Health Economics and Reimbursement Summary of PROPOSED Medicare Hospital Outpatient, Ambulatory Surgical Center and Physician Payment s Interventional Cardiology Peripheral Interventions Rhythm Management On July 3, 2014, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) proposed policies and payment rates for Medicare s Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Centers (ASC). CMS also released the CY proposed rule and payment rates for the Physician Fee Schedule (PFS). As is customary, CMS provides the public the ability to comment on proposed changes prior to finalizing their decisions in the Final Rules. The final policy and payment rate are expected about November 1, 2014, and are effective on January 1,. Hospital Outpatient: Average rates for outpatient services would increase by 2.1% in for more than 4,000 hospitals that participate in Medicare. Ambulatory Surgical Center: Overall ASC payments are proposed to increase is 1.2%, over CY 2014 rates. Approximately 5,300 ASC s participate in Medicare and are paid under the ASC payment system. Physician Fee Schedule: As a result of the recent Sustainable Growth (SGR) patch passed earlier this year, the current conversion factor of $35.8228 is effective through March 31,. The proposed rates reflected in the Physician Tables reflect the current conversion factor. In the proposed Physician Rule, CMS is mandated by law to control spending by reducing the conversion factor by 20.9% effective on April 1, if Congress does not provide a short term fix to minimize the SGR. Changes Affecting Broader Medicare Policies Comprehensive APCs - Based on the recommendation in last year s Final Rule, CMS is proposing to move forward with the implementation of Comprehensive APCs. Comprehensive APCs combine a number of procedures required to support the delivery of the primary service into a single all-inclusive payment. Based on their proposal, CMS is making modifications to restructure all device-dependent APCs into 28 comprehensive APCs (c-apcs). To ensure appropriate accounting of all resources, CMS is proposing to apply complexity criteria for multiple procedure combinations designed as c-apcs performed on the same date of service to allow for mapping to a higher APC within that clinical family of procedures. In addition, they propose to package add-on codes performed with primary service assigned to the c-apc. According to the Agency, the policy is being pursued to improve the accuracy and transparency of their payment for certain device-dependent services. Comprehensive APCs result in a single all-inclusive payment for the primary service with no additional reimbursement for concomitant procedures performed during the same operative session. Page 1 of 26
Change to Inpatient Admission Documentation or Certification - While CMS did not change the two-midnight stay requirement for inpatient admissions, the requirements for physician certification of inpatient admissions is proposed to be revised which should be less burdensome to both hospitals and physicians. Under this proposal, physicians would only need to certify for long-stay cases over twenty days and costly outlier cases. CMS believes that in most cases, the admission order, medical record and notes contain sufficient information to support the medical necessity Business of an Unit Name inpatient admission. Hospital Outpatient Quality Reporting (OQR) Program - The Hospital Outpatient Quality Reporting Program (Hospital OQR) is a pay for quality data reporting program implemented for outpatient hospital services. Under the Hospital OQR Program, hospitals must meet administrative, data collection and submission, validation, and publication requirements or receive a two percentage point reduction in their annual payment update (APU). CMS is proposing to remove three measures, including one cardiac care measure, OQR-4: Aspirin at Arrival, as well as two prophylactic antibiotic surgery measures as performance is high with little variation between hospitals. CMS also is proposing modifications to the Hospital OQR Program validation process and formalization of a review and corrections period. Implementation of Physician Value-Based - CMS continues to implement the value-based modifier for physicians as required by the Affordable Care Act. This modifier is similar in concept to the value-based purchasing program for hospitals. In their proposal, CMS is extending the program to solo practitioners and to physicians in groups of two or more eligible professionals for participating in the Physician Quality Reporting System (PQRS). The 2017 valuebased modifier is based on performance. CMS also proposes to increase the maximum amount of payment risk under the program from 2% in 2016 to 4% in 2017. Valuation and Coding of the Global Surgical Package for Physician Payments - Physician payments for surgical procedures also include payment for services before and after the surgery. CMS believes payment rates for many of these surgical codes may be overinflated because they have not been updated in many years. As a result, CMS is proposing over time to remove the costs of services performed before and after the surgery from the surgical procedure payment rate and have providers bill individually for those services. We will be conducting analyses and reaching out to physician societies to better understand the impact over the next few weeks. Open Payments Physician Sunshine Act Changes - CMS proposes a policy change in the Sunshine Act by eliminating one exclusion for continuing medical education (CME) from physician disclosure. Currently payments provided as compensation for speaking at a CME program do not have to be reported if (1) the event is accredited by one of several organizations listed by CMS; (2) the manufacturer is not paying the covered recipient directly; and (3) if the manufacturer does not select the recipient speaker or provide a list of identifiable individuals to be considered as speakers. In response to comments, CMS is proposing to eliminate this exclusion. However, CMS will still retain exclusion under their indirect payment provisions and consider payment to be excluded from reporting if the manufacturer provides funding to a CME provider but does not select nor pay the covered recipient directly nor provide the CME provider with a list of identifiable covered recipients to be considered as speakers. Physician Quality Reporting System (PQRS) - Beginning in, a downward payment adjustment will apply to eligible professionals who do not satisfactorily report data on quality measures for covered professional services or satisfactorily participate in a Qualified Clinical Data Registry (QCDR). In the CY, CMS has proposed to add 28 new individual measures and two measures groups to fill existing measure gaps, as well as remove 73 measures from reporting for the PQRS. These proposed changes would bring the PQRS individual measure set to 240 total measures. While some additions are not cardiovascular specific, other measures may apply. For example, one measure entitled Closing the Referral Loop will track the receipt of a Specialist (i.e. cardiologist or EP) Report for the percentage of patients with referrals. The percentage will be how often the referring provider receives a report from the Specialist provider to whom the patient was referred. Another possible measure is Controlling High Blood Pressure where the percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement period. Page 2 of 26
CMS is proposing to make QCDR measure data available on Physician Compare, collected at the individual level or aggregated to a higher level of the QCDR s choosing such as the group practice level. Table Index Business Unit Name At the end of the document the following three tables list detailed changes for select Interventional Cardiology (IC), Peripheral Intervention (PI), and Rhythm Management (RM), (reflective of Cardiac Rhythm Management and Electrophysiology) device related procedures: Table 1: Hospital Outpatient CY Payment s Table 2: ASC CY Payment s Table 3: Physician CY Fee Schedule ( rates calculated with current conversion factor of $35.8228 and do not reflect proposed 20.9% SGR reduction.) Highlights for Interventional Cardiology (IC), Peripheral Interventions (PI) and Rhythm Management (RM), are as follows: Hospital Outpatient Payments (See Table 1 for Details) Significant HOPPS/ASC Rule Proposals affecting many cardiovascular procedures Packaged services - Seven new categories of items and services are proposed for packaging into the APC procedure payment, including drugs and biologicals, diagnostics and laboratory tests, ancillary services, add-on codes, and device removal procedures. These will be bundled with the primary procedure payment and will no longer be separately paid. Comprehensive APCs As highlighted earlier, CMS is proposing to replace all device-dependent APC s with 28 new comprehensive APCs which include the primary service and all adjunct services provided to support the delivery of the primary service. Impact to Payments - CMS has increased payment on many APCs as a result of the packaging and composite APC proposals to reflect the increase in overall costs and elimination of separate payment for multiple procedures, additional vessels procedures and other services indicated above. CMS is proposing to pay only for the main/primary procedure or initial service code on a claim. A new status indicator J1 will assigned to the packaged CPT codes. For cardiovascular-specific procedures, the non-weighted average outpatient proposed payment rates from Table 1 are: Interventional Cardiology increase by 49%. Peripheral Intervention increase by 2% Rhythm Management increase by 10% Interventional Cardiology comprehensive APCs will positively affect the level of reimbursement for Percutaneous Coronary Intervention (PCI) procedures. Drug-eluting stent procedures with atherectomy, CTO, AMI, or BMS with atherectomy have proposed payment rate of $14,759. This compares to a range of CY2014 rates for these procedures of $6,364 to $7,714. Drug-eluting stent with PTCA, bare metal stent procedures, or atherectomy without stent proposed payment rate of $9,549 compared to a range of $6,364 to $8,843. When DES is part of CTO, AMI, atherectomy, or most second main coronary vessel procedures, the procedures will group to the higher paying APC 0319 as a Complexity Adjusted APC. Page 3 of 26
Peripheral Intervention PTA-only procedures proposed to decrease 2% to $4,334. Stent with/without PTA procedures proposed to increase 5% to $9,549. Combined PTA, Stent and atherectomy procedures proposed to decrease 5% to $14,759. Business Unit Name Embolization proposed to increase 8% to $9,549 which reflects a change from APC 0082 to 0229. Rhythm Management comprehensive APCs for Rhythm Management procedures would result in several substantial reimbursement increases, in particular for CRT and ablation procedures. CMS proposed to reassign the S-ICD system implant procedure from APC 0107 (ICD pulse generator only) to APC 0108 (ICD/CRT-D system implants). The resulting year-over- year hospital proposed payment increase is ~ $5,627 or 22.5% for. This change would fully map all facility S-ICD procedures to the same payment categories as transvenous ICDs procedures. As a result of the severity adjusted comprehensive APCs, the CRT-D replacement (APC assignment change from 0107 to 0108) would increase by 22.5% and CRT-P system implant procedures would increase by 56%. Comprehensive EP studies in conjunction with ablation procedures would increase by 8%. Single chamber pacemaker implants would increase 7.8%; dual chamber pacemaker implants would decrease by 10%. Dual and single ICD implants would decrease by 4.7% WATCHMAN Left Atrial Appendage Closure procedure (0281T) is restricted to the inpatient hospital site of service. Ambulatory Surgical Center (See Table 2 for Detail) Peripheral Interventions All lower extremity bundled PTA, stent and atherectomy procedures are allowed in the ASC; however, less than 1% of PI procedures performed within the ASC. Rhythm Management ASC payments generally are down with the exception of S-ICD system implants. While most RM procedures are allowed in the ASC setting, less than 1% are actually performed in ASCs. S-ICD payments would increase by 18% to ~$27,000. CRT-D system implant proposed to decrease by 8.7%. ICD system implants proposed to decrease by 8.7%, ICD PG only payment rates proposed to decrease by 10.8%. Dual chamber pacemaker system implant payment rates proposed to decrease by 16%, while dual chamber pacemaker PG only payment rates proposed to increase by 7.5% Physician Payments (See Table 3 for Details) Please note that the payment rates listed in this document do not include the approximately 20.9% reduction in rates which would be required by the Sustainable Growth. In addition, the calculations have been made using the CY2014 conversion factor of $35.8228 currently effective through March 31,. The expectation is that Congress will continue to do short term fixes to minimize the Sustainable Growth (SGR). Physician Fee Schedule Information (Table 3 Non-Weighted Average) The overall average change for select procedures is as follows: In-Facility In-Office Interventional Cardiology increase 0.3% N/A Peripheral Interventions no change -1% Rhythm Management increase 0.9% N/A Page 4 of 26
Interventional Cardiology Coronary Stenting DES & BMS stent payment proposed to increase by 0.3% to $625. CTO and DES/BMS stent with atherectomy proposed to increase 0.2% and 0.3% respectively to $700. Business Unit Name AMI PCI proposed to increase 0.3% to $701. Structural Heart-Valves TAVR range of codes stable, up slightly 0.1%. Peripheral Interventions CPT Code Evaluation - CMS has specifically cited Thrombectomy CPT 36870 as potentially being mis-valued. The Agency welcomes stakeholder input on what the reimbursement value of this procedure should be in the future (FY 2016). Physician In-Facility reimbursement is proposed to remain relatively flat. Reimbursement of physicians for procedures done in their office is proposed to decrease 1%. Atherectomy payments increase 1.4% to $12,751. HAM payments decrease 1.3% to $1,520. Embolization payments increase 0.8% to $7,354. Thrombectomy payments decrease 0.1% to $1,865. Rhythm Management Physician Quality Report System (PQRS) - Additional proposed PQRS reporting measures for have been added which are applicable to Rhythm Management including Cardiac Tamponade and/or Pericardiocentesis following Atrial Fibrillation Ablation and Infection within 180 days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision. Payment rates for device implants would remain relatively flat at a 0.81% increase. Ablation and mapping procedures would remain relatively flat at a 0.91% increase. Comments or Questions If you have questions or would like additional information please contact: Interventional Cardiology (IC)/Peripheral Interventions (PI) Tom Meskan IC and PI Deb Lorenz IC Brent Hale - PI 763-494-2016 763-494-2112 763-494-1448 Tom.Meskan@bsci.com Deb.Lorenz@bsci.com Brent.Hale@bsci.com Rhythm Management (RM) Call 1-800-CARDIAC (request reimbursement support) CRM.Reimbursement@bsci.com Page 5 of 26
1 CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Business Unit Name Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. 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. 2 Please note: this coding information may include some codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved. Note: Some of the codes presented above may be used to code for a variety of procedures (diagnostic and therapeutic) employed in the field of electrophysiology, including atrial fibrillation, atrial flutter, AV Node, SVT and VT ablations. Please note that no Boston Scientific products are approved for sale in the US for ablation for atrial fibrillation. Page 6 of 26
Table 1: CY Hospital Outpatient Payment s for Select Procedures APC Descriptor CY CY vs. 2014 Final % YoY Change Interventional Cardiology 0080 Diagnostic Cardiac Catheterization $2,600 $2,587 $13 0.51% 0082 Coronary or Non Coronary Atherectomy to be deleted in CY * 0083 Level I Endovascular Procedures $4,334 $4,410 $76 1.73% 0104 0229 * 0229 0319 Transcatheter Placement of Intracoronary Stents Level II Endovascular Procedures (Atherectomy, BMS, BMS AMI, BMS CTO, BMS Bypass Graft; Previous APC 104) Level II Endovascular Procedures (DES w/ptca and DES Bypass Graft; Previous APC 656) Level III Endovascular Procedures (BMS w Atherectomy; Previous APC 104) to be deleted in CY $9,549 $6,364 $3,185 50.04% $9,549 $7,714 $1,835 23.78% $14,759 $6,364 $8,395 131.91% 0319 Level III Endovascular Procedures (DES w Atherectomy, DES CTO, or DES AMI; Previous APC 656) $14,759 $7,714 $7,045 91.33% 0656 Transcatheter Placement of Intracoronary Drug Eluting Stents to be deleted in CY Peripheral Interventions 0082 Coronary or Non Coronary Atherectomy to be deleted in CY * 0083 Level I Endovascular Procedures (PTA) $4,334 $4,410 $76 1.73% 0088 Thrombectomy $3,281 $3,272 $9 0.29% 0093 Vascular Reconstruction/Fistula Repair $2,443 $2,847 $404 14.18% 0152 Level I Percutaneous Abdominal and Biliary Procedures (Biliary Stenting) $1,832 $1,788 $44 2.45% 0161 Level II Cystourethroscopy and other Genitourinary Procedures $1,235 $1,205 $30 2.51% * 0229 Level II Endovascular Procedures (PTA & Stent, Embolization) $9,549 $9,120 $429 4.70% * 0319 Level IV Endovascular Procedures (PTA, Stent & Atherectomy) $14,759 $15,510 $751 4.84% 0415 Level II Endoscopy Lower Airway $2,261 $2,000 $261 13.05% 0427 Level II Tube Changes and Repositioning $1,454 $1,306 $148 11.30% 0652 Insertion of Intraperitoneal and Pleural Catheters $2,641 $2,417 $224 9.26% 0668 Level I Angiography and Venography $843 $827 $16 1.95% 0676 Thrombolysis and Other Device Revisions $200 $184 $16 8.75% 2616 Brachytherapy, non str,yttrium 90 $16,017 $16,829 $812 4.82% Rhythm Management 0089 Level III Pacemaker and Similar Procedures (PM system, Previous APC 0655) $9,478 $10,588 $1,110 10.48% 0090 Level II Pacemaker and Similar Procedures (PM replacement or lead only) $6,649 NA NA NA 0655 Pacemaker Dual Chamber System $16,536 $10,588 $5,947 56.17% 0108 S ICD Implant Level II ICD and Similar Procedures (Previous APC 0107) $30,645 $25,018 $5,627 22.49% 0108 Level II ICD and Similar Procedures (ICD or CRTD System or CRT-D Replacement) $30,645 $32,145 $1,500 4.66% 0107 Level I ICD and Similar Procedures (ICD/S ICD PG only, Previous APC 0107) $23,083 $25,018 $1,935 7.74% 0080 Diagnostic Cardiac Catheterization $2,600 $2,587 $13 0.51% 7
Table 1: CY Hospital Outpatient Payment s for Select Procedures APC Descriptor CY CY vs. 2014 Final % YoY Change 0084 Level I EP Procedures $881 $754 $127 16.85% 0085 Level II EP Procedures $4,592 $4,233 $359 8.48% 0086 Level III Electrophysiologic Procedures (EP study + Ablation, Previous APC 8000) $14,169 $13,115 $1,054 8.04% * Symbol notes comprehensive APC 8
CPT Peripheral Interventions Hemodialysis PTA Table 2: Ambulatory Surgical Center (ASC) ASC CY Payment s for Select Procedures CY CY Payment Payment 35476 Transluminal balloon angioplasty, percutaneous; venous 35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Iliac Revascularization * 37220 Transluminal peripheral angioplasty, percutaneous; iliac vs. $ $ $ % $1,243 $923 $319 34.57% $1,318 $978 $339 34.69% $2,069 $2,436 ($367) 15.08% 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed $6,023 $5,038 $985 19.55% * Iliac procedures shown as sample: All 15 LE bundled codes (37220 37235) are allowed in the ASC Thrombectomy 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and $1,170 $1,703 ($533) 31.29% intra graft thrombolysis) 34490 Thrombectomy, with or without catheter; axillary and subclavian vein, by arm incision $1,776 $1,807 ($31) 1.74% Trach Bronch Stent 31631 Bronchosopy (rigid or flexible); with tracheal dilation and placement of tracheal stent $1,224 $1,105 $119 10.77% Biliary Stenting 47556 Biliary endoscopy, percutaneous via T tube or other tract; with dilation of biliary duct stricture(s) with stent $2,194 $2,268 ($74) 3.28% 47510 Insert catheter, bile duct $992 $988 $4 0.39% 47525 Change bile duct catheter $643 $722 ($79) 10.89% 47530 Revise/reinsert bile tube $643 $722 ($79) 10.89% 49421 Insert abdom drain, perm $1,292 $1,335 ($43) 3.24% 50392 Insert kidney drain $669 $666 $3 0.44% 49423 Exchange drainage catheter $643 $722 ($79) 10.89% 9
CPT Table 2: Ambulatory Surgical Center (ASC) ASC CY Payment s for Select Procedures CY CY Payment Payment vs. $ $ $ % Rhythm Management 33208 Pacemaker dual chamber system implant $7,799 $9,286 ($1,487) 16.01% 33213 Pacemaker dual chamber pulse generator only $7,799 $7,256 $543 7.48% 33249 ICD system implant $27,005 $29,600 ($2,595) 8.77% 33240 ICD pulse generator only $20,400 $22,882 ($2,481) 10.84% 0319T S ICD System Implant $27,005 $22,882 $4,123 18.02% 33249 + CRT-D System implant (33249 & 33225 when performed on the same 33225 day) $29,600 $29,600 $0 0.00% 10
Table 3: Physician Fee Schedule CY Rule Payment s Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. CPT Facility Interventional Cardiology Diagnostic Catheterization 93451 26 Right heart catheterization including measurement(s) of oxygen $149 ($2) 1.42% $149 ($2) 1.42% 93451 saturation and cardiac output, when performed NA NA NA $793 $4 0.45% 93452 26 Left heart catheterization including intraprocedural injection(s) $262 ($4) 1.35% $262 ($4) 1.35% 93452 for left ventriculography; imaging supervision and NA NA NA $896 $9 1.05% 93453 26 Combined right heart cath and left heart catheterization $344 ($4) 1.03% $344 ($4) 1.03% 93453 including intraprocedural injection(s) for left ventriculography, NA NA NA $1,153 $5 0.41% 93454 26 Catheter placement in coronary artery(s) for coronary $263 ($4) 1.34% $263 ($4) 1.34% 93454 angiography, including intraprocedural injection(s) for coronary NA NA NA $907 $3 0.36% 93455 26 Catheter placement in coronary artery(s) for coronary $304 ($4) 1.16% $304 ($4) 1.16% 93455 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,056 $4 0.37% 93456 26 Catheter placement in coronary artery(s) for coronary $339 ($3) 0.84% $339 ($3) 0.84% 93456 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,135 $3 0.28% 93457 26 Catheter placement in coronary artery(s) for coronary $379 ($4) 1.03% $379 ($4) 1.03% 93457 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,282 $3 0.20% 93458 26 Catheter placement in coronary artery(s) for coronary $320 ($5) 1.65% $320 ($5) 1.65% 93458 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,086 $3 0.23% 93459 26 Catheter placement in coronary artery(s) for coronary $362 ($5) 1.37% $362 ($5) 1.37% 93459 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,200 $4 0.30% 93460 26 Catheter placement in coronary artery(s) for coronary $403 ($5) 1.23% $403 ($5) 1.23% 93460 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,289 $5 0.39% 93461 26 Catheter placement in coronary artery(s) for coronary $446 ($5) 1.11% $446 ($5) 1.11% 93461 angiography, including intraprocedural injection(s) for coronary NA NA NA $1,474 $6 0.39% 93462 93463 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure) $214 ($0) 0.17% $214 ($0) 0.17% $101 ($8) 7.54% $101 ($8) 7.54% 93464 26 Physiologic exercise study (eg, bicycle or arm ergometry) $89 ($9) 9.45% $89 ($9) 9.45% 93464 including assessing hemodynamic measurements before and NA NA NA $278 ($6) 2.27% 93531 26 Combined right heart catheterization and retrograde left heart cath, for congenital cardiac anomalies $451 ($12) 2.63% $451 ($12) 2.63% 93532 26 Combined right heart catheterization and transseptal left heart cath through intact septum with or w/o retrograde left heart catheterization, for congenital cardiac anomalies $559 $4 0.65% $559 $4 0.65% 11
CPT Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility 93533 26 Combined right heart catheterization and transseptal left heart cath through existing septal opening, with or w/o retrograde left heart catheterization, for congenital cardiac anomalies $374 $2 0.48% $374 $2 0.48% Diagnostic Cath Injection 93565 93566 93567 93568 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective left ventricular or left arterial angiography (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for supravalvular aotography (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure) $47 $3 5.65% $47 $3 5.65% $48 $4 8.06% $174 $1 0.62% $54 $4 8.63% $143 $1 0.50% $49 $4 7.94% $155 $1 0.70% Angioplasty without Stent Percutaneous transluminal coronary angioplasty; single major 92920 coronary artery or branch $563 $2 0.32% NA NA NA 92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) $0 $0 NA $0 $0 NA Atherectomy without Stent Percutaneous transluminal coronary atherectomy, with 92924 coronary angioplasty when performed; single major coronary artery or branch 92925 Stent with Angioplasty 92928 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch $669 $1 0.21% NA NA NA $0 $0 NA $0 $0 NA $625 $2 0.34% NA NA NA 12
CPT Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility 92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) $0 $0 NA $0 $0 NA Stent with Atherectomy 92933 92934 Bypass Graft 92937 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel $700 $2 0.31% NA NA NA $0 $0 NA $0 $0 NA $625 $2 0.29% NA NA NA 92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) $0 $0 NA $0 $0 NA Acute Myocardial Infarction 92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel $701 $2 0.26% NA NA NA Chronic Total Occlusion 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel $700 $1 0.21% NA NA NA 13
CPT Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility 92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) $0 $0 NA $0 $0 NA Thrombectomy 92973 Percutaneous transluminal coronary thrombectomy mechanical $183 $1 0.39% NA NA NA IVUS 92978 26 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) $100 $10 10.67% $100 $10 10.67% 92979 26 FFR 93571 26 93572 26 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure) Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure) Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure) $81 $8 10.29% $81 $8 10.29% $100 $10 10.67% $100 $10 10.67% $80 $7 9.27% $80 $7 9.27% Valvuloplasty 92986 Percutaneous balloon valvuloplasty; aortic valve $1,257 ($113) 8.26% NA NA NA 92987 Percutaneous balloon valvuloplasty; mitral valve $1,299 ($116) 8.20% NA NA NA 92990 Percutaneous balloon valvuloplasty; pulmonary valve $1,020 ($93) 8.37% NA NA NA Transcatheter Aortic Valve Replacement 33361 33362 Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; percutaneous femoral artery approach Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; open femoral artery approach $1,406 $2 0.15% NA NA NA $1,536 $1 0.09% NA NA NA 14
CPT 33363 33364 33365 33366 Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; open axillary artery approach $1,615 $26 1.65% NA NA NA Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; open iliac artery approach $1,672 $0 0.02% NA NA NA Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; transaortic approach (e.g., median $1,841 ($3) 0.14% NA NA NA sternotomy, mediastinotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) $2,007 $12 0.61% NA NA NA 33367 33368 33369 Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (e.g., femoral vessels) (list separately in addition to code for primary procedure) Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (e.g., femoral, iliac, axillary vessels) (list separately in addition to code for primary procedure) Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (e.g., aorta, right atrium, pulmonary artery) (list separately in addition to code for primary procedure) $640 ($4) 0.56% NA NA NA $775 ($5) 0.64% NA NA NA $1,024 ($5) 0.52% NA NA NA 15
Table 3: Physician Fee Schedule CY Rule Payment s Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. CPT Facility Peripheral Interventions Non Coronary Angioplasty Transluminal balloon angioplasty, percutaneous; 35475 $349 ($6) 1.81% $1,588 ($22) 1.36% brachiocephalic trunk or branches, each vessel 35476 Transluminal balloon angioplasty, percutaneous; venous $282 ($1) 0.38% $1,452 ($18) 1.19% Radiological S&I (Non Cor Angioplasty) 75962 26 Transluminal balloon angioplasty, peripheral artery other than $27 $0 0.00% $27 $0 0.00% 75962 cervical carotid, renal or other visceral artery, iliac or lower NA NA NA $140 ($8) 5.11% 75964 26 Transluminal balloon angioplasty, each additional peripheral $18 ($0) 1.96% $18 ($0) 1.96% 75964 artery other than cervical carotid, renal or other visceral artery, NA NA NA $87 ($8) 7.95% 75966 26 Transluminal balloon angioplasty, renal/visceral artery, $65 $1 2.25% $65 $1 2.25% 75966 radiological S&I NA NA NA $172 ($4) 2.04% 75968 26 Transluminal balloon angioplasty, renal/visceral, each additional $18 $1 4.08% $18 $1 4.08% 75968 artery, S&I (List separately in addition to code for primary NA NA NA $89 $0 0.40% 75978 26 Transluminal balloon angioplasty, venous (eg, subclavian $27 $0 0.00% $27 $0 0.00% 75978 stenosis), radiological S&I NA NA NA $138 ($8) 5.42% Iliac Artery Revascularization 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty $435 ($1) 0.16% $3,211 ($24) 0.75% 37221 37222 37223 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) $534 $4 0.68% $4,736 ($14) 0.29% $196 $0 0.00% $901 ($10) 1.14% $225 $1 0.32% $2,640 $2 0.07% Femoral/Popliteal Artery Revascularization Revascularization, endovascular, open or percutaneous, 37224 femoral/popliteal artery(s), unilateral; with transluminal angioplasty 37225 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with atherectomy, includes angioplasty within same vessel, when performed $479 ($3) 0.60% $3,896 ($23) 0.59% $648 ($2) 0.28% $11,210 $20 0.18% 16
CPT 37226 Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s),unilateral;with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $562 $29 5.38% $9,218 $30 0.33% 37227 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed $779 ($3) 0.41% $15,143 $79 0.52% BSC currently has no stents FDA approved for use in the infrainguinal regions of the lower extremities Tibeal / Peroneal Artery Revascularization Revascularization, endovascular, open or percutaneous, 37228 tibeal\peroneal artery, unilateral, initial vessel; with transluminal angioplasty $585 ($2) 0.37% $5,542 ($27) 0.48% 37229 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed $756 ($3) 0.42% $11,062 $41 0.37% 37230 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $746 $10 1.36% $8,455 $21 0.25% 37231 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed $810 $4 0.49% $13,589 $126 0.93% 37232 37233 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code fore primary procedure) Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code fore primary procedure) $212 ($1) 0.34% $1,236 ($2) 0.17% $345 ($3) 0.82% $1,496 $10 0.65% BSC currently has no stents FDA approved for use in the infrainguinal regions of the lower extremities 37234 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code fore primary procedure) $298 $3 1.09% $3,951 $16 0.41% 17
CPT Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility 37235 Revascularization, endovascular, open or percutaneous, tibeal\peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code fore primary procedure) $411 ($17) 3.94% $4,249 $232 5.78% 37236 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) $458 ($24) 4.98% $2,834 ($29) 1.00% $225 $0 0.00% $1,234 ($9) 0.75% 37238 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) $333 ($5) 1.48% $4,182 ($4) 0.09% $167 $9 5.92% $2,073 ($8) 0.38% Catheter Access 36140 Introduction of needle or intracatheter; extremity artery $107 ($0) 0.33% $444 ($1) 0.32% 36147 Access av dial grft for eval $194 ($0) 0.18% $850 ($3) 0.34% 36148 Access av dial grft for proc $51 $0 0.70% $266 $1 0.27% 36160 Introduction of needle or intracatheter, aortic, translumbar $129 ($4) 3.22% $504 ($16) 3.10% 36200 Introduction of catheter, aorta $159 $0 0.23% $634 ($0) 0.06% Catheter Placement 36215 36216 Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family $245 ($7) 2.70% $1,145 $25 2.21% $285 ($3) 1.00% $1,190 ($73) 5.81% 18
CPT 36217 36218 36245 36246 36247 Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. Facility Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a $337 ($8) 2.39% $1,924 ($249) 11.44% vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (list in addition to code for initial second or third order vessel as appropriate) Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family $55 $0 0.00% $188 ($15) 7.56% $263 ($4) 1.34% $1,389 $5 0.34% $280 $0 0.00% $907 $0 0.04% $331 ($4) 1.07% $1,603 ($4) 0.27% 36248 Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate $52 ($2) 3.36% $155 ($1) 0.69% Carotid Artery Stenting 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection $1,135 $7 0.64% NA NA NA 37216 Vena Cava Filters 37191 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; without distal embolic protection Insertion of inferior vena cava filter, endovascular approach including vascular access, vessel selection and radiological supervision and interpretation (including ultrasound) when performed. $1,049 ($1) 0.07% NA NA NA $249 ($1) 0.29% $2,676 ($8) 0.28% 37192 Repositioning of inferior vena cava filter, endovascular approach including vascular access, vessel selection and radiological supervision and interpretation (including ultrasound) when performed. $425 $48 12.75% $1,738 $183 11.80% 37193 Retrieval (removal) of inferior vena cava filter, endovascular approach including vascular access, vessel selection and radiological supervision and interpretation (including ultrasound) when performed. $382 ($3) 0.84% $1,630 ($8) 0.48% 19
Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. CPT Facility Thrombectomy 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra graft thrombolysis) $313 ($0) 0.11% $1,865 ($2) 0.10% 34101 Thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision 34111 Thrombectomy, with or without catheter; radial or ulnar artery, by arm incision 34201 Thrombectomy, with or without catheter; femoral\popliteal, aortoiliac artery, by leg incision 34490 Thrombectomy, with or without catheter; axillary and subclavian vein, by arm incision Non Coronary IVUS 37250 Intravascular ultrasound (non coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List separately in addition to code for primary procedure) $632 ($3) 0.51% NA NA NA $629 ($6) 0.96% NA NA NA $1,085 ($8) 0.75% NA NA NA $641 $1 0.22% NA NA NA $111 ($1) 0.64% NA NA NA 37251 Intravascular ultrasound (non coronary vessel) during diagnostic evaluation and/or therapeutic intervention; each additional vessel (List separately in addition to code for primary procedure) $84 ($0) 0.00% NA NA NA Radiological S&I (Non Cor IVUS) 75945 26 Intravascular ultrasound (peripheral vessel) radiological supervision and interpretation; initial vessel $20 $0 1.79% $20 $0 1.79% 75946 26 each additional non coronary vessel (List separately in addition to code for primary procedure) $20 $0 0.00% $20 $0 0.00% Angiograms 75710 26 Angiography, extremity, unilateral, radiological supervision and $56 $0 0.65% $56 $0 0.65% 75710 interpretation NA NA NA $162 ($15) 8.32% 75716 26 Angiography, extremity, bilateral, radiological supervision and $66 $1 1.66% $66 $1 1.66% 75716 interpretation NA NA NA $188 ($23) 11.02% 75726 26 Angiography, visceral, selective or supraselective (with or $58 $1 1.26% $58 $1 1.26% 75726 without flush aortogram), radiological supervision and NA NA NA $151 ($14) 8.68% BSC currently has no stents FDA approved for use in the infrainguinal regions of the lower extremities 75731 26 Angiography, adrenal, unilateral, selective, radiological $58 $0 0.62% $58 $0 0.62% 75731 supervision and interpretation NA NA NA $171 ($12) 6.65% 75733 26 Angiography, adrenal, bilateral, selective, radiological $65 $0 0.56% $65 $0 0.56% 75733 supervision and interpretation NA NA NA $184 ($21) 10.14% 75736 26 Angiography, pelvic, selective or supraselective, radiological $59 $4 7.79% $59 $4 7.79% 75736 supervision and interpretation NA NA NA $164 ($10) 5.77% Bronchoscopy 31631 Bronchosopy; with placement of tracheal stent(s) (inludes tracheal/bronchial dilation as required) $238 $0 0.15% NA NA NA 20
Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. CPT Facility Biliary Stenting 47556 Biliary endoscopy, percutaneous via T Tube or other tract; with dilation of biliary duct stricture(s) with stent Radiological S&I (Biliary stenting) Percutaneous transhepatic dilation of biliary duct stricture with 74363 26 or without placement of stent, radiological supervision and interpretation Transhepatic Shunts (TIPS) $436 ($1) 0.25% NA NA NA $45 ($0) 0.79% $45 ($0) 0.79% 37182 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein cath, portography with hemodynamic evaluation, intrahepatic tract formation/dilation, stent placement and all associated imaging and guidance and documentation) $873 ($2) 0.25% NA NA NA 37183 Embolization 37241 Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS)(includes venous access, hepatic and portal vein cath, portography with hemodynamic evaluation, intrahepatic tract recanulization / dilation, stent placement and all associated imaging and guidance and documentation) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) $411 ($1) 0.17% $6,001 $45 0.76% $462 ($1) 0.31% $4,667 $33 0.70% 37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) $516 ($2) 0.35% $7,867 $62 0.79% 37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction $615 ($2) 0.35% $9,932 $78 0.80% 37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation $718 ($3) 0.35% $6,950 $51 0.73% 21
Note: s subject to change and do NOT reflect the 20.1% SGR reduction expected to be addressed by Congress In vs. vs. CPT Facility Drainage 47510 Introduction of percutaneous transhepatic catheter for biliary drainage $487 $0 0.00% NA NA NA 47511 Introduction of percutaneous transhepatic stent for internal and external biliary drainage $597 ($1) 0.18% NA NA NA 47525 Change of percutaneous biliary drainage catheter $87 $0 0.00% $528 $7 1.30% 47530 Revision and/or reinsertion of transhepatic tube $364 $2 0.49% $1,399 $4 0.31% 49421 Insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent $238 $3 1.07% NA NA NA 50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous $186 $0 0.19% NA NA NA 49423 Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) $75 $0 0.00% $557 $2 0.39% 75980 26 75982 26 75984 26 Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation $74 $1 0.98% $74 $1 0.98% $73 $0 0.49% $73 $0 0.49% $36 $0 0.00% $36 $0 0.00% 22