Davis reimbursement review

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2013 VASCULAR INTERVENTIONS REIMBURSEMENTPRESENTED BY: DAVID DAVIS


DisclaimerHealth economic and reimbursement information provided by Spectranetics Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Spectranetics encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Spectranetics recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

Spectranetics does not promote the use of its products outside their FDA-approved label.

CPT® Disclaimer: CPT Copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American 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.


REIMBURSEMENT BASICS


Place of Service Determines Fee ScheduleICD-9-CM Diagnosis Codes

(Why patient received treatment)

CPT/HCPCS Procedure CodesHospital outpatient, ASC & physician

service(s)

APC Payment

ASC Payment

ICD-9-CM Procedure Codes

Hospital inpatient service(s)

MS-DRG Payment(Hospital Inpatient)

Physician Fee Schedule

Non Facility Payment (Office)

Facility Payment(Hospital)


Inpatient vs Outpatient

The decision to admit an individual is a complex medical judgment that is made by the physician with the cooperation of the hospital staff.

Reference: Medicare Physician Guide October 2008, pg. 45


Key to Reimbursement Acronyms• CMS- Centers for Medicare & Medicaid Services• APC- Ambulatory Payment Classification• ASC- Ambulatory Surgery Center • OBL- Office Based Lab• PFS- Physician Fee Schedule• OPPS- Outpatient Prospective Payment System• IPPS- Inpatient Prospective Payment System • MS-DRG- Medicare Severity Diagnosis Related Group• CPT- Common Procedural Terminology. Book published annually by AMA• SGR- Sustainable Growth Rate


LOWER EXTREMITY INTERVENTIONS


Peripheral Intervention OverviewCodes 37224-37235 describe lower extremity interventions. In addition to the intervention performed, the codes include:• Accessing the vessel• Selectively catheterizing the vessel• Crossing the lesion• Radiological S&I (Supervision and Interpretation) directly related to the

intervention• Embolic protection (if used)• Closure of the arteriotomy by pressure, closure device or suture• Post-procedure Imaging

See important notes on the uses and limitations of this information on slide 2. CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Diagnostic AngiographyDiagnostic Angiography may be separately coded if:

1.No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR

2.A prior study is available, but as documented in the medical record:

a. The patient’s condition with respect to the clinical indication has changed since the prior study, OR

b. There is inadequate visualization of the anatomy and/ or pathology, OR

c. There is a clinical change during the procedure that requires new evaluation outside the target area of intervention

If diagnostic angiography is necessary, is performed at the same session as the interventional procedure and meets the above criteria, modifier -59 must be appended to the diagnostic radiological supervision and interpretation code(s) to denote that diagnostic work has been done following these guidelines.



Lower Extremity Coding Rules• One primary code is used per vessel territory

• If second or third vessels are treated in the iliac and/or tibial/peroneal territories, use add-on codes

• If more than one stent is placed in the same vessel then the code should be reported only once

• If a lesion extends across the margins of one territory into another but can be opened with a single therapy, only report one code

• For bifurcation lesions which require therapy of 2 distinct branches, report primary code and an add-on code

• When the same territories of both legs are treated in the same session use modifier -59 to denote that different legs are being treated, even if the mode of therapy is different



Coding Hierarchy

NOTE: The CPT code numbers do not reflect this hierarchy.


CPT reporting structureIliac Territory3 Vessels (Common, External and Internal)3 possible codes: 1 base and up to 2 add-on codes

Femoral/Popliteal TerritoryEntire fem/pop territory is considered a single vessel for CPT reporting1 possible code

Tibial/Peroneal 3 Vessels (anterior tibial, posterior tibial, and peroneal)3 possible codes: 1 base and up to 2 add-on codes



Femoral/Popliteal Territory

37224 Fem/Pop PTA

37226 Fem/Pop PTA with Stent

37225 Fem/Pop PTA with Atherectomy

37227 Fem/Pop PTA with Stent and Atherectomy

A single interventional code is used no matter what combination of PTA/ stent/ atherectomy is applied to all segments, including the common, deep and superficial femoral arteries as well as the popliteal artery.



Tibial/ Peroneal Territory

37228 Tibial PTA37230 Tibial PTA with Stent37229 Tibial PTA with Atherectomy37231 Tibial PTA with Stent and Atherectomy +37232 Tibial PTA, add’l vessel +37234 Tibial PTA with Stent, add’l vessel +37233 Tibial PTA with Atherectomy, add’l vessel +37235 Tibial PTA with Stent and Atherectomy, add’l vessel

A single primary code is used for the initial tibial/ peroneal artery treated in each leg. If other tibial/ peroneal vessels are also treated in the same leg, these interventions are reported with the appropriate add-on.



Lower Extremity Medicare PaymentCPT Descriptor

2013 ASC Medicare

Avg. Payment

2013 APC Medicare Avg.

Payment

% Change from 2012

2013 OBL Medicare Avg. Payment

% Change from 2012

2013 Physician Medicare Payment

% Change from 2012

37224 Fem/pop revas w/tla $2,257 $4,023 -13% $4,134 4% $468 -1%

37225 Fem/pop revas w/ather $4,857 $8,657 7% $11,858 5% $632 -1%

37226 Fem/pop revasc w/stent $4,857 $8,657 7% $9,750 3% $518 -1%

37227 Fem/pop revasc stnt & ather $11,601 $14,596 3% $16,022 5% $763 -1%

37228 Tib/per revasc w/tla $2,257 $4,023 -13% $5,893 4% $572 -1%

37229 Tib/per revasc w/ather $4,857 $8,657 7% $11,680 5% $738 -1%

37230 Tib/per revasc w/stent $4,857 $8,657 7% $8,904 1% $715 0%

37231 Tib/per revasc stent & ather $11,601 $14,596 3% $14,210 0% $778 0%

+37232 Tib/per revasc add-on $2,257 $4,023 -13% $1,307 3% $207 0%

+37233 Tibper revasc w/ather add-on $4,857 $8,657 7% $1,563 2% $338 -1%

+37234 Revsc opn/prq tib/pero stent $2,257 $4,023 -13% $4,228 4% $286 0%

+37235 Tib/per revasc stnt & ather $2,257 $4,023 -13% $4,312 0% $395 -2%



Hospital Inpatient Reimbursement, Peripheral

MS DRG Descriptor

FY 2012 Medicare National

Avg. Payment

FY 2013 National Avg.

Payment$ chg % chg

Peripheral Revascularization

252 OTHER VASCULAR PROCEDURES W MCC $16,817 $17,452 $635 4%

253 OTHER VASCULAR PROCEDURES W CC $13,758 $14,285 $527 4%

254 OTHER VASCULAR PROCEDURES W/O CC/MCC $9,303 $9,590 $287 3%


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