CY2015 Hospital Outpatient: Endovascular Procedure APCs Complexity Adjustments Comprehensive Ambulatory Payment Classifications (c-apcs) CMS finalized the implementation of 25 Comprehensive APC to further efforts to pay providers for quality, not quantity of care. A comprehensive APC (c-apc) packages payments for services supplies rather than providing separate multiple payments for each individual service. In CY2015, c-apcs will provide a single all-inclusive payment for the primary service with no additional reimbursement for additional adjunctive services supplies used during the delivery of the primary service. As part of its c-apc system, CMS created 12 clinical families (for example vascular) to reflect clinical homogeneity resource utilization identification of c-apcs. In the table below are the three vascular family c-apcs. c-apc National Average Payment 0083 Level I Endovascular Procedures $4,537 0229 Level II Endovascular Procedures $9,624 0319 Level III Endovascular Procedures $14,841 Complexity Adjustments To ensure appropriate accounting of all resources, CMS is also applying complexity criteria for multiple procedure combinations on the same date of service to allow for mapping to a higher APC within that clinical family of procedures. Code combinations are pairs of HCPCS. The highest payment for the family is the top level of the family of APCs. For the vascular family, APC 0319 Level III Endovascular Procedures is the highest level of payment. Outlined in this document include the following: List of HCPCS\ for the base Level I APC 0083, Level II APC 0229, Level III APC 0319 (CMS Addendum C*) List of HCPCS\ pairs for complexity adjustment from APC 0083 to APC 0229 or APC 0229 to APC 0319 (CMS Addendum J*) Disclaimers Health economic reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources is subject to change without notice as a result of complex frequently changing laws, regulations, rules policies. This information is presented for illustrative purposes only does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit appropriate codes, charges, modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists /or legal counsel regarding coding, coverage reimbursement matters. Boston Scientific does not promote the use of its products outside their FDAapproved label. Copyright 2014 American Medical Association. All rights reserved. is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, /or related components are not assigned by the AMA, are not part of, 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. *Source: CMS Medicare Fee for Service Payment_ Hospital Outpatient PPS CY2015 OPPS Addendum C J found at http://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations--notices-items/cms-1613- FC.html?DLPage=1&DLSort=2&DLSortDir=descending It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 1 of 6
List of Base Assigned to APC 0083 APC 0083 - Level I Endovascular Procedures 35458 Transluminal balloon angioplasty, open; brachiocephalic trunk or branches, each vessel 35460 Transluminal balloon angioplasty, open; venous 35471 Transluminal balloon angioplasty, percutaneous; renal or visceral 35472 Transluminal balloon angioplasty, percutaneous; aortic 35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel 35476 Transluminal balloon angioplasty, percutaneous; venous 36870 37183 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction intra-graft thrombolysis) Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement all associated imaging guidance documentation) 37220 iliac, unilateral, initial vessel; with transluminal angioplasty 37224 femoral, popliteal (s), unilateral; with transluminal angioplasty 92920 Percutaneous transluminal coronary angioplasty; single major coronary or branch 92986 Percutaneous balloon valvuloplasty; aortic valve List of Coding Pairs for Complexity Adjustment from APC 0083 to APC 0229 APC 0229 - Level II Complexity Adjustments 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction intra-graft thrombolysis) 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction intra-graft thrombolysis) 92920 Percutaneous transluminal coronary angioplasty; single major coronary or branch 92920 Percutaneous transluminal coronary angioplasty; single major coronary or branch 92920 Percutaneous transluminal coronary angioplasty; single major coronary or branch 92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary (List separately in addition to code for primary procedure) It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 2 of 6
List of Base Assigned to APC 0229 APC 0229 - Level II Endovascular Procedures iliac, includes angioplasty 37221 within the same vessel, when femoral, popliteal (s), unilateral; with atherectomy, includes angioplasty within the same 37225 vessel, when femoral, popliteal (s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when Note: BSC currently has no stents FDA-approved for use in the infrainguinal region of the lower extremities. 37228 tibial, peroneal, unilateral, initial vessel; with transluminal angioplasty 37236 vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological S&U 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision interpretation including angioplasty within the same vessel, when ; initial vein supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to 37241 complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous capillary hemangiomas, varices, varicoceles) supervision interpretation, intraprocedural roadmapping, imaging guidance 37242 necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) 37243 supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, 61623 positioning inflation of occlusion balloon, concomitant neurological monitoring, radiologic supervision interpretation of all angiography required for balloon occlusion to exclude vascular injury post occlusion 61626 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) 92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when 92928 Percutaneous transcatheter placement of 92937 coronary bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel 92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary or coronary bypass graft, any combination of intracoronary stent, atherectomy angioplasty, including aspiration thrombectomy when, single vessel 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary, coronary branch, or coronary bypass graft, any combination of intracoronary stent, atherectomy angioplasty; single vessel 92987 Percutaneous balloon valvuloplasty; mitral valve 92990 Percutaneous balloon valvuloplasty; pulmonary valve 92997 Percutaneous transluminal pulmonary balloon angioplasty; single vessel 0234T 0236T 0237T Note: 37221 37225 Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision interpretation; renal Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision interpretation; abdominal aorta Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision interpretation; brachiocephalic trunk branches, each vessel coronary bypass graft (internal mammary, free arterial, venous), any combination of drugeluting intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel BSC currently has no stents FDA-approved for use in the infrainguinal region of the lower extremities. List of Coding Pairs for Complexity Adjustment from APC 0229 to APC 0319 APC 0319 - Level III Complexity Adjustments iliac, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when femoral, popliteal (s), unilateral; with atherectomy, includes angioplasty within the same vessel, when 37236 37221 percutaneous, including radiological supervision interpretation iliac, includes angioplasty within the same vessel, when It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 3 of 6
37225 37241 37242 37242 37243 37243 Note: List of Coding Pairs for Complexity Adjustment from APC 0229 to APC 0319 APC 0319 - Level III Complexity Adjustments femoral, popliteal (s), unilateral; with atherectomy, includes angioplasty within the same vessel, when femoral, popliteal (s), unilateral; with transluminal stent femoral, popliteal (s), unilateral; with transluminal stent femoral, popliteal (s), unilateral; with transluminal stent femoral, popliteal (s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when femoral, popliteal (s), unilateral; with transluminal stent supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous capillary hemangiomas, varices, varicoceles) supervision interpretation, intraprocedural roadmapping, 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) supervision interpretation, intraprocedural roadmapping, 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) supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction Vascular embolization or occlusion, inclusive of all radiological supervision interpretation, intraprocedural roadmapping, imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction femoral, popliteal (s), unilateral; with transluminal angioplasty femoral, popliteal (s), unilateral; with transluminal angioplasty 37236 37221 37225 37236 37238 37221 37236 37221 37236 37221 37236 BSC currently has no stents FDA-approved for use in the infrainguinal region of the lower extremities. percutaneous, including radiological supervision interpretation iliac, includes angioplasty within the same vessel, when femoral, popliteal (s), unilateral; with atherectomy, includes angioplasty within the same vessel, when femoral, popliteal (s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when percutaneous, including radiological supervision interpretation intracoronary stent(s), with coronary angioplasty when ; single major coronary or branch Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision interpretation including angioplasty within the same vessel, when ; initial vein iliac, includes angioplasty within the same vessel, when percutaneous, including radiological supervision interpretation iliac, includes angioplasty within the same vessel, when percutaneous, including radiological supervision interpretation iliac, includes angioplasty within the same vessel, when percutaneous, including radiological supervision interpretation It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 4 of 6
92928 List of Coding Pairs for Complexity Adjustment from APC 0229 to APC 0319 APC 0319 - Level III Complexity Adjustments femoral, popliteal (s), unilateral; with transluminal angioplasty Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when ; single major coronary or branch coronary bypass graft (internal mammary, free intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel coronary bypass graft (internal mammary, free intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel coronary bypass graft (internal mammary, free intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel coronary bypass graft (internal mammary, free intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel 37238 C9601 33208 33210 37221 37236 92924 C9601 C9605 C9601 C9605 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision interpretation including angioplasty within the same vessel, when ; initial vein Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when ; each additional branch of a major coronary (list separately in addition to code for primary procedure) Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial ventricular Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) iliac, includes angioplasty within the same vessel, when percutaneous, including radiological supervision interpretation including all angioplasty within the same vessel, when ; initial Percutaneous transluminal coronary atherectomy, with coronary angioplasty when intracoronary stent(s), with coronary angioplasty when ; single major coronary or branch Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when ; each additional branch of a major coronary (list separately in addition to code for primary procedure) coronary bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy angioplasty, including distal protection when ; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) intracoronary stent(s), with coronary angioplasty when ; single major coronary or branch Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when ; each additional branch of a major coronary (list separately in addition to code for primary procedure) coronary bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy angioplasty, including distal protection when ; single vessel coronary bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy angioplasty, including distal protection when ; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 5 of 6
37227 37229 37230 37231 92933 93580 List of Base Assigned to APC 0319 APC 0319 - Level III Endovascular Procedures femoral, popliteal (s), unilateral; with transluminal stent placement(s) atherectomy, includes angioplasty within the same vessel, when tibial, peroneal, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when tibial, peroneal, unilateral, initial vessel; with transluminal stent tibial, peroneal, unilateral, initial vessel; with transluminal stent placement(s) atherectomy, includes angioplasty within the same vessel, when Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when ; single major coronary or branch Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant 93581 Percutaneous transcatheter closure of a congenital ventricular septal defect with implant 93582 Percutaneous transcatheter closure of patent ductus arteriosus 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision interpretation; iliac, each vessel 0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular C9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when ; single major coronary or branch C9606 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary or coronary bypass graft, any combination of drug-eluting intracoronary stent, atherectomy angioplasty, including aspiration thrombectomy when, single vessel C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary, coronary branch, or coronary bypass graft, any combination of drug-eluting intracoronary stent, atherectomy angioplasty; single vessel APC 0319 does not have complexity adjustment as it is the highest payment for the family is the top level for the vascular family APCs. Note: BSC currently has no stents FDA-approved for use in the infrainguinal region of the lower extremities. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services to submit to appropriate codes. See page 1 for important information about the uses limitations of this document. IC-300702-AA MAR2015 Page 6 of 6