Nuclear Cardiology Reimbursement. Todd Lamb, BS, AS, CNMT Clinical Operations Mgr Regions Hospital St. Paul, MN

Transcription

1 Nuclear Cardiology Reimbursement Todd Lamb, BS, AS, CNMT Clinical Operations Mgr Regions Hospital St. Paul, MN

2 Slides are not to be reproduced without the permission of the author

3 Slides are not to be reproduced without the permission of the author

4 Slides are not to be reproduced without the permission of the author

5 Slides are not to be reproduced without the permission of the author

6 Slides are not to be reproduced without the permission of the author

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9 9 That crazy administrator must have put out that 2 for 1 sign for Tetrofosmin and Mag3 nuclear exams again!!

10 Dean Mobbs; Michael D. Greicius; Eiman Abdel-Azim; Vinod Menon; Allan L. Reiss. Humor modulates the mesolimbic reward centers.. Neuron 40(5):1041-8,

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19 CPT or HCPCS code Hospital Revenue Code APC group Units Status National 2004 APC Payment Rates Effective January 1, 2004 National 2004 PFS (RBRVS) TC Payment Rates Effective March 1, TC SPECT MP w/ rest/stress Myocardial Scan 1 S $ $ TC MPI w/ wall motion Myocardial Add-on Scans 1 S $83.33 $ TC MPI w/ EF Myocardial Add-on Scans 1 S $83.33 $ TC Stress Test 0341 or CV Stress Test 1 X $86.54 $67.21 J0152 Adenosine per 30 mg 60 and 90 mg vials Adenosine 30 mg 1 K $56.71 $66.56 (4/2003 AWP) A mTc Sestamibi per dose K $ (2 X )* $ (2 X )* Comparison of Technical Rates Total $ Based on 60 mg of adenosine $ Based on 60 mg of adenosine 19

20 1.Adenosine (Adenoscan) *HCPCS code J per 30 mg Dosage is calculated according to the patient's weight (140 mcg/kg/minute) for 6 minutes. The total dose is not to exceed 0.84 mg/kg (for a 200-lb person, the total maximum dose would equal 76 mg). 2.Note: Code J Adenosine (Adenocard) 6mg. It is inappropriate to use this code when billing Medicare Part B in conjunction with a stress test. This drug is indicated for treatment of supraventricular tachycardia (SVT) 427.0, , and will be denied as not medically necessary when billed in conjunction with cardiac stress testing. 20

21 CPT or HCPCS code Hospital Revenue Code APC group Units Status National 2004 APC Payment Rates Effective January 1, 2004 National 2004 PFS (RBRVS) TC Payment Rates Effective March 1, TC SPECT MP w/ rest/stress Myocardial Scan 1 S $ $ TC MPI w/ wall motion Myocardial Add-on Scans 1 S $83.33 $ TC MPI w/ EF Myocardial Add-on Scans 1 S $83.33 $ TC Stress Test 0341 or CV Stress Test 1 X $86.54 $67.21 J0280 Aminophyllin up to 250 mg, inj K Packaged into APC rate?? J1245 Dipyridamole injection, per 10 mg K $68.90 (5 X 13.78)* $ (5 X 21.89)* A mTc Sestamibi per dose K $ (2 X )* $ (2 X )* Comparison of Technical Rates Total $ $ NOT incl. Possible aminophyllin reimb. 21

22 CPT or HCPCS code Hospital Revenue Code APC group Units Status National 2004 APC Payment Rates Effective January 1, 2004 National 2004 PFS (RBRVS) TC Payment Rates Effective March 1, TC SPECT MP w/ rest/stress Myocardial Scan 1 S $ $ TC MPI w/ wall motion Myocardial Add-on Scans 1 S $83.33 $ TC MPI w/ EF Myocardial Add-on Scans 1 S $83.33 $ TC Stress Test 0341 or CV Stress Test 1 X $86.54 $67.21 A Thallium K $73.16 $ (4 X 29.45)* J1245 Dipyridamole injection, per 10 mg K $68.90 (5 X 13.78)* $ (5 X 21.89)* A mTc Tetrofosmin per dose K $ (1 X )* $ (1 X )* Comparison of Technical Rates Total $ $

23 CPT or HCPCS code Hospital Revenue Code APC group Units Status National 2004 APC Payment Rates Effective January 1, 2004 National 2004 PFS (RBRVS) TC Payment Rates Effective March 1, TC Cardiac Blood pool imaging S $ $ TC RVEF- First pass Add-on code S $83.33 $61.98 Q3010 Tc-99m labeled RBC s N Packaged into APC rate Carrier determined Comparison of Technical Rates Total $ $

24 RADIOPHARMACEUTICALS & NUCLEAR CARDIOLOGY RELATED DRUGS 1600 A9500 Technetium TC 99m sestamibi Supply of Radiopharmaceutical Diagnostic Imaging Agent, Technetium TC 99m sestamibi, per dose CARDIOLITE / MIRALUMA K $ A9502 Technetium TC99M tetrofosmin Supply of Radiopharmaceutical Diagnostic Imaging Agent, Technetium TC99M tetrofosmin, per unit dose 1603 A9505 TI-201 per mci MYOVIEW K $ THALLIUM 201 K $18.29 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Thallous chloride TL 201, per mci A9514 Technetium Tc99m Pyrophosphate Supply of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc99m Pyrophosphate, per mci 9025 A9526 Ammonia N-13, per dose 1775 C1775 FDG, per dose (4-40 mci) PYROLITE *Use this code for myocardial infarct imaging. Do not use this code for GBP, RVG or MUGA procedures see Q3010 N-13 N Packaged into APC rate K $ K $ Supply of radiopharmaceutical diagnostic imaging agent, fluorodeoxyglucose F18 (2-deoxy-2-[18F]fluoro-D-glucose), per dose (4-40 mci/ml) FDG / F-18 The new branded radiopharmaceutical "C" codes listed below have caused much confusion in the nuclear medicine community 9408 C9408 FDG, brand, per dose K $ J0150 Injection adenosine 6 mg ADENOCARD K $11.34 Injection Adenosine, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) 0917 J0152 Adenosine injection, 30 mg K $56.71 J0280 Aminophyllin up to 250 MG, inj. N Packaged into APC rate 24

25 RADIOPHARMACEUTICALS & NUCLEAR CARDIOLOGY RELATED DRUGS Cont'd J0460 Atropine sulfate injection, up to 0.3 mg N Packaged into APC rate J1120 Acetazolamide sodium injection, up to 500 mg N Packaged into APC Diamox rate J1160 Inj, digoxin, up to 0.5 mg N Packaged into APC Lanoxin rate 0380 J1245 Dipyridamole injection, per 10mg Persantine IV K $13.78 J1250 Inj dobutamine HCL/250 mg N Packaged Dobutrex into APC rate J1610 Glucagon hydrochloride per 1MG N Packaged into APC rate J1800 Propranolol HCL injection, up to 1 mg N Packaged Inderal into APC rate 9025 Q3000 Rubidium RB-82 K $ Supply of radiopharmaceutical diagnostic imaging agent, rubidium RB-82, per dose Q3010 Tc-99m Labeled Red Blood Cells Supply of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc99m Labeled Red Blood Cells, per mci Rb-82 ULTRATAG or Cold PYP + 99m Tc Code to be used for both the invivo/invitro methods of tagging Red Blood Cells N Packaged into APC rate 25

26 Imaging Center Reimbursement and Comparison MN Locality Fee schedule weighted (WPS- AVG Medicare) Reimburse ment difference per case CPT and Description CMS Part Heart image (3d), multiple $ $ $ $ Heart wall motion add-on $ $ $56.87 ($106.14) Heart function add-on $ $ $56.87 ($106.14) National Payment Rate CPT/ Long Description Payment Prof. Tech. Global HCPCS Status (26) (TC) (--) Myocardial imaging,(pet), metabolic C/R $79.16 carrier priced carrier priced Myocardial perfusion imaging; (planar) A $44.80 $93.34 $ Myocardial perfusion imaging; (planar) A $64.22 $ $ Myocardial perfusion imaging; A $56.75 $ $ Myocardial perfusion imaging; A $76.17 $ $ Myocardial imaging, infarct avid, planar; A $36.59 $ $ Myocardial imaging, infarct avid, planar; A $41.82 $ $ Myocardial imaging, infarct avid, planar; A $47.79 $ $ Cardiac blood pool imaging, gated A $51.53 $ $ Cardiac blood pool imaging, gated A $76.17 $ $ Myocardial perfusion study with wall A $32.48 $61.98 $ Myocardial perfusion study with ejection A $32.48 $61.98 $ Cardiac blood pool imaging (planar), A $51.90 $ $ Cardiac blood pool imaging (planar), A $77.29 $ $ Myocardial imaging, positron emission I $80.28 $0.00 $ Myocardial imaging, positron emission I $ $0.00 $ Cardiac blood pool imaging, gated A $61.61 $ $ Cardiac blood pool imaging, gated A $26.14 $ $ Unlisted Cardiovascular nuclear exam C carrier priced carrier priced carrier priced 26

27 Medicare Hospital Out Patient APC Nuclear Cardiology Procedures Indicat or E K N S Effective January 1, Revised Implemented April 5, 2004 Service Non-covered Items and Services Not paid under Outpatient PPS Non Pass-Through Drug/ Biological Paid under Outpatient PPS Incidental services, packaged into APC rate Packaged Significant Procedure, Not Discounted When Multiple Paid under Outpatient PPS NUCLEAR CARDIOLOGY PROCEDURE LIST ( GAMMA CAMERA AND PET) CPT/ Trade Status Payment APC HCPCS Description Name IndicatorRate CY Cardiac shunt detection imaging S $ Myocardial imaging, (PET), metabolic evaluation S $ MPI; (planar) single study S $ MPI; (planar) multiple studies, S $ MPI; tomographic (SPECT), single study S $ MPI; tomographic (SPECT), multiple studies S $ Myocardial perfusion study with wall motion (Add-On code) S $ Myocardial perfusion study with ejection fraction (Add-On code) S $ Myocardial imaging, infarct avid, planar S $ Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique S $ Myocardial imaging, infarct avid, planar; tomographic SPECT w or w/o quantification S $ Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress S $ MUGA, at rest, with right ventricular EF by first pass technique (Add-On Code) S $ Cardiac blood pool imaging, gated equilibrium; multiple studies S $ MUGA (planar), first pass technique; single study S $ MUGA (planar), first pass technique; multiple studies, at rest and with stress S $ Myocardial imaging, (PET), perfusion; single study at rest or stress E Myocardial imaging, (PET), perfusion; multiple studies at rest and/or stress E MUGA, SPECT, at rest S $ Unlisted Cardiovascular nuclear exam S $ Cardiovascular stress test with our with out pharmacological intervention; tracing only X $

28 Carrier Loc. Number Locality Name Revised Work PE GPCI* MP GPCI* Number GPCI MINNESOTA MANHATTAN, NY NYC SUBURBS/LONG I., NY POUGHKPSIE/N NYC SUBURBS, NY QUEENS, NY REST OF NEW YORK METROPOLITAN PHILADELPHIA, PA REST OF PENNSYLVANIA Carrier Loc. Number 2005 Locality Name Revised Work PE GPCI MP GPCI Number GPCI MINNESOTA MANHATTAN, NY NYC SUBURBS/LONG I., NY POUGHKPSIE/N NYC SUBURBS, NY QUEENS, NY REST OF NEW YORK METROPOLITAN PHILADELPHIA, PA REST OF PENNSYLVANIA

29 Reimbursement for CPT tomographic (SPECT), multiple studies, at rest and/or stress (exercise and/ or pharmalogic) and redistribution and/or rest injection, with or without quantification. CPT MEDICARE DEFINED LOCALITY MEDICARE MEDICARE REIMBURSE MENT NOT INCLUDING GPCI ADJUSTED MEDICARE REIMBURSE MINNESOTA $ $ MANHATTAN, NY $ $ NYC SUBURBS/LONG I., NY $ $ POUGHKPSIE/N NYC SUBURBS, NY $ $ QUEENS, NY $ $ REST OF NEW YORK $ $ METROPOLITAN PHILADELPHIA, PA $ $ REST OF PENNSYLVANIA $ $

30 Cardiac PET Medicare Timeline Rb-82 Generator produced for cardiac rest and stress imaging FDA approved in 1989 CMS approval in 1994 NH 3 : Cyclotron produced for cardiac rest and stress imaging FDA safety and efficacy finding (2000 FR) CMS approval (Jan, 2004) FDG: for myocardial viability FDA safety and efficacy finding in (2000 FR) CMS approval for in 2001, expanded

31 Medicare Coverage Criteria Cardiac rest-stress stress perfusion ( 82 Rb) When performed in place of SPECT perfusion; or When following an inconclusive SPECT image Cardiac rest-stress stress perfusion ( 13 NH 3 ) When performed in place of SPECT perfusion; or When following an inconclusive SPECT image Myocardial Viability ( 18 FDG) Primary or initial diagnostic study for determining myocardial viability prior to revascularization Following an inconclusive SPECT 31

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34 CODE Description Payment (2004) G0037 CV Rb-82 PET $ Number of Intended PET Patients Per Week = 15 Number of Incremental Referrals Per Week = 1 Q3000 Rb-82 per inj.(162.63) $ SPECT Tc 99m Isotope Expense Per Dose = $75.00 SPECT Tl 201 Isotope Expense Per Dose = Wall Motion SPECT Dual Isotope Expense (average per dose) Ejection Fraction Number of Rb-82 Injections Per Patient = 2 Revenue per study $ 1, Sestamibi 0 Total Tetrofosmin 2 Procedure Revenue 60 $ 65, Thallium (mci) 0 Isotope Expense $ 27, Net Revenue $ 38,

35 Perfusion of the Heart Using Ammonia N-13: Effective for service performed on or after October 1, 2003, PET scans performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA-approved radiopharmaceutical ammonia N-13 are covered, provided the following requirements are met. Limitations: The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT); or The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For the purposes of this requirement, an inconclusive test is a test(s), whose results are equivocal, technically uninterruptible, or discordant with a patient s other clinical data and must be documented in the beneficiary s file.) 35

36 Hospital based NUCLEAR CARDIOLOGY PROCEDURE LIST ( GAMMA CAMERA AND PET) CPT/ Trade Status Payment APC HCPCS Description Name Indicator Rate CY G0032 PET MPI (following rest SPECT, 78464); S $ G0033 PET MPI, (following rest SPECT, S $ G0034 PET MPI, (following stress SPECT, S $ G0035 PET MPI, (following stress SPECT, S $ G0036 PET MPI, (following coronary S $ G0037 PET MPI, (following coronary S $ G0038 PET MPI, (following stress planar MPI, S $ G0039 PET MPI, (following stress planar MPI, S $ G0040 PET MPI, (following stress S $ G0041 PET MPI, (following stress S $ G0042 PET MPI, (following stress MUGA, S $ G0043 PET MPI, (following stress MUGA, S $ G0044 PET MPI, (following rest ECG, 93015); S $ G0045 PET MPI, (following rest ECG, 93015); S $ G0046 PET MPI, (following stress ECG, S $ G0047 PET MPI, (following rest ECG, 93015); S $

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