Medicare Hospital Outpatient Changes Effective January 1, 2013 1
This presentation is intended for education use. Any duplication is prohibited without written consent of Medtronic s Economic Strategies and Solutions department. This information does not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for their interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restriction 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 practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. Note: CPT code descriptions may be abbreviated and not listed in their entirety in all cases in this presentation. For full descriptions, please refer to your 2013 CPT code book. 2
Today s Agenda Executive Summary CPT and APC Changes for CRDM Procedures 2013 Medicare National APC Payments CRDM Payment Examples Reporting Device Credits to Medicare CPT and APC Changes for Vascular Procedures Contact Information Appendix Q & A 3
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Medtronic CRDM Economic Strategies and Solutions Department Our Mission To educate customers on the economically efficient use of our products and therapies. Our Goals Educate customers on coverage, coding, policy, and reimbursement issues. Create support programs that help providers understand how our products can be used in a cost-effective manner. Engage in collaboration and dialogue on economic issues that impact quality and patient access in the healthcare system. www.medtronic.com/crdmreimbursement 5
Regional Economic Managers (REMs) 6
Executive Summary 7
Medicare CY 2013 OPPS Updates 1.8% Payment: $71.313 CY 2013 conversion factor when meeting OQR* $70.016 CY 2012 conversion factor (CF)** $ 1.297 Hospital Outpatient Payment Increase Coding and APC assignment: Deleted: Codes 93651 (catheter ablation/svt) and 93652 (catheter ablation/vt) APC 0086 as a result of deleted codes 93651 and 93652 Added: five new catheter ablation CPT codes: 93653, 93654, 93656 plus Add-on codes +93655 and +93657. Sources: Fact Sheets, CY 2013 OPPS Final Rule, CPT code book See Appendix * Hospital OQR (Outpatient Quality Reporting) Program ** 2012 CF revised Federal Register /Vol. 77, No. 2 /Wednesday, January 4, 2012 /Rules and Regulations 8
2013 Payment Determination Quality Measures The CY 2013 payment determination originally included twentythree quality measures however OP-19 was suspended and OP-15 was postponed. See Appendix for the 2013-2015 quality measures. OP-16 measure will be removed effective January 1, 2013 Troponin results for Emergency Department AMI patients or chest pain patients (with probable cardiac chest pain) received within 60 minutes of arrival Sources: Fact Sheets, CY 2013 OPPS Final Rule, CPT code book; See Appendix https://www.qualitynet.org/ 9
CPT and APC Changes for CRDM Procedures 10
2013: Two Deleted CPT Codes CPT CPT code description Deleted codes effective January 1, 2013 93651 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination 93652 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia WHY? 2013 CPT code book 11
New Ablation Codes Primary and Add-on CPT added three new primary ablation codes that combine the elements of the EP study with the ablation procedure: 1. EPS plus SVT (supraventricular) ablation 2. EPS plus VT (ventricular tachycardia) ablation 3. EPS plus PVI (Pulmonary Vein Isolation for A-fib) To accommodate treatment of additional lesions after the primary code, CPT added 2 new add-on codes: 1. Ablation of additional discrete mechanism, or SVT or VT remaining after the primary procedure. 2. Additional ablation (linear or focal) to treat AF remaining after PVI. CPT 93650 for AV (atrioventricular node) ablation remains unchanged Let s take a closer look! 12
2013 : Five New CPT Codes CPT CPT code description New codes effective January 1, 2013 93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry (Do not report 93653 in conjunction with 93600-93603, 93610, 93612, 93618-93620, 93642, 93654) 2013 CPT code book 93653 Combines EP study and SVT ablation and includes: Induction or attempted induction of arrhythmia Right atrial pacing and recording Right ventricular pacing and recording His bundle recording SVT ablation 13
2013 New CPT Codes CPT CPT code description New codes effective January 1, 2013 93654 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed (Do not report 93654 in conjunction with 93279-93284, 93286-93289, 93600-93603, 93609, 93610, 93612, 93613, 93618-93620, 93622, 93642, 93653) 2013 CPT code book 93654 Combines EP study and ablation for VT and includes: Induction or attempted induction of arrhythmia Right atrial pacing and recording Right ventricular pacing and recording His Bundle recording VT ablation And when performed: 3D mapping (93613) LV pacing and recording (93622) 14
2013 New CPT Codes CPT CPT code description New codes effective January 1, 2013 93656 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation (Do not report 93656 in conjunction with 93279-93284, 93286-93289, 93462, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93621, 93653, 93654) 2013 CPT code book 93656 Combines EP study and PVI and includes: Induction or attempted induction of arrhythmia Transseptal catheterization(s) 93462 Right ventricular pacing and recording His Bundle recording PVI (Pulmonary Vein Isolation) And when possible: Right atrial pacing and recording 15
2013 New CPT Codes CPT CPT code description New codes effective January 1, 2013 +93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (Use 93655 in conjunction with 93653, 93654, 93656) Add-on code +93655: May be reported with 93653, 93654, 93656 2013 CPT code book 16
2013 New CPT Codes CPT CPT code description New codes effective January 1, 2013 +93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (Use 93657 in conjunction with 93656) Add-on code +93657: May be reported with 93656 2013 CPT code book 17
What codes remain separately billable with each of the new Ablation Codes? CPT Code Brief Description 93653 SVT X = may be separately billable 93654 VT +93609 Standard (2D) mapping Not reportable with 93613 X +93613 3D mapping X Not reportable with 93609 +93621 Left atrial pacing/recording X X +93622 LV pacing/recording X X +93623 Isuprel infusion X X X +93462 Transseptal catheterizations X X 93656 PVI +93655 Additional ablation(s) after X X X basic ablation +93657 Additional ablation(s) after PVI X +93662 Intra cardiac Echo (ICE) X X X X X 2013 CPT code book 18
2013 APC Assignment for Single Encounter Single EPS or Catheter Ablation of AV Node CPT Brief Description APC 2013 APC 2012 % Change 93619 93620 93650 EPS without induction or EPS w/induction or Ablate AV node 0085 $3,922 0085 $3,762 4.2% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 19
2013 APC Changes for CRDM Procedures CPT 93651 93652 Brief Description (applicable for 2012) Catheter ablation of SVT or VT APC 2013 APC 2012 % Change NA CPT codes and APC 0086 deleted effective 1-1-2013 0086 or 8000 NA Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 20
Composite Payments for EP Studies and Ablations Composite APC: Provides a single payment for all clinically-related services provided within an encounter or episode of care. Medicare may consider creating APCs for services that are frequently provided in the same encounter. The composite consists of codes from defined groups A, B, C: Group A: 93619, 93620 Group B: 93650 Group C: 93653, 93654, 93656 For 2013, Composite APC 8000 includes procedure codes in Group C Codes in Group C are new codes that have packaged EP study and ablation procedures. While they are mapped to the Composite APC 8000, only one of the new codes is required for the composite payment. 21
2013 Composite APC Assignment: Includes New CPT Codes in Group C Composite APC 8000 CPT Brief Description APC 2013 APC 2012 % Change Group A: At least one in Group A and Group B 93619 EPS without induction 93620 EPS with induction Group B: 93650 Ablate AV node Group C: At least one in Group C 93653 New 93654 New 93656 New EPS, Ablate SVT EPS, Ablate VT EPS, treatment of AF by pulmonary vein isolation ablation $11,146 $11,388-2.1% $11,146 $11,388-2.1% Source: OPPS Final rule Federal Register, Table 4, page 68247-68248 Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 22
Documentation: Coding/Billing for New Ablation Codes When coding an EPS, if all the components of the code are not performed and documented, bill the component codes separately. 1 For the new composite ablation codes, consider reduced service modifier -52 when all the components of each code are not performed and documented. 2 Source: 1 HRS Coding Guide 2012, p. 37. 2 CPT code book 2013 23
2013 Medicare National APC Payments 24
Outpatient hospital APC payments 2009-2013 show variability. National Medicare Hospital Outpatient Payment Rates for Significant Medtronic Therapies Therapy/CPT Code CY CY CY CY CY CY APC~ 2009 2010^ 2011 2012 2013 13-09 ICDs (33249) $28,251 $27,728 $26,830 $29,767 $30,680 +8.6% APC 0108 composite composite CRT-Ds (33249 and +33225) APC 0108 & 0418/0655 $32,822 +33225 APC 0418 $34,591 +33225 APC 0418 $32,145 +33225 APC 0418 $29,767 composite $30,680 composite -6.5% Pacemakers (33208) APC 0655 $9,512 $9,559 $9,485 $9,693 $10,187 +7.1% Medicare national payment rates indicated are based on information included in the CMS Federal Registers for CY 2009 2013 ~APC: Ambulatory Payment Classification; CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restriction 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 practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. ^ APC payment rates reflect changes based on the Affordable Care Act.. 25
CRDM Payment Examples 26
Status Indicators Status Indicator 1 Item/Code/Service 1 C M N S T Q3 X Inpatient Procedures. Not paid under OPPS. Admit patient. Bill as Inpatient. (e.g., 33203: Insertion of epicardial electrode(s); endoscopic approach) Items and Services Not Billable to the Fiscal Intermediary/MAC. Not paid under OPPS. (e.g., 93294, 93295, 93297, 93298) Items and Services Packaged into APC Rates. Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment. (e.g., 93613, 93621, 93622, 93623, 93640, 93641, 93662) Significant Procedure, Not Discounted when Multiple. Paid under OPPS; separate APC payment. (e.g., 33282: Insert patient activated cardiac event recorder) Significant Procedure, Multiple Reduction Applies. Paid under OPPS; separate APC payment. (e.g., 33216 insert single transvenous lead) Codes that may be paid through a Composite APC. (1) Composite APC payment based on OPPS composite-specific payment criteria. (2) Separate APC payment or packaged into payment for other services. (e.g., 93656) Ancillary Services. Paid under OPPS; separate APC payment. (e.g., 93290: Interrogation device evaluation (in person); implantable cardiovascular monitor system) 1 Addendum D1 is available at: http://www.cms.gov/hospitaloutpatientpps/hord/list.asp#topofpage 27
Hospital OP coding ICD generator replacement 1,2 Replacement and defibrillator threshold testing of a single chamber ICD pulse generator that has reach end of life and the endocardial lead does not need to be replaced. Description CPT APC Payment SC ICD generator replacement (SI T) 33262 0107 $22,512 Threshold Testing at Implant (SI N) 93641 NA Packaged Total Payment $22,512 Include applicable HCPCS C-Codes for device SC: Single Chamber 1 HRS 2012: Coding Guide for Heart Rhythm Procedures and Services, page 57 2 2013 CPT page 177, Professional Edition 28
Hospital OP coding Initial insertion of ICD 1,2 An asymptomatic patient with chronic ischemic heart disease and prior history of MI 8 weeks ago presents with LVEF < 35% after office evaluation and echo is referred for prophylactic (Primary Prevention) ICD implant. The patient receives a single chamber ICD without an EP study. The device is tested via defibrillator threshold testing at time of implant. Description CPT APC Payment SC ICD System Implant (SI T) 33249-Q0 0108 $30,680 Threshold Testing (SI N) 93641 NA Packaged Total Payment $30,680 Include applicable HCPCS C-Codes for device and leads SC: Single Chamber 1 CPT 2013 page 177, Professional Edition 2 HRS 2012: Coding Guide for Heart Rhythm Procedures and Services, page 62 29
Hospital OP coding Upgrade ICD to Bi-V ICD 1 A patient with congestive heart failure is optimally managed on drug therapy. Based on the current condition of the patient, the physician determines Bi-Ventricular therapy is needed. This patient s existing ICD generator met secondary prevention ICD coverage. The patient s dual chamber ICD generator is removed, an LV lead is inserted along with the Bi-V ICD generator. The device is tested at time of implant. Description CPT APC Payment DC ICD gen. removed Bi-V ICD gen. inserted (SI T) 33264 0107 $22,512 LV lead inserted (SI-T) +33225 0655 $5,093 2 Threshold Testing (SI N) 93641 NA Packaged Total Payment $27,605 Include applicable HCPCS C-Codes for device and lead DC: Dual Chamber Bi-V: Biventricular / Cardiac Resynchronization Therapy 1 CPT 2013 page 177, Professional Edition 2 50% multiple procedure reduction 30
Hospital OP coding Remove and Replace LV lead 1 A dislodged left ventricular lead attached to a dual chamber system placed yesterday in the coronary sinus is removed and the left ventricular lead is replaced. Pacemaker recommended codes: 33224-78 for Bi-V CRT pacemaker lead insertion 33235-78 for Bi-V CRT pacemaker lead removal ICD recommended codes: 33224-78 for Bi-V CRT ICD lead insertion 33244-78 for Bi-V CRT ICD lead removal Modifier 78: Unplanned return to the Operating Room/Procedure Room by the Same Physician or Other Qualified Health Care Professional following Initial Procedure for a Related Procedure During the Postoperative Period 1 HRS 2012: Coding Guide for Heart Rhythm Procedures and Services, page 53 31
Hospital OP Coding: Ablation Example Documented SVT 1,2 Patient has recurrent palpitations. An event monitor has documented supraventricular tachycardia (SVT). Multielectrode catheters are advanced into the respective cardiac chambers where they will be used to pace & record. Pacing & sensing is performed in the RA and RV. His bundle recording is obtained. Refractory periods are measured. Attempts at arrhythmia induction are performed via maneuvers that include burst pacing and premature pacing using programmed electrical stimulation at multiple drive cycle lengths from multiple atrial and ventricular sites. Once the SVT is induced, pacing maneuvers are performed to elucidate the mechanism of the tachycardia. Once the combination of both diagnostics maneuvers and mapping is complete, catheter ablation may be performed. An ablation is maneuvered from the sites of vascular access to the appropriate cardiac location to facilitate delivery of ablative energy. Multiple lesions are delivered to ensure eradication of the arrhythmia focus and to provide consolidation lesions in the surrounding tissue. Throughout the ablation, the patient is monitored for hemodynamic compromise due to cardiac perforation, bradyarrhythmias, or tachyarrhythmias, embolic phenomena, or damage to cardiac or vascular structures. Following the ablation portion of the procedure, further electrophysiologic testing is performed to assess the outcome of ablation using decremental, burst, and premature pacing maneuvers. These are repeated following a 30-minute period following the conclusion of the final ablation lesion. Sheaths are removed, appropriate hemostasis is achieved, and followup assessment of the patient for any complications is performed. Description CPT APC Payment Treatment of SVT(composite) 93653 8000 $11,146 (Do not report 93653 in conjunction with 93600-93603, 93610, 93612, 93618-93620, 93642, 93654) Include applicable HCPCS C-Codes for catheters 1 CPT Changes 2013 - An Insider s View, page 292-293 2 2013 CPT page 519-522, Professional Edition 32
SVT Ablation Example: CPT 93653 Brief Description Induction or attempted induction of arrhythmia RA pacing/recording RV pacing/recording His bundle recording SVT ablation Required for SVT Ablation 93653 X X X X X Documentation supports that all components of CPT 93653 were performed Add-on code +93655 may be reported with 93653 2013 CPT code book 33 33
VT Ablation: CPT 93654 Brief Description Induction or attempted induction of arrhythmia RA pacing/recording RV pacing/recording His bundle recording VT ablation 3D mapping LV pacing/recording Required for VT Ablation 93654 X X X X X X When performed X When performed Documentation supports that all components of CPT 93654 were performed Add-on code +93655 may be reported with 93654 2013 CPT code book 34 34
PVI Ablation: CPT 93656 Brief Description Induction or attempted induction of arrhythmia Transseptal catheterizations RV pacing/recording His bundle recording PVI Atrial pacing/recording Required for PVI 93656 X X X X X X When performed Add-on codes +93655 and +93657 may be reported with 93656 Documentation supports that all components of CPT 93656 were performed 2013 CPT code book 35 35
Reporting Device Credits to Medicare 36
OIG Audits Device Credits OIG (Office of Inspector General) audits have disclosed that hospitals are not always reporting device credits consistently and accurately According to OIG findings: Medicare providers are expected to pursue free replacements or reduced pricing under warranties. Hospitals should ensure that there are policies and procedures in place to track and appropriately report device credits. https://oig.hhs.gov/reports-and-publications/oas/cms.asp 37
Medicare Device Credit Patient Example 1 FB Modifier FC Modifier CY 2013 APC and CPT code CY 2013 APC Title Final CY 2013 Device Offset % for No Cost / Full Credit Case Final CY 2013 Device Offset % for Partial Credit Case 0654 (CPT 33228) (remove and replace generator) Level II Insertion/ Replacement of Permanent Pacemaker 74% 1 $2,006 Payment ($7,715 *.74 = $5,709; $7,715 - $5,709 = $2,006) 37% 1 $4,860 Payment ($7,715 *.37 = $2,855; $7,715 - $2,855 = $4,860) Medicare national payment rate for APC 0654 is $7,715 1 OPPS Final Rule, page 68360 of the Federal Register dated November 15, 2012 Table 29: APCs to which the no cost/full credit and partial credit device adjustment policy will apply in CY 2013, pages 68359-68360 38
Hypothetical UB-04 Claim Submission FB modifier: 33228-FB Procedure charge determined by hospital C1785 Device charge, determined by hospital ~ < $1.01 FC modifier: 33228-FC C1785 Procedure charge determined by hospital Device charge, determined by hospital Condition code should also be included (49 or 50) OPPS Final Rule, page 68360 of the Federal Register dated November 15, 2012 Table 29: APCs to which the no cost/full credit and partial credit device adjustment policy will apply in CY 2013, pages 68359-68360. Table 30 identifies the applicable C-Codes, page 68361-68362. 39
Condition Codes 49 and 50 Condition Code 49: Product Replacement within Product Lifecycle Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly. Condition Code 50: Product Replacement for Known Recall of a Product Manufacturer or FDA has identified the product for recall and therefore replacement. Source: CMS Manual Pub 100-04 Medicare Claims Processing, Transmittal 741 dated November 4, 2005 is available at: http://www.cms.gov/transmittals/downloads/r741cp.pdf 40
Full Credit for Only One Device Component Hypothetical Example The dual chamber pacemaker generator is recalled and needs to be replaced. The hospital received this pacemaker generator at no cost. During the implant, the physician determines that the Right Ventricular (RV) lead is at end of life so this lead is capped and a replacement RV lead is implanted at full cost to the hospital. Since the generator and at least one lead constitutes a system implant, the appropriate CPT code is 33207. Medicare provided clarification on the correct way to report this service: 33207-FB Hospitals should assign the FB or FC modifier to the procedure code, and the offset (payment reduction) will be applied to that particular service. OPPS Final Rule, page 68357 of the Federal Register dated November 15, 2012 41
CPT and APC Changes for Vascular Procedures 42
Outpatient Payment: CY 2013 HOPPS National Unadjusted APC Code Description CY 2012 CY 2013 CORONARY 0080 Diagnostic Cardiac Catheterization $2,721 $2,650 (-2.6%) 0082 Coronary or Non-Coronary Atherectomy $7,365 $7,671 (4.2%) 0083 Coronary or Non-Coronary Angioplasty and Percutaneous Valvuloplasty $4,611 $4,023 (-12.8%) 0104 Transcatheter Placement of Intracoronary Stents (BMS) $5,694 $6,110 (7.3%) 0656 Transcatheter Placement of Intracoronary Drug-Eluting Stents $7,409 $7,763 (4.8%) PERIPHERAL / NON-CORONARY 0082 Coronary or Non-Coronary Atherectomy $7,365 $7,671 (4.2%) 0083 Level I Endovascular Revascularization of the Lower Extremity $4,624 $4,023 (-13.0%) 0088 Thrombectomy $2,874 $3,100 (7.9%) 0229 Level II Endovascular Revascularization of the Lower Extremity $8,096 $8,657 (6.9%) 0319 Level III Endovascular Revascularization of the Lower Extremity $14,210 $14,596 (2.7%) 0279 Level II Angiography and Venography $2,088 $2,220 (6.3%) 0280 Level III Angiography and Venography $3,478 $3,630 (4.4%) Sources: Addendum A for CY 2013 and the October 2012 release for CY 2012 43 Source: CY 2013 HOPPS Final Rule
Vascular Changes: New and Deleted CPT Codes Percutaneous Coronary Intervention (PCI) Codes 6 deleted PCI codes 92980, 92981, 92982, 92984, 92995, 92996 13 new PCI CPT codes 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944 9 new C-Codes for drug-eluting stents (DES) C9600 - C9608 Diagnostic Carotid Angiograms 8 new CPT codes 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228 8 deleted CPT codes 75650, 75660, 75662, 75665, 75671, 75676, 75680, 75685 Webinars on these updates: http://www.eventsvc.com/medtroniccv/ Held Dec 5 & 6 On Demand replay available at this site January update webinar TBD RSVP to jennifer.m.williams@medtronic.com 44
Medtronic economic resources include webcasts for hospitals & physicians on key topics www.medtronic.com/crdmreimbursement 45
Contact Information 46
Medtronic Cardiovascular Contact Information Vascular Contact: Alex Au-Yeung: Alex.c.au-yeung@medtronic.com Or Jennifer Williams: Jennifer.m.williams@medtronic.com Coding Hotline number: 1 (877) 347-9662 Submit a question: http://www.medtronic.com/physician/cvreimbursement/ vascular-reimbursement-q.html 47
CRDM Information To ensure you receive advance notification of webcast events, it is very easy to register at www.medtronic.com/crdmreimbursement: Join our E-mail List Subscribe to receive news and updates. 48
Appendix 49
Data Sources CMS November 1, 2012 Fact Sheet: CMS Issues Outpatient Policy and Payment Changes http://www.cms.gov/apps/media/fact_sheets.asp The OPPS Final Rule Home Page for CY 2013 and CY 2012: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/HospitalOutpatientPPS/index.html November 15, 2012 Federal Register publication of the CY 2013 Final Rule (CMS-1589-FC) http://www.gpo.gov/fdsys/pkg/fr-2012-11-15/pdf/2012-26902.pdf November 30, 2011 Federal Register publication of the CY 2012 Final Rule (CMS-1525-FC) http://www.gpo.gov/fdsys/pkg/fr-2011-11-30/pdf/2011-28612.pdf April 24, 2012 Federal Register publication of the CY 2012 Corrections http://www.gpo.gov/fdsys/pkg/fr-2012-04-24/pdf/2012-9837.pdf 50
Quality Measures Hospital OQR Program Measures for CY 2013 - CY 2015 OP-1 Median time to fibrinolysis (2008) OP-2 Fibrinolytic therapy received within 30 minutes (2008) OP-3 Median time to transfer to another facility for acute coronary intervention (2008) OP-4 Aspirin at arrival (2008) OP-5 Median time to ECG (2008) OP-6 Timing of antibiotic prophylaxis (2008) OP-7 Prophylactic antibiotic selection for surgical patients (2008) OP-8 MRI lumbar spine for low back pain (2009) OP-9 Mammography follow-up rates (2009) OP-10 Abdomen CT use of contrast material (2009) 10 Measures 51
Quality Measures Hospital OQR Program Measures for CY 2013 - CY 2015 OP-11 Thorax CT Use of Contrast Material (2009) OP-12 The ability for providers with HIT to receive laboratory data electronically directly into their qualified/certified EHR system as discrete searchable data (2011) OP-13 Cardiac imaging for preoperative risk assessment for non cardiac Low risk surgery (2012) OP-14 Simultaneous use of brain Computed Tomography (CT) and sinus Computed Tomography (CT) (2012) OP-15* Use of brain Computed Tomography (CT) in the emergency department for atraumatic headache (2012) OP-17 Tracking clinical results between visits (2012) * Information for OP-15 will not be reported in Hospital Compare in 2012. Public reporting for this measure will will occur in July 2013 at the earliest and this measure will not be used in the 2014 payment determination. 6 Measures; Total 16 Measures 52
Quality Measures Hospital OQR Program Measures for CY 2013 - CY 2015 OP-18 OP-19** OP-20 OP-21 OP-22 OP-23 Median time from ED arrival to ED departure for discharged ED patients (1-1-2012 encounters) Transition record with specified elements received by discharged ED patients (1-1-2012 encounters) Door to diagnostic evaluation by a qualified medical professional (1-1-2012 encounters) ED - median time to pain management for long bone fracture (1-1-2012 encounters) ED patient left without being seen (1-1-2012 encounters) ED - head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan interpretation within 45 minutes of arrival (1-1-2012 encounters) ** Data collection for OP-19 was suspended effective with January 1, 2012 encounters until further notice 6 Measures; Total 22 Measures 53
Quality Measures Hospital OQR Program Measures for CY 2013 - CY 2015 OP-24*** Cardiac Rehabilitation Patient Referral from an Outpatient Setting (1-1-2013) OP-25 Safety Surgery Checklist (1-1-2013) OP-26 Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures (1-1-2013) (Procedure Category: Cardiovascular Corresponding HCPCS Codes: 33000 through 37999) *** Data collection for OP-24 is deferred from January 1, 2013 to January 1, 2014, and its first application toward a payment determination would be for CY 2015 rather than CY 2014. 3 Measures; Total 25 Measures 54
CRDM CPT Code Description Changes CPT code +33225 2012 +33225 2013 CPT code description Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket revision) (List separately in addition to code for primary procedure) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure) The cardiac device monitoring codes (93279-93295, 93297-93298) had the following change: 2012 with physician analysis, review and report 2013 with analysis, review and report by a physician or other qualified health care professional 55
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33206 Insert pacer system; atrial 33207 Insert pacer system; ventricle 33208 Insert pacer system; A and V 33210 Insert temporary lead, single 33211 Insert temporary leads, dual 33212 Insert pacer gen. only; w/ single lead 33213 Insert pacer gen. only; w/ dual leads APC 0089 $8,230 (T) APC 0089 $8,230 (T) APC 0655 $10,187 (T) APC 0106 $3,766 (T) APC 0106 $3,766 (T) APC 0090 $6,612 (T) APC 0654 $7,715 (T) APC 2012 and SI APC 0089 $7,833 (T) APC 0089 $7,833 (T) APC 0655 $9,693 (T) APC 0106 $3,476 (T) APC 0106 $3,476 (T) APC 0090 $6,602 (T) APC 0654 $7,235 (T) % Change 5.1% 5.1% 5.1 % 8.3% 8.3% 0.2% 6.6% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 56
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33214 Upgrade single pacer to dual pacer 33215 Reposition previously placed RA or RV lead 33216 Insert single lead, pacer/icd 33217 Insert 2 leads, pacer/icd 33218 Repair single lead, pacer/icd 33220 Repair 2 leads, pacer/icd 33221 Insert pacer gen. only; w/ multiple leads APC 0655 $10,187 (T) APC 0105 $1,683 (T) APC 0106 $3,766 (T) APC 0106 $3,766 (T) APC 0105 $1,683 (T) APC 0105 $1,683 (T) APC 0654 $7,715 (T) APC 2012 and SI APC 0655 $9,693 (T) APC 0105 $1,596 (T) APC 0106 $3,476 (T) APC 0106 $3,476 (T) APC 0105 $1,596 (T) APC 0105 $1,596 (T) APC 0654 $7,235 (T) % Change 5.1 % 5.5% 8.3% 8.3% 5.5% 5.5% 6.6% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 57
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33222 Revise/relocate pacer skin pocket 33223 Revise/relocate ICD skin pocket 33224 Insert LV lead, attach to existing pacer/icd +33225 Insert LV lead at time of pacer/icd generator implant 33226 Reposition previously placed LV lead 33227 Remove pacer gen. and replace pacer gen.; single lead system APC 0136 $1,112 (T) APC 0136 $1,112 (T) APC 0655 $10,187 (T) APC 0655** $10,187 (T) APC 0105 $1,683 (T) APC 0090 $6,612 (T) APC 2012 and SI APC 0136 $1,172 (T) APC 0136 $1,172 (T) APC 0655 $9,693 (T) APC 0655** $9,693 (T) APC 0105 $1,596 (T) APC 0090 $6,602 (T) % Change -5.1% -5.1% 5.1% 5.1% 5.5% 0.2% ** Single Composite APC 0108 is applicable when ICD/CRT-D generator and leads are implanted on same date of service. Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 58
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33228 Remove pacer and replace pacer gen.; dual lead system 33229 Remove pacer and replace pacer gen.; multiple lead system 33230 Insert ICD gen. only; w/ existing dual leads 33231 Insert ICD gen. only; w/ multiple leads 33234 Remove pacer lead; single 33235 Remove pacer leads; dual APC 0654 $7,715 (T) APC 0654 $7,715 (T) APC 0107 $22,512 (T) APC 0107 $22,512 (T) APC 0105 $1,683 (T) APC 0105 $1,683 (T) APC 2012 and SI APC 0654 $7,235 (T) APC 0654 $7,235 (T) APC 0107 $24,290 (T) APC 0107 $24,290 (T) APC 0105 $1,596 (T) APC 0105 $1,596 (T) % Change 6.6% 6.6% -7.3% -7.3% 5.5% 5.5% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 59
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33240 Insert ICD gen. only; w/ single lead APC 0107 $22,512 (T) 33241 Remove ICD gen. only APC 0105 $1,683 (T) 33244 Remove ICD leads; by transvenous extraction 33249 Insert or replace ICD system w/ transvenous leads, single or dual chamber 33262 Remove ICD and replace ICD gen.; single lead system APC 0105 $1,683 (T) APC 0108** $30,680 (T) APC 0107 $22,512 (T) APC 2012 and SI APC 0107 $24,290 (T) APC 0105 $1,596 (T) APC 0105 $1,596 (T) APC 0108** $29,767 (T) APC 0107 $24,290 (T) % Change -7.3% 5.5% 5.5% 3.1% -7.3% ** Single Composite APC 0108 is applicable when ICD/CRT-D generator and leads are implanted on same date of service. Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 60
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 33263 Remove ICD and replace ICD gen.; dual lead system 33264 Remove ICD and replace ICD gen.; multiple lead system 33282 Insert patient-activated cardiac event recorder (ILR) APC 0107 $22,512 (T) APC 0107 $22,512 (T) APC 0680 $5,893 (S) 33284 Remove ILR APC 0020 $584 (T) APC 2012 and SI APC 0107 $24,290 (T) APC 0107 $24,290 (T) APC 0680 $5,633 (S) APC 0020 $579 (T) % Change -7.3% -7.3% 4.6% 0.9% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 61
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 92960 Cardioversion, external APC 0679 $400 (S) 92961 Cardioversion, internal APC 0679 $400 (S) 93279 Program device evaluation; single lead pacemaker system 93280 Program device evaluation; dual lead pacemaker system 93281 Program device evaluation; multiple lead pacemaker system 93282 Program device evaluation; single lead ICD system APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 2012 and SI APC 0679 $374 (S) APC 0679 $374 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) % Change 6.9% 6.9% -1.6% -1.6% -1.6% -1.6% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 62
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93283 Program device evaluation; dual lead ICD system 93284 Program device evaluation; multiple lead ICD system APC 0690 $33.95 (S) APC 0690 $33.95 (S) 93285 Program device evaluation; ILR APC 0690 $33.95 (S) APC 2012 and SI APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) % Change -1.6% -1.6% -1.6% 93286 Peri-procedural device evaluation, pacer Status N Status N NA 93287 Peri-procedural device evaluation, ICD Status N Status N NA 93288 Interrogation device evaluation; all pacemaker systems 93289 Interrogation device evaluation; all ICD systems 93290 Interrogation device evaluation; implantable CV monitor (ICM) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0035 $23.43 (X) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0035 $18.81 (X) -1.6% -1.6% 24.4% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 63
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93291 Interrogation device evaluation, ILR 93292 Interrogation; wearable ICD system 93293 Transtelephonic pacemaker evaluation(s), up to 90 days 93296 Interrogation device evaluation(s), up to 90 days; pacemaker system or ICD system 93299 Interrogation device evaluation(s), (remote), up to 30 days; ILR or ICM 93306 Echo, transthoracic, 2D, complete, with spectral and color flow Doppler APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0690 $33.95 (S) APC 0269 $390 (S) APC 2012 and SI APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) APC 0269 $393 (S) % Change -1.6% -1.6% -1.6% -1.6% -1.6% -0.8% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 64
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93307 Echo, transthoracic, 2D, complete, w/o spectral and color flow 93308 Echo, transthoracic, 2D, follow-up or limited study APC 0269 $390 (S) APC 0697 $213 (S) 93350 Stress TTE APC 0269 $390 (S) 93351 Stress TTE complete APC 0270 $559 (S) +93462 Transseptal puncture APC 0080 $2,650 (T) 93600 Bundle of His recording APC 0084 $705 (S) APC 2012 and SI APC 0269 $393 (S) APC 0697 $221 (S) APC 0269 $393 (S) APC 0270 $580 (S) APC 0080 $2,721 (T) APC 0084 $695 (S) % Change -0.8% -3.6% -0.8% -3.6% -2.6% 1.4% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 65
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93602 Intra-atrial recording APC 0084 $705 (S) 93603 Right ventricular recording APC 0084 $705 (S) 93610 Intra-atrial pacing APC 0084 $705 (S) 93612 Intraventricular pacing APC 0084 $705 (S) 93615 Esophageal pacing of atrial electrogram 93616 Esophageal pacing of atrial electrogram; w/recording APC 0084 $705 (S) APC 0084 $705 (S) APC 2012 and SI APC 0084 $695 (S) APC 0084 $695 (S) APC 0084 $695 (S) APC 0084 $695 (S) APC 0084 $695 (S) APC 0084 $695 (S) % Change 1.4% 1.4% 1.4% 1.4% 1.4% 1.4% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 66
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93618 Induction of arrhythmia by electrical pacing 93619 Comprehensive EP study; without induction of arrhythmia 93620 Comprehensive EP study; with induction of arrhythmia 93624 EP follow-up study with pacing and recording to test effectiveness 93642 EP evaluation of single or dual chamber ICD 93650 Catheter ablation of AV node function APC 0084 $705 (S) APC 0085 $3,922 (T) APC 0085 $3,922 (T) APC 0085 $3,922 (T) APC 0084 $705 (S) APC 0085 $3,922 (T) APC 2012 and SI APC 0084 $695 (S) APC 0085 $3,762 (T) APC 0085 $3,762 (T) APC 0085 $3,762 (T) APC 0084 $695 (S) APC 0085 $3,762 (T) % Change 1.4% 4.2% 4.2% 4.2% 1.4% 4.2% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 67
APC CRDM National Payment Comparisons CPT Brief Description APC 2013 and SI 93653 Composite 93654 Composite 93656 Composite EPS, catheter ablation of SVT EPS, catheter ablation of VT EPS, catheter ablation of AF by PVI APC 8000 $11,146 (Q3) 93660 Tilt table evaluation APC 0101 $304 (S) 93724 Electronic analysis of antitachycardia pacemaker system APC 0690 $33.95 (S) 93745 Set up wearable ICD APC 0690 $33.95 (S) APC 2012 and SI 93651 APC 0086 $8,979 (T) 93652 APC 0086 $8,979 (T) 93651 APC 0086 $8,979 (T) APC 0101 $299 (S) APC 0690 $34.50 (S) APC 0690 $34.50 (S) % Change Comparison not valid as a result of new packaged ablation codes 1.7% -1.6% -1.6% Source: Addendum B. Final OPPS Payment by HCPCS Code for CY 2013 and CY 2012 68