common combinations of procedures performed in the cardiac cath lab and, as you can see, the codes reported have gone from five in 2010 to one in 2011. Code 93458 includes coronary angiography, as well as a left heart cath. Like the other non-congenital cath codes, a left ventriculogram is included, when performed.

Example 2: A patient undergoes a left and right heart cath and a coronary angiography, left and right ventriculography, saphenous vein bypass graft imaging, left internal mammary graft imaging, and supravalvular aortography. A vascular closure device was placed at the conclusion of the procedure.

In 2011, code 93461 includes the LHC, RHC, coronary angiography; bypass graft imaging including the saphenous vein, internal mammary artery (IMA), and left ventriculogram. Code 93566 is reported additionally for the right ventriculogram, and 93567 is reported for the supravalvular aortogram. All the 2011 codes include imaging S&I, as well as vascular closure device placement and all associated imaging.

Wide scale changes for 2011 are here, but with diligent use of these codes, cardiac cath coding will become easier because fewer codes in general will be required to report each case. It is imperative to learn the new concepts introduced in 2011, and carefully note exactly which procedures are included with each new cath code.

Heart Cath Terminology

Accurate code selection begins with knowing the definitions for common heart cath terminology.

• A left heart catheterization (LHC) involves entry into the left side of the heart (left atrium, left ventricle) for pressure measurements.
• A right heart catheterization (RHC) involves access via the venous system into the right side of the heart (right atrium, right ventricle, and pulmonary arteries) for obtaining blood samples, and pressure and cardiac outputs.
• Ventriculography is the injection of contrast into the right and/or left ventricle(s) to visualize these chambers and to study function of these chambers.

David Dunn, MD, FACS, CIRCC, CPC-H, CCC, is vice president of ZHealth. He oversees physician coding, instructs for ZHealth educational programs, and contributes to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dr. Dunn is also certified in vascular surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board (NAB).

March 1st, 2011

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CMS Revises Ornish and Pritikin Program NCDs

The Centers for Medicare & Medicaid Services (CMS) recently revised the national coverage determinations (NCDs) for both the Ornish Program for Reversing Heart Disease (section 20.31.2 of the NCD Manual) and the Pritikin Program (section 20.31.1 of the NCD Manual).

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October 1st, 2010

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New CR/ICR Coverage, New Supplier Code

A new supplier specialty code is being established as part of new Medicare Part B policy which, effective Jan. 1, deems cardiac rehabilitation (CR) programs and intensive cardiac rehabilitation (ICR) programs covered services.

The Centers for Medicare & Medicaid Services (CMS) is establishing specialty code 31 Intensive cardiac rehabilitation, effective Jan. 1, to describe the specific/unique types of medicine that physicians and non-physician practitioners (NPPs) provide to patients who have experienced one or more of the following:

• An acute myocardial infarction within the preceding 12 months;
• A coronary artery bypass surgery;
• Current stable angina pectoris;
• Heart valve repair or replacement;
• Percutaneous transluminal coronary angioplasty or coronary stenting;
• A heart or heart-lung transplant; or
• Other cardiac conditions as specified through a National Coverage Determination (NCD) (CR only).

To receive reimbursement for CR and ICR services provided to Medicare patients, physicians, and NPPs must be enrolled in Medicare under supplier specialty code 31 and the services must be provided in a physician’s office—type of service code (TOS) 11—or hospital outpatient setting (TOS 22). ICR programs also must be approved by CMS through the NCD process.

Program requirements include the following components: 1) physician-prescribed exercise each day CR and ICR items and services are furnished; 2) cardiac risk factor modification; 3) psychosocial assessment; 4) outcomes assessment; and 5) an individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.

CR sessions are limited to a maximum of two 1-hour sessions per day up to 36 sessions furnished over a period of up to 36 weeks, with the option for an additional 36 sessions at Medicare contractor discretion over an extended period of time. ICR sessions are limited to 72 1-hour sessions, up to six sessions per day, over a period of up to 18 weeks. Append modifier KX Documentation on file to line items that exceed the maximum number of allowed sessions to indicate there is documentation on file supporting the need for further treatments.

Report CR services without continuous monitoring using CPT® 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); report CR services with continuous monitoring using CPT® 93798 Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).

ICR services with exercise are reported with HCPCS Level II code G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session; ICR services without exercise are reported with HCPCS Level II code G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session.

CMS instructs physicians to append modifier GA Waiver of liability statement on file to the procedure code if an Advanced Beneficiary Notice (ABN) is on file for the patient or modifier GZ Item or service expected to be denied as not reasonable and necessary if an ABN isn’t on file.

For detailed information regarding CR and ICR policy and claims processing, see the 2010 Medicare Physician Fee Schedule Final Rule with Comment Final Rule (pages 62004 – 62005), published in the Federal Register on Nov. 25, 2009. Also see MLN Matters article MM6850 and CMS Transmittal 170, Change Request (CR) 6850, issued May 21.

May 28th, 2010

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