2015 Facility and Physician Billing Guide Heart Valve Technologies

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1 2015 Facility and Physician Billing Guide Heart Valve Technologies PHYSICIAN BILLING CODES Clinicians use Current Procedural Terminology (CPT 1 ) codes to bill for procedures and services. Each CPT code is assigned unique relative value units (RVUs), which are used to determine payment by the Centers for Medicare & Medicaid Services (CMS) and other payers. Some commonly billed CPT codes used to describe procedures related to Edwards Lifesciences Heart Valve technologies are listed below. 2 This list may not be comprehensive or complete. These procedures may be subject to the CMS multiple procedure reduction rule. When applicable, a payment reduction of 50% is applied to all payment amounts except the procedure with the greatest RVUs, which is paid at 100% unless exempt by CPT instructions or payer policy. Medicare National Valvuloplasty, aortic valve; open, with cardiopulmonary bypass $2, Valvuloplasty, aortic valve; open, with inflow occlusion $1, Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass $1, Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve $2, Replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand) $2, Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve $2, Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus $3, Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) $3, Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) $3, Valvotomy, mitral valve; closed heart $1, Valvotomy, mitral valve; open heart, with cardiopulmonary bypass $1, Valvuloplasty, mitral valve, with cardiopulmonary bypass $2, Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring $2, Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring $2, Replacement, mitral valve, with cardiopulmonary bypass $2, Valvectomy, tricuspid valve, with cardiopulmonary bypass $2, Valvuloplasty, tricuspid valve; without ring insertion $3, Valvuloplasty, tricuspid valve; with ring insertion $2, Replacement, tricuspid valve, with cardiopulmonary bypass $2, Tricuspid valve repositioning and plication for Ebstein anomaly $2,539 Surgical Services for Valve Repair/Replacement Procedures

2 Medicare National Valvotomy, pulmonary valve, closed heart; transventricular $1, Valvotomy, pulmonary valve, closed heart; via pulmonary artery $1, Replacement, pulmonary valve $2, Unlisted procedure, cardiac surgery Contractor priced Percutaneous balloon valvuloplasty; aortic valve $1, Percutaneous balloon valvuloplasty; mitral valve $1, Percutaneous balloon valvuloplasty; pulmonary valve $1,123 Surgical Services for Valve Repair/Replacement Procedures (cont.) Medicare National Coronary artery bypass, vein only; single coronary venous graft $2, Coronary artery bypass, vein only; 2 coronary venous grafts $2, Coronary artery bypass, vein only; 3 coronary venous grafts $2, Coronary artery bypass, vein only; 4 coronary venous grafts $2, Coronary artery bypass, vein only; 5 coronary venous grafts $2, Coronary artery bypass, vein only; 6 or more coronary venous grafts $2, Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) $ Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 $ Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 $ Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 $ Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 $ Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for primary $870 procedure) Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for $546 primary procedure) Coronary artery bypass, using arterial graft(s); single arterial graft $1, Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts $2, Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts $2, Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts $2, Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure (List separately in addition to code for primary procedure) $266 Surgical Services for CABG Procedures

3 Medicare National Introduction of catheter, right heart or main pulmonary artery 4 $ Introduction of catheter, aorta 4 $ Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous 4 $52 Anesthesia Services Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2D image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis 5 Insertion and placement of flow directed catheter (e.g., Swan-Ganz catheter) for monitoring purposes $121 $132 INPATIENT HOSPITAL BILLING CODES Medicare inpatient hospital reimbursement is based upon the Medicare Severity-Diagnosis Related Group (MS-DRG) classification system, which assigns MS-DRGs based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. The following codes generally describe procedures associated with the use of Edwards Lifesciences Heart Valve technologies. 3 ICD-9-CM 6 Procedure Code Valve Repair/Replacement Procedures Closed heart valvotomy, unspecified valve Closed heart valvotomy, aortic valve Closed heart valvotomy, mitral valve Closed heart valvotomy, pulmonary valve Closed heart valvotomy, tricuspid valve Open heart valvuloplasty without replacement, unspecified valve Open heart valvuloplasty of aortic valve without replacement Open heart valvuloplasty of mitral valve without replacement Open heart valvuloplasty of pulmonary valve without replacement Open heart valvuloplasty of tricuspid valve without replacement Open and other replacement of unspecified heart valve Open and other replacement of aortic valve with tissue graft Open and other replacement of aortic valve Open and other replacement of mitral valve with tissue graft Open and other replacement of mitral valve Open and other replacement of pulmonary valve with tissue graft Open and other replacement of pulmonary valve Open and other replacement of tricuspid valve with tissue graft Open and other replacement of tricuspid valve Annuloplasty Other operations on valves of heart Arterial catheterization Diagnostic ultrasound of heart

4 ICD-9-CM 6 Procedure Code CABG Procedures Aortocoronary bypass for heart revascularization, not otherwise specified (Aorto)coronary bypass of one coronary artery (Aorto)coronary bypass of two coronary artery (Aorto)coronary bypass of three coronary artery (Aorto)coronary bypass of four or more coronary artery Single internal mammary-coronary artery bypass Double internal mammary-coronary artery bypass Abdominal-coronary artery bypass Other bypass anastomosis for heart revascularization Arterial catheterization Extracorporeal circulation auxiliary to open heart surgery INPATIENT HOSPITAL REIMBURSEMENT Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on Medicare Severity-Diagnosis Related Groups (MS-DRGs). All services and supplies provided during the inpatient admission are bundled into a single MS-DRG payment rate for each patient regardless of the length of stay, intensity of treatments, or number of procedures performed. MS-DRG assignment is usually determined based on the patient s primary diagnosis or procedure performed, as indicated by the ICD-9-CM codes on the billing form. MS-DRG 7 FY2014 Medicare National Average Payment 8 FY2015 Medicare National Average Payment 9 Valve Repair/Replacement Procedures 216 procedures with cardiac catheterization with MCC 217 procedures with cardiac catheterization with CC 218 procedures with cardiac catheterization without MCC or CC 219 procedures without cardiac catheterization with MCC 220 procedures without cardiac catheterization with CC 221 procedures without cardiac catheterization without MCC or CC $54,981 $55,862 $36,442 $37,123 $31,470 $32,667 $45,928 $45,203 $30,690 $30,533 $26,924 $27,185 CABG Procedures 231 Coronary bypass with PTCA with MCC $45,328 $45, Coronary bypass with PTCA without MCC $32,562 $32, Coronary bypass with cardiac catheterization with MCC $42,851 $43, Coronary bypass with cardiac catheterization without MCC $27,955 $28, Coronary bypass without cardiac catheterization with MCC $33,915 $33, Coronary bypass without cardiac catheterization without MCC $22,045 $22,261

5 REVENUE CODES 10 AND HCPCS CODES Revenue codes help hospitals categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting purposes. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. It may be appropriate for hospitals to capture the cost of products used for the procedures described above within Revenue Code 0278 (Medical/Surgical Supply Other Implant) or Revenue Code 0360 (Operating Room Services - General). Health Care Common Procedural Coding System (HCPCS) codes include level I codes (CPT, described above) and level II codes (other products, supplies, and services not included in CPT). Level II HCPCS codes, including C codes, are not applicable to Edwards products utilized in the procedures described above. C codes are used in conjunction with the Medicare prospective payment system for outpatient procedures only. DISCLAIMER Reimbursement information provided by Edwards Lifesciences is gathered from third-party sources and is presented for informational purposes only. Edwards makes no representation, warranty or guarantee as to the timeliness, accuracy or completeness of the information and such information is not, and should not be construed as reimbursement, coding or legal advice. Any and all references to reimbursement codes are provided as examples only and are not intended to be a recommendation or advice as to the appropriate code for the a particular patient, diagnosis, product or procedure or a guarantee or promise of coverage or payment, nor does Edwards Lifesciences warranty that codes listed are appropriate in all related clinical scenarios. It is the responsibility of the provider to determine if coverage exists and what requirements are necessary for submitting a proper claim for reimbursement to a health plan or payer, including the appropriate code(s) for products provided or services rendered. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently; service providers are responsible for all decisions relating to coding and reimbursement submissions. Medicare s Correct Coding Initiative and commercial payer policies are reviewed and updated several times each year. Accordingly, Edwards strongly recommends consultation with payers, reimbursement specialists and/or legal counsel regarding appropriate product or procedure codes, coverage, and reimbursement matters. 1 Current Procedure Terminology (CPT) copyright 2015, American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use. 2 Not all codes provided are applicable for the clinical scenarios in which Edwards Lifesciences Heart Valve technologies are used. The provider is responsible for selecting the most appropriate code(s) for the patient s clinical presentation. When diagnostic services are performed, it may be appropriate to add applicable codes according to the service provided following the correct coding guidelines. Services that are considered a component of another procedure may not always be coded and billed separately. 3 For all Medicare Payments for physician, hospital outpatient, and ASC services, the multiple procedure reduction rule may apply. Consult with coding and billing staff, and payer policy for further guidance. National average Medicare payment is calculated using the Conversion Factor of $ It is likely that Congress will pass another temporary physician payment fix in order to avert the Sustainable Growth Rate (SGR) payment cut for when these rates expire on March 31, Federal Register Volume 79, Number 219, November 13, National average is based on factors such as geography, teaching vs. non-teaching hospital, rural vs. urban area, etc. and your payment may be different based on these factors. This payment will differ for commercial payers. Payments are effective January 1, 2015-March 31, For Minimal Incision Valve Surgery procedures, multiple catheters and/or cannulae are typically used; therefore, the use of modifier -59 may be required. Check with internal billing staff and payer policies for clarification. 5 Diagnostic procedures performed in the facility setting may require the use of modifier -26 to reflect the professional component of the service only. Check with internal billing staff and payer policies for clarification. Intraoperative Transesophageal echocardiography (TEE) is a non-covered service for many payers. Providers may wish to review Medicare s Correct Coding Initiative when providing anesthesia services in conjunction with TEE. Consult payer policies and contracts for clarification. 6 International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, ICD-9-CM for hospitals, volume 1, 2, & 3. 7 DRG Expert: A Comprehensive Guidebook to the DRG Classification System, CMS Federal Register, Volume 78; Number 160, August 19, Payments are effective October 1, September 30, CMS Federal Register, Volume 79; Number 163, August 22, Payments are effective October 1, September 30, National Uniform Billing Committee, American Hospital Association CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards, Edwards Lifesciences, the stylized E logo and Swan-Ganz are trademarks or service marks of Edwards Lifesciences Corporation Edwards Lifesciences Corporation. All rights reserved. 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