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Davis reimbursement review
This document discusses reimbursement for vascular interventions and provides coding guidance for lower extremity peripheral interventions. It begins with basic reimbursement concepts like place of service, diagnosis and procedure codes. It then reviews inpatient vs outpatient criteria and key acronyms. Coding rules and hierarchies are presented for lower extremity interventions including the femoral/popliteal, iliac and tibial/peroneal territories. Medicare payment rates for 2013 are shown for common lower extremity codes.
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- 1. 1 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 2013 VASCULAR INTERVENTIONS REIMBURSEMENT PRESENTED BY: DAVID DAVIS
- 2. 2 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Disclaimer Health 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.
- 3. 3 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 REIMBURSEMENT BASICS
- 4. 4 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Place of Service Determines Fee Schedule ICD-9-CM Diagnosis Codes (Why patient received treatment) CPT/HCPCS Procedure Codes Hospital 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)
- 5. 5 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 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
- 6. 6 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 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
- 7. 14 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 LOWER EXTREMITY INTERVENTIONS
- 8. 15 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Peripheral Intervention Overview Codes 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.
- 9. 16 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Diagnostic Angiography Diagnostic 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. 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.
- 10. 17 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 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 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.
- 11. 18 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Coding Hierarchy NOTE: The CPT code numbers do not reflect this hierarchy.
- 12. 19 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 CPT reporting structure Iliac Territory 3 Vessels (Common, External and Internal) 3 possible codes: 1 base and up to 2 add-on codes Femoral/Popliteal Territory Entire fem/pop territory is considered a single vessel for CPT reporting 1 possible code Tibial/Peroneal 3 Vessels (anterior tibial, posterior tibial, and peroneal) 3 possible codes: 1 base and up to 2 add-on codes 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.
- 13. 20 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 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. 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.
- 14. 21 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Tibial/ Peroneal Territory 37228 Tibial PTA 37230 Tibial PTA with Stent 37229 Tibial PTA with Atherectomy 37231 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. 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.
- 15. 25 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Lower Extremity Medicare Payment CPT 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% 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.
- 16. 26 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 Hospital Inpatient Reimbursement, Peripheral MS DRGDescriptor 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%
- 17. 27 ©2013 Spectranetics.All Rights Reserved. Approved for External Distribution D019409-01 012013 THE END DAVID.DAVIS@SPNC.COM
Editor's Notes
- #6 What patient is considered an inpatient and what patient is considered an outpatient? According to Medicare Physician Guide October 2008, pg. 45 which can be found on the CMS website… An inpatient is an individual who has been admitted to a hospital for the purpose of receiving inpatient hospital services. Generally, an individual is considered an inpatient if he or she is formally admitted as inpatient with the expectation of remaining at least overnight and occupying a bed. The individual is considered an inpatient even if he or she can later be discharged or transferred to another hospital and does not actually use a hospital bed. The physician or other practitioner responsible for an individual's care at the hospital is responsible for deciding whether he or she should be admitted as an inpatient The physician or practitioner should also use a 24-hour period as a benchmark by ordering admission for individuals who are expected to need hospital care for 24 hours or more and treating other individuals on an outpatient basis.