Arkansas Health Care Payment Improvement Initiative Percutaneous Coronary Intervention Algorithm Summary

Transcription

1 Arkansas Health Care Payment Improvement Initiative Percutaneous Coronary Intervention Algorithm Summary

2 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 2 of 8 Triggers PAP assignment Exclusions Professional claim for PCI (angioplasty, stent, thrombectomy, artherectomy, injection or transfusion of thrombolytic agent, transcathereter placement of ration delivery device) For specific ICD-9-CM, and CPT/HCPCS procedure, please see dataset. The Principal Accountable Provider (PAP) for an episode is the Interventional Cardiologist or Interventional Radiologist who is enrolled in an Arkansas Blue Plan provider network that performs services for the patient with PCI code. If the patient transfers from one facility to another, both of which having a PCI DRG code, then the final discharging facility will be the PAP. Episodes meeting one or more of the following criteria will be excluded: A. The patient has claims or enrollment records that indicate coordination of benefits with another payer not associated with the Arkansas Blue Plans within the duration of the episode B. The patient does not have continuous coverage with at least one Arkansas Blue Plan throughout the entire episode C. The overall episode cost for the patient exceeds the outlier criteria. Currently, the outlier threshold is set at three standard deviations above the average episode cost for all patients otherwise included in the reporting period for all PAPs D. The patient was discharged against medical advice or due to expiration. E. PCI that converts to CABG within 1 day F. Patients is less than 18 years old G. Patient is 65 years or older H. Episode overlaps with another episode I. Provider terminated prior to report publication or is VA J. The patient s claims indicated any of the following co-morbidities within 365 days prior to the trigger procedure through the end of the episode: 1) Abortion complications, 2) Amnios, 3) Arteritis NOS, 4) Bladder cancer, 5) Bone cancer, 6) Brain cancer, 7) Breast Cancer, 8) Bronchial/lung cancer, 9) Cervix cancer, 10) Colon cancer, 11) Esophageal cancer, 12) Female genital cancer, 13) Fetal disturbances, 14) Forceps or vacuum extractor delivery, 15) GI/Perit Cancer, 16) Head/Neck cancer, 17) HIV, 18) Hodgkin's lymphoma, 19) Kidney/renal cancer, 20) Leukemias, 21) Liver cancer, 22) Maintenance chemical, 23) Male genital cancer, 24) Malignant neoplasm, 25) Malposition, 26) Multiple myeloma, 27) Neoplasm unspecified, 28) Non-Hodgkin's lymphoma, 29) Other perinatal diagnosis, 30) Other primary cancer, 31) Other respiratory cancer, 32) Ovarian cancer, 33) Pancreas cancer, 34) Pelvic obstruction, 35) Perinatal jaundice, 36) Poison nonmedical, 37) Polyarteritis nodosa and allied conditions, 38) Prostate cancer, 39) Rectum/anus cancer, 40) Respiratory distress, 41) Skin melanoma, 42) Spontaneous abortion, 43) Stomach cancer, 44) Suicide and intentional self-inflicted injury, 45) Testicle cancer, 46) Thyroid cancer, 47) Transplant, 48) Umbilical cord complications, 49) Urinary organ cancer, 50) Uterus cancer, 51) Louse-borne typhus, 52) Dialysis, 53) Complications from organ transplants, 54) Secondary malignancy, 55) ESRD (end stage renal disease) K. Patient is an Exchange member L. Patient is an Access Only member

3 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 3 of 8 Episode time window Claims included Quality measures Utilization measures Adjustments Exclusion Included in the episode are all related services if a diagnostic angiogram is done within 30 days prior to the PCI procedure and 30 days after PCI procedure, including inpatient and outpatient facility services, professional services, and related medications. If no diagnostic angiogram performed episodes will start on the date of the PCI and episode will include 30 days after PCI procedure, including inpatient and outpatient facility services, professional services, and related medications. Discharges will be included for both types of episodes, even if the readmission discharge is after 30 day period. The following services are included if incurred within the episode: A. All claims for inpatient admissions. Claims with a DRG on the CMS list of exclusions for cardiac surgery will not be included in the episode. B. All claims in the following places of service that show a CABG related ICD-9-CM diagnosis: inpatient professional, emergency room, skilled nursing facility, comprehensive inpatient rehab facility C. All claims for select CPT/HCPCS procedures in the following places of service: office, outpatient facility, ambulance D. All claims for medications related to delivery, recover, and complications of procedure After all above criteria are applied, remaining claims will be excluded for select CPT/HCPCS procedures, regardless of the place of service in which it is billed. Quality measures to pass (payment related): A. Adverse Outcomes in 30 days; reporting both the percent of patients with any adverse outcome below and the percent with each of the following: myocardial infarction, stroke, stent thrombosis, post-op hemorrhage, AV fistula, pulmonary embolism, wound infection. Threshold is less than or equal to 5% episodes Quality measures to track (not payment related): A. There are currently no measures to track Utilization measures to track (not payment related): A. Percent of patients receiving simultaneous interventions on multiple vessels B. Percent of patients receiving staged interventions on multiple vessels C. Percent of stents placed that are drug-eluting The total reimbursements attributed to the PAP will be adjusted based on complications that resulted in variations in treatment using a multiplier determined by regression. Over time, risk factors may be added or subtracted based on new research and/or empirical evidence. Patients who have co-morbid condition(s) matching the following diagnosis will be excluded: ICD-9-CM : , 042, 042.0, ,080, 140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9, 141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9, 142.0, 142.1, 142.2, 142.8, 142.9, 143.0, 143.1, 143.8, 143.9, 144.0, 144.1, 144.8, , 145.1, 145.2, 145.3, 145.4, 145.5, 145.6, 145.8, 145.9, 146.0, 146.1, 146.2, 146.3, 146.4, 146.5, 146.6, 146.7, 146.8, 146.9, 147.0, 147.1, 147.2, 147.3, 147.8, 147.9, 148.0, 148.1, 148.2, 148.3, 148.8, 148.9, 149.0, 149.1, 149.8, 149.9, 150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9, 151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 155, 155.0, 155.1, 155.2, 156, 156.0, 156.1, 156.2, 156.8, 156.9, 157, 157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9, 158.0, 158.8, 158.9, 159.0, 159.1, 159.8, 159.9, 160.0, 160.1, 160.2, 160.3, 160.4, 160.5, 160.8, 160.9, 161.0, 161.1, 161.2, 161.3, 161.8, 161.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 163.0, 163.1, 163.8, 163.9, 164.0, 164.1, 164.3, 164.8, 164.9, 165.0, 165.8, 165.9, 170.0, 170.1, 170.2, 170.3, 170.4, 170.5, 170.6, 170.7, 170.8, 170.9, 171.0, 171.2, 171.3, 171.4, 171.5, 171.6, 171.7, 171.8, 171.9, 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 175.0, 175.9, 176.0, 176.1, 176.2, 176.3, 176.4, 176.5, 176.8, 176.9, 179, 180.0, 180.1, 180.8, 180.9, 181, 182.0, 182.1, 182.8, 183.0, 183.2, 183.3, 183.4, 183.5, 183.8,

4 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 4 of 8 Exclusion 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 185, 186.0, 186.9, 187.1, 187.2, 187.3, 187.4, 187.5, 187.6, 187.7, 187.8, 187.9, 188.0, 188.1, 188.2, 188.3, 188.4, 188.5,188.6, 188.7, 188.8,188.9,189.0, 189.1, 189.2, 189.3, 189.4, 189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3, 192.8,192.9, 193, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.0, 195.1, 195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9, 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, , , , 199.0, 199.1, 199.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,201.26, , , , , , , , , , , , 201.5, , , , , , , , , , , , , , , , , ,201.70, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,202.94, , , , , 203.0, , , , 203.1, , , , 203.8, , ,203.82, 204.0, , , , , , , 204.2, , , , 204.8, , , , 204.9, , , , 205.0, , , , 205.1, , , , 205.2, , , ,205.3, , , , 205.8, , , , 205.9, , , , 206.0, , , , 206.1, , , , 206.2, , , , 206.8, , , , 206.9, , , , 207.0, , Patients who have co-morbid condition(s) matching the following diagnosis will be excluded: ICD-9-CM : , 207.1, , , , 207.2, , , , 207.8, , , , 208.0, , , , 208.1, , , , 208.2, , , , 208.8, , , , 208.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 230.0, 230.1, 230.2, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9, 231.0, 231.1, 231.2, 231.8, 231.9, 233.0,233.1, 233.2,233.3, , , , , 233.4, 233.5, 233.6, 233.7, 233.9, 234.0, 234.8, 234.9, 235.0, 235.1, 235.2, 235.3, 235.4, 235.5, 235.6, 235.7,235.8, 235.9, 236.0, 236.1, 236.2, 236.3, 236.4, 236.5, 236.6, 236.7, , , , 237.0, 237.1, 237.2, 237.3, 237.4, 237.5, 237.6, 237.7, , , , , , 237.9, 238.0, 238.1, 238.2, 238.3, 238.4, 238.5, 238.6, 238.7, , , , , , , , , 238.8, 238.9, 239.0, 239.1, 239.2, 239.3, 239.4, 239.5, 239.6, 239.7, 239.8, , , 239.9, , ,

5 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 5 of 8 Exclusion Patients who have co-morbid condition(s) matching the following diagnosis will be excluded: ICD-9-CM : , 446.0, 446.1, , , , 446.3, 446.4, 446.5, 446.6, 446.7, 447.6, , 585.5, 585.6, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, , , , , , ,652.20, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,653.33,653.40,653.41, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,658.33, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,662.10, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 760.0, 760.1, 760.2, 760.3, 760.4, 760.5, 760.6, , , , , , , , , , , 760.8,760.9, 761.0, 761.1, 761.2, 761.3, 761.4, 761.5, 761.6, 761.7, 761.8, 761.9, 762.0, 762.1, 762.2, 762.3, 762.4, 762.5, 762.6, 762.7, 762.8, 762.9, 763.0, 763.1, 763.2, 763.3, 763.4, 763.5, 763.6, 763.7, 763.8, , , , , , 763.9, 766.0,766.1, 766.2, , , 769, 770.0, 770.1, , , , , , , , , , 770.2, 770.3, 770.4, 770.5, 770.6, 770.7, 770.8, , , , , , , , , 770.9, 771.0, 771.1, 771.2, 771.3, 771.4, 771.5, 771.6, 771.7, 771.8, , , , 772.0, 772.1, , , , , , 772.2, 772.3, 772.4, 772.5, 772.6, 772.8, 772.9, 773.0, 773.1, 773.2, 773.3, 773.4, 773.5, 774.0, 774.1, 774.2, , , , 774.4, 774.5, 774.6, 774.7, 775.0, 775.1, 775.2, 775.3, 775.4, 775.5, 775.6, 775.7, 775.8, , , 775.9, 776.0, 776.1, 776.2, 776.3, 776.4, 776.5, 776.6, 776.7, 776.8, 776.9, 777.1, 777.2, 777.3, 777.4, 777.5, , , , , 777.6, 777.8, 777.9, 778.0, 778.1, 778.2, 778.3, 778.4, 778.5, 778.6, 778.7, 778.8, 778.9, 779.0, 779.1, 779.2, 779.3, , , , , 779.4, 779.6, 779.7, 779.8, , , , , , , 779.9, , , ,789.7, 792.3, 795.0, , 795.1, , , , , , , , 795.8, , , , , , , 909.1, 980.1, 980.2, 980.3, 980.8, 980.9, 981, 982.0, 982.1, 982.2, 982.3, 982.4, 982.8, 983.0, 983.1, 983.2, 983.9, 984.0, 984.1, 984.8, 984.9, 985.0, 985.1, 985.2, 985.3, 985.4, 985.5, 985.6, 985.8, 985.9, 986, 986., 987.0, 987.1, 987.2, 987.3, Patients who have co-morbid condition(s) matching the following diagnosis will be excluded: ICD-9-CM : 987.5, 987.6, 987.7, 987.8, 987.9, 988.0, 988.1, 988.2, 988.8, 988.9, 989.0, 989.1, 989.2, 989.3, 989.4, 989.5, 989.6, 989.7, 989.8, , , , , , 989.9, 996.8, , , , ,996.84,996.85, , , , , E950.0, E950.1, E950.2, E950.3, E950.4, E950.5, E950.6, E950.7, E950.8, E950.9, E951.0, E951.1, E951.8, E952.0, E952.1, E952.8, E952.9, E953.0, E953.1, E953.8, E953.9, E954, E955.0, E955.1, E955.2, E955.3, E955.4, E955.5, E955.6, E955.7, E955.9, E956, E957.0, E957.1, E957.2, E957.9, E958.0, E958.1, E958.2, E958.3, E958.4, E958.5, E958.6, E958.7, E958.8, E958.9, V08, V10.0, V10.00, V10.01, V10.02, V10.03, V10.04, V10.05, V10.06, V10.07, V10.09, V10.11, V10.12, V10.20, V10.21, V10.22, V10.29, V10.3, V10.40, V10.41, V10.42, V10.43, V10.44, V10.45, V10.46, V10.47, V10.48, V10.49, V10.50, V10.51, V10.52, V10.53, V10.59, V10.60, V10.61, V10.62, V10.63, V10.69, V10.71, V10.72, V10.79,

6 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 6 of 8 Exclusion ICD-9-CM : V10.81, V10.82, V10.84, V10.85, V10.86, V10.87, V10.88, V10.89, V10.9,V10.90, V10.91, V13.7, V42.0, V42.1, V42.5, V42.7, V45.1, V45.11, V45.12, V50.2, V56, V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, V58.0, V58.1, V58.11, V58.12, V62.84, V66.1, V66.2, V67.1, V67.2, V71.1 Patients who have claims including any of the following procedure will be excluded: CPT : 33510, 33511, 33512, 33513, 33514, 33516, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, HCPCS : S2205,S2206,S2207,S2208,S2209 ICD-9-Procedure Codes: 36.10,36.11,36.12,36.13,36.14,36.15,36.16,36.17,36.19,36.20 Patients who have claims including any of the following CPT/HCPCS procedure on the same day as the trigger procedure will be excluded: CPT : 30118, 30130, 30140, 30520, 30801, 30802, 30901, 30903, 30905, 30930, 31000, 31020, 31231, 31238, 31525, 31526, 31622, 38510, 41010, 41112, 41115, 42140, 42408, 42960, 42962, 44970, 58558, 58661, For patients who have claims indicating transportation charges, those costs will be excluded from the episode calculations: CPT : 0A434, A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0435, A0436, A0800, A0888, A0998, A0999, G0240, G0241, Q3017, S9960, S9961 Claims included Claims with the following DRG are excluded based on the CMS exclusions for cardiac surgery: MS-DRG : 0005, 0006, 0007, 0008, 0010, 0011, 0013,0014,0016,0017,0020,0021, 0022, 0023, 0024, 0025, 0026, 0027, 0028, 0029, 0030, 0031, 0032, 0033, 0037, 0038, 0039, 0040, 0041, 0042, 0113, 0114, 0115, 0116, 0117, 0129, 0130, 0131, 0132, 0133, 0134, 0135, 0136, 0137, 0138, 0139, 0163, 0164, 0165, 0326, 0327, 0328, 0329, 0330, 0331, 0332, 0333, 0334, 0335, 0336, 0337, 0338, 0339, 0340, 0341, 0342, 0343, 0344, 0345, 0346, 0347, 0348, 0349, 0350, 0351, 0352, 0353, 0354, 0355, 0405, 0406, 0407, 0408, 0409, 0410, 0411, 0412, 0413, 0414, 0415, 0416, 0417, 0418, 0419, 0420, 0421, 0422, 0423, 0424, 0425, 0453, 0454, 0455, 0456, 0457, 0458, 0459, 0460, 0461, 0462, 0463, 0464, 0465, 0466, 0467, 0468, 0469, 0470, 0471, 0472, 0473, 0474, 0475, 0476, 0477, 0478, 0479, 0480, 0481, 0482, 0483, 0484, 0485, 0486, 0487, 0488, 0489, 0490, 0491, 0492, 0493, 0494, 0495, 0496, 0497, 0498, 0499, 0500, 0501, 0502, 0503, 0504, 0505, 0506, 0507, 0508, 0509, 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0570, 0571, 0572, 0573, 0574, 0575, 0576, 0577, 0578, 0579, 0580, 0581, 0582, 0583, 0584, 0585, 0614, 0615, 0619, 0620, 0621, 0625, 0626, 0627, 0628, 0629, 0630, 0652, 0653, 0654, 0655, 0656, 0657, 0658, 0659, 0660, 0661, 0662, 0663, 0664, 0665, 0666, 0667, 0668, 0669, 0670, 0671, 0672, 0707, 0708, 0709, 0710, 0711, 0712, 0713, 0714, 0715, 0716, 0717, 0718, 0734, 0735, 0736, 0737, 0738, 0739, 0740, 0741, 0742, 0743, 0744, 0745, 0746, 0747, 0748, 0749, 0750, 0765, 0766, 0767, 0768, 0769, 0770, 0799, 0800, 0801, 0820, 0821, 0822, 0823, 0824, 0825, 0826, 0827, 0828, 0829, 0830, 0876, 0901, 0902, 0903, 0904, 0905, 0906, 0907, 0908, 0909, 0927, 0928, 0929, 0955, 0956, 0957, 0958, 0959,0969, 0970, 0984, 0985, 0986 In addition to all inpatient facility claims, claims with one of the following diagnoses are included when performed in an inpatient professional, emergency room, skilled nursing facility, or comprehensive inpatient rehab facility: ICD-9-CM : , , , , , , , , , , , , , , , , , , , , 251.1, 251.2, , , , , 278.1, 293.1, , , , ,

7 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 7 of 8 Claims included ICD-9-CM : , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 411.0, 411.1, , , , , , , , , , 412, 413.0, 413.1, 413.9, , , , , , , , , , , , , , , , , , , 414.2, 414.3, 414.4, 414.8, 414.9, , , 423.3, 425.0, , , , , , , , , 425.2, 425.3, 425.4, 425.5, 425.7, 425.8, 425.9, 426.0, , , , , 426.2, 426.3, 426.4, , , , , , 426.6, 426.7, , , , , , , , , , 426.9, 427.0, 427.2, 42 In addition to all inpatient facility claims, claims with one of the following diagnoses are included when performed in an inpatient professional, emergency room, skilled nursing facility, or comprehensive inpatient rehab facility: ICD-9-CM : , , , , 427.5, , , , , , 427.9, 428.0, 428.1, , , , , , , , , , , , , 428.9, 429.0, 429.1, 429.2, 429.3, 429.5, 429.6, , , , , , , , , , , , 429.9, , , , , 512.1, 514, 519.2, , , , , , , , , , , , 785.0, 785.1, , , , , , , , , , , , , , , , , , , , , , , , 998.2, , , , , , , , , , , , , E870.0, E884.2, E884.3, E884.4, E884.5, E884.6, V09.0, V45.00, V45.01, V45.02, V45.03, V45.04, V45.05, V45.06, V45.07, V45.08, V45.09, V45.11, V45.12, V45.2, V45.3, V45.4, V45.51, V45.52, V45.53, V45.54, V45.55, V45.56,V45.57, V45.58, V45.59, V45.61, V45.62, V45.63, V45.64, V45.65, V45.66, V45.67, V45.68, V45.69, V45.71, V45.72, V45.73, V45.74, V45.75, V45.76, V45.77, V45.78, V45.79, V45.81, V45.82, V45.83, V45.84, V45.85, V45.86, V45.87, V45.88, V45.89, V53.31, V53.32, V53.39, V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.4, V85.41, V85.42, V85.43, V85.44, V85.45, V85.53, V85.54 Claims with the following procedure are also included when performed in an office, outpatient facility, or ambulance: CPT/HCPCS procedure : 12020, 12021, 13160, 13206, 33207, 33208, 33209, 33210, 33211, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33219, 33220, 33221, 33222, 33223, 33224, 33225, 33226, 33227, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33236, 33237, 33238, 33240, 33241, 33242, 33243, 33244, 33249, 33510, 33511, 33512, 33513, 33514, 33515, 33516, 33517, 33518, 33519, 33520, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 33572, 33967, 33970, 33973, 35701, 35820, 35875, 35876, 35905, 71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75600, 75605, 75625, 75630, 75635, 75658, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75774, 75791, 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92942, 92943, 92944, 92960, 92973, 92974, 92975, 92980, 92981, 92982, 92983, 92984, 92995, 92996, 93000, 93005, 93010, 93015, 93016, 93017, 93018, 93024, 93025, 93040, 93041, 93042, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93278, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93501, 93508, 93510, 93511, 93514, 93524, 93526, 93527, 93528, 93529, 93539, 93540, 93541, 93542, 93543, 93544, 93545, 93555, 93556, 93600, 93602, 93603, 93609, 93610, 93612, 93613, 93615, 93616, 93618, 93619, 93620, 93621, 93622, 93623, 93624, 93631, 93640, 93641, 93642, 93650, 93651, 93652, 93653, 93654, 93655, 93656, 93657, 93797, 93798, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608, G0269, G0290, G0291, SS205, SS209

8 Percutaneous Coronary Intervention (PCI) Algorithm Summary v1.0 Page 8 of 8 Claims included Claims with the following procedure are also included when performed in an office, outpatient facility, or ambulance: ICD-9 CM procedure : 00.40, 00.41, 00.42, 00.43, 00.44, 00.45, 00.46, 00.47, 00.48, 00.50, 00.51, 00.52, 00.53, 00.54, 00.66, 36.00, 36.01, 36.02, 36.03, 36.04, 36.05, 36.06, 36.07, 36.09, 36.10, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16, 36.17, 36.19, 36.20, 37.00, 37.21, 37.22, 37.23, 37.26, 37.27, 37.29, 37.34, 37.61, 37.70, 37.71, 37.72, 37.73, 37.74, 37.75, 37.76, 37.77, 37.78, 37.79, 37.80, 37.81, 37.82, 37.83, 37.85, 37.86, 37.87, 37.89, 37.94, 37.95, 37.96, 37.97, 37.98, 37.99, 84.49, 86.04, 86.59, 87.44, 88.4, 88.40, 88.41, 88.42, 88.43, 88.44, 88.45, 88.46, 88.47, 88.48, 88.49, 88.5, 88.50, 88.51, 88.52, 88.53, 88.54, 88.55, 88.56, 88.57, 88.58, 88.59, 88.60, 88.61, 88.62, 88.63, 88.64, 88.65, 88.66, 88.67, 88.68, 88.72, 88.92, 89.41, 89.42, 89.43, 89.44, 89.45, 89.46, 89.47, 89.48, 89.49, 89.50, 89.51, 89.52, 89.53, 89.54, 89.55, 89.56, 89.57, 89.58, 89.59, 89.60, 89.61, 89.62, 89.63, 89.64, 89.65, 89.66, 89.67, 89.68, 89.69, 92.05, 93.36, 96.59, 99.10, 99.60, 99.61, 99.62, 99.64, Quality Utilization NDC: There are more than 97,000 NDC, can provide upon request. Adverse Outcomes is determined by claims that have one of the following diagnosis in diagnostic, facility and professional services within 30 days of trigger claim. ICD-9-CM : 410, , , , , V12.55, Utilization measures to track (not payment related): Percent of patients receiving simultaneous interventions on multiple vessels calculated based on claims with procedure on the same date as the trigger. ICD-9-CM procedure : 00.41, 00.42, 00.43, 00.44, 00.46, 00.47, CPT/HCPS procedure : 92921,92925, 92929, 92934, 92938, 92942, Percent of patients receiving staged interventions on multiple vessels calculated based on claims with procedure within 30 days of trigger. ICD-9-CM procedure : 00.40, 00.41, 00.42, 00.43, 00.44, 00.45, 00.46, 00.47, CPT/HCPCS procedure : 92921, 92925, 92929, 92934, 92938, 92942, Percent of stents placed that are drug-eluting calculated based on claims with this procedure code reported ICD-9-CM procedure : 36.07