2014 Cordis Cardiac & Vascular Procedures Reimbursement Guide

Transcription

1 2014 Cordis Cardiac & Vascular Procedures Reimbursement Guide

2 Table of Contents Description Page 1 Hospital Inpatient Issues 2 Hospital Inpatient Coding 4 Hospital Inpatient Reimbursement 8 Hospital Outpatient Issues 12 Hospital Outpatient Reimbursement 14 Ambulatory Surgery Center and Independent Diagnostic Testing Facility Issues 18 Physician Reimbursement Issues 22 Bundling NCCI and OCE Issues 23 CPT Coding Updates in Recent Years 25 Modifiers 29 Case Study Payment Examples 31 Disclaimer The information contained in this guide is provided to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Cordis Corporation concerning levels of reimbursement, payment or charge. Similarly, all CPT and HCPCS codes are supplied for information purposes only and represent no statement, promise or guarantee by Cordis Corporation that these codes will be appropriate or that reimbursement will be made. It is important to research coverage and payment for procedures on a payer-specific basis as coverage policies and guidelines vary by payer. The information in this guide is broad-based and intended to address a wide range of reimbursement situations that you may encounter. It references many different procedures and types of devices. Such a broad discussion is not intended to suggest or imply that Cordis offers products for every use or procedure discussed. As always, please refer to the package insert for a complete description of indications and contraindications for any medical device type mentioned in these materials prior to use. The case study examples are provided only to illustrate a possible reimbursement scenario. It is not intended as direction on how to conduct or code for a procedure. Individual procedures and corresponding codes will vary based on the physician s medical judgment and circumstances of the case. We trust you will find this guide useful. The guide is an example of the commitment of Cordis Corporation to providing quality products and services to our customers. For more information about Cordis Corporation, please visit us at or contact our Customer Service department at Cordis Corporation 2014

3 2 HOSPITAL INPATIENT ISSUES Introduction to the 2014 Hospital Inpatient Prospective Payment System (IPPS) Final Rule On August 2, 2013, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for acute inpatient hospital services, detailing changes to Medicare payment rates and policies for fiscal year The final rule appeared in the August 19th Federal Register and will be effective for discharges on or after October 1, Medicare previously adopted the Medicare Severity Diagnosis Related Group (MS-DRG) system to better account for patient severity of illness, expanding the number of payment groups from 538 to 745; there are now 751 MS-DRGs. The intent of the MS-DRG system is to more accurately stratify groups of Medicare patients with varying levels of severity than the prior DRG system by better aligning payments with the anticipated costs of care, and are assigned based upon the presence or absence of specific ICD-9-CM diagnosis codes indicating complications or comorbidities (CCs) and/or major complications or comorbidities (MCCs). Complications include all conditions that develop after inpatient admission which affect treatment and/or length of stay; cormorbidities are conditions which pre-exist at the time of admission. While most commercial insurers are also following MS-DRGs, some may utilize other reimbursement methods. 2 Among other key changes in the IPPS for FY 2014 are the following: 2 1) FY 2014 Inpatient Hospital Update: The final rule updates IPPS payment rates by 1.7% for hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program, which reflects a market basket increase of 2.5% reduced by several adjustment factors. 2) Quality Measure Reporting for 2014 Updates: Under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU), in effect since 2004, hospitals that choose not to participate or fail to meet criteria for successful reporting in a given year received the annual payment update (APU) reduced by 2.0%. The 2013 final rule reduced the number of measures in the IQR program from 72 to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination. 3 3) Hospital Readmissions Reduction Program: The Affordable Care Act established this program, under which payments to certain hospitals will be reduced to account for excess readmissions. Two new measures bring the total to five: acute myocardial infarction (AMI) or heart attack, heart failure, pneumonia, hip/knee arthroplasty, and chronic obstructive pulmonary disease. 4) Other Payment Policy Updates: The Final Rule also addresses operational details regarding: The Hospital Value-Based Purchasing (VBP) Program; Admissions and Medical Review Criteria for Inpatient Services; Part B Rebilling for Inpatient Services in Hospitals later determined to be outpatient stays; Medicare Disproportionate Share Hospitals (DSH) payments; and Direct Graduate Medical Education (DGME). Expiring provisions include: the Medicare-Dependent Hospital (MDH) Program, and Affordable Care Act changes to the Low-Volume Hospital Payment Adjustment. 1 October 1, 2013 through September 30, Centers for Medicare and Medicaid Services Fact Sheet: CMS Finalizes FY 2014 Policy and Payment Changes for Inpatient Stays in Acute-Care and Long-Term Hospitals; August 2, 2013; Sheets. 3 Centers for Medicare and Medicaid Services Fact Sheet: CMS Final Rule to Improve Quality of Care During Hospital Inpatient Stays; August 2, 2013;

4 3 5) Quality Reporting Programs: The Affordable Care Act called for CMS to create new quality reporting programs for two types of hospitals that are exempt from payment under the IPPS. The Hospital IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups. By statute, annual payment updates for hospitals that do not participate successfully in the Hospital IQR program are reduced by 2.0 percentage points. Beginning with fiscal year 2015, hospitals that do not participate will lose one-quarter of the percentage increase in their payment updates. Since the implementation of this financial penalty, hospital participation has increased to well over 99 percent. For the FY 2016 payment determination and subsequent years, CMS will remove six chart abstracted measures and one structural measure. We will suspend one chart-abstracted measure and adopt five new claims-based measures: (1) 30-day risk-standardized COPD Readmission; (2) 30-day risk standardized COPD mortality; (3) 30- day risk standardized stroke readmission; (4) 30-day risk standardized stroke mortality; and (5) AMI payment per episode of care. In the final rule, CMS finalizes a policy to validate two new chart- abstracted Healthcare Associated Infections measures: hospital-onset methicillin-resistant staphylococcus aureas (MRSA) bacteremia, and clostridium difficile. CMS is also finalizing a proposal to reduce the number of records used for HAI validation from 48 records per year to 36 records per year beginning with the FY 2015 payment determination and to provide hospitals with the option to transmit secure electronic versions of medical information to meet validation requirements. 6) Hospital Acquired Conditions: The FY 2014 hospital payment rule finalizes the general framework for the Hospital- Acquired Condition (HAC) Reduction Program for the FY 2015 implementation. Section 3008 of the Affordable Care Act requires CMS to establish a program for IPPS hospitals to improve patient safety, by imposing financial penalties on hospitals that perform poorly with regard to hospital-acquired conditions. HACs are conditions that patients did not have when they were admitted to the hospital, but which developed during the hospital stay. Under the HAC Reduction Program, hospitals that rank in the lowest-performing quartile of hospital-acquired conditions will be paid 99 percent of what otherwise would have been paid under IPPS, beginning in FY The rule finalizes the quality measures and the scoring methodology to determine this quartile, as well as the process hospitals will use to review and correct their data. In the first year of the program, FY 2015, CMS will use measures that are part of the IQR program. The HAC measures will consist of two domains of measure sets. Domain 1 will include the Agency for Health Care Research and Quality (AHRQ) composite PSI #90. This measure includes the following indicators: Pressure ulcer rate (PSI 3); Iatrogenic pneumothorax rate (PSI 6); Central venous catheter-related blood stream infection rate (PSI 7); Postoperative hip fracture rate (PSI 8); Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12); Postoperative sepsis rate (PSI 13); Wound dehiscence rate (PSI 14); and Accidental puncture and laceration rate (PSI 15). Domain 2 measures consist of two healthcare-associated infection measures developed by the Centers for Disease Control and Prevention s (CDC) National Health Safety Network: Central Line-Associated Blood Stream Infection and Catheter-Associated Urinary Tract Infection. Hospitals will be given a score for each measure within the two domains. A domain score will be calculated with Domain 1 weighted at 35 percent and Domain 2 weighted at 65 percent to determine a total score under the program. Risk factors such as the patient s age, gender, and comorbidities will be considered in the calculation of the measure rates so that hospitals serving a large proportion of sicker patients will not be penalized unfairly. Hospitals will be able to review and correct their information. 7) Never Events: CMS has also implemented a policy to not pay for medical care that harms patients or leads to complications that could have been prevented involving three identified Never Events. For dates of service on or after January 15, 2009, hospitals should submit the non-covered TOB 110, clearly indicating in Remarks one of the applicable 2-digit surgical error codes: MX: MY: MZ: Wrong Surgery on Patient Surgery on Wrong Body Part Surgery on Wrong Patient

5 4 Hospital Inpatient Coding Medicare uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify diagnoses and procedures in the hospital inpatient setting. Hospitals must report the principal diagnosis using an appropriate ICD-9-CM code, as well as any secondary diagnoses some of which may be considered CCs or MCCs for MS-DRG assignment. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The circumstances of inpatient admission always govern the selection of principal diagnosis. 4 Diagnosis codes should be reported to the highest level of specificity available a code is invalid if it has not been coded to the full number of digits required for that code. A minimum of one diagnosis code is required on all claims, and it is possible to report up to eighteen. Medicare may require additional clinical information specific to each patient to determine coverage and payment for the reported procedure. Table 1 includes ICD-9-CM diagnosis codes commonly used to report peripheral vascular and cerebrovascular conditions: Table 1: Common ICD-9-CM Diagnosis Codes Peripheral Vascular Conditions Diagnosis Code 5 Description Pulmonary embolism and infarction, other Chronic pulmonary embolism Occlusion and stenosis of carotid artery, without mention of cerebral infarction Occlusion and stenosis of carotid artery, with cerebral infarction Occlusion and stenosis of precerebral arteries, multiple and bilateral, without mention of cerebral infarction Occlusion and stenosis of precerebral arteries, multiple and bilateral, with cerebral infarction Atherosclerosis of aorta Atherosclerosis of renal artery Atherosclerosis of native arteries of the extremities Chronic total occlusion of artery of the extremities Atherosclerosis of other specified vessels Peripheral vascular disease, unspecified Arterial embolism and thrombosis of the extremities Arterial embolism and thrombosis of other specified arteries Atheroembolism Stricture of artery Hyperplasia of renal artery Acute / chronic venous embolism and thrombosis of vessels of various specified sites Hemorrhage, unspecified 4 The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD-9-CM Tabular Addenda, National Center for Health Statistics, June 10, Note that there are no ICD-9-CM diagnosis code changes or relevant ICD-9-CM procedure code changes for FY 2014, reflecting the partial code freeze in preparation for transition ICD-10-CM and ICD-10-PCS in October 2014.

6 5 Table 2 includes ICD-9-CM diagnosis codes commonly used to report cardiac conditions: Table 2: Common ICD-9-CM Diagnosis Codes Cardiac Conditions Diagnosis Code Description Acute myocardial infarction Other acute and subacute forms of ischemic heart disease Angina pectoris Coronary atherosclerosis Chronic total occlusion of coronary artery Coronary atherosclerosis due to lipid rich plaque Coronary atherosclerosis due to calcified coronary lesion Other specified forms of ischemic heart disease Chronic ischemic heart disease, unspecified For inpatient admissions involving procedures, hospitals must also report ICD-9-CM procedure code(s) for the surgical and other procedures, up to six procedures on a claim. Medicare recognizes certain ICD-9-CM procedure codes used in the inpatient setting to report percutaneous angiography, angioplasty, stenting, and other procedures. The following two tables list some of the most commonly used codes for cardiovascular diagnostic and therapeutic procedures. Table 3: Common ICD-9-CM Procedure Codes Diagnostic Procedures Procedure Code 6 Description Head and Neck Vessels Arteriography of cerebral arteries Phlebography of veins of head and neck using contrast material Peripheral Vascular Intravascular pressure measurement of intrathoracic arteries Intravascular pressure measurement of peripheral arteries Intravascular pressure measurement, other specified and unspecified vessels Intravascular imaging of non-coronary vessel(s) by optical coherence tomography Arteriography using contrast material, unspecified site Aortography Arteriography of pulmonary arteries Arteriography of other intrathoracic vessels Arteriography of renal arteries Arteriography of other intra-abdominal arteries Arteriography of femoral and other lower extremity arteries Arteriography of other specified sites Phlebography using contrast material, unspecified site Phlebography of pulmonary veins using contrast material Phlebography of other intrathoracic veins using contrast material Phlebography of other intra-abdominal veins using contrast material Phlebography of femoral and other lower extremity veins using contrast material Phlebography of other specified sites using contrast material Coronary Vessels and Cardiac Imaging Right heart cardiac catheterization Left heart cardiac catheterization Combined right and left heart cardiac catheterization Intravascular imaging of coronary vessel(s) by optical coherence tomography Angiocardiography using contrast material 6 Ibid.

7 6 Table 4: Common ICD-9-CM Procedure Codes -- Cardiovascular Interventional Procedures and IVUS Procedure Code Description Head and Neck Vessels Intravascular imaging of extracranial cerebral vessels Percutaneous angioplasty of extracranial vessel(s) Percutaneous insertion of carotid artery stent(s) Percutaneous insertion of other extracranial artery stent(s) Percutaneous atherectomy of extracranial vessel(s) Endovascular removal of obstruction from head and neck vessel(s) Other endovascular procedures on other vessels Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Peripheral Vascular Intravascular imaging of intrathoracic vessels Intravascular imaging of peripheral vessels Intravascular imaging of renal vessels Intravascular imaging, other specified vessel(s) Insertion of drug-eluting stent(s) of other peripheral vessel(s) Insertion of drug-eluting stent(s) of superficial femoral artery Atherectomy of other non-coronary vessels 38.7 Interruption of the vena cava Angioplasty of other non-coronary vessel(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Coronary Vessels Intravascular imaging of coronary vessels Super-saturated oxygen therapy Intravascular pressure measurement of coronary arteries Percutaneous transluminal coronary angioplasty [PTCA] Transluminal intracoronary atherectomy Intracoronary artery thrombolytic infusion Insertion of non-drug-eluting coronary artery stent(s) Insertion of drug-eluting coronary artery stent(s) Other removal of coronary artery obstruction Injections / Infusions and Other Supportive Therapies Insertion of pulsation balloon Insertion of percutaneous external heart assist device Injection or infusion of thrombolytic agent Injection of anticoagulant Injection or infusion of platelet inhibitor Nonoperative removal of heart assist system Additional procedure codes relevant to vascular procedures are the adjunct vascular system procedure codes, which indicate multi-vessel and multi-stent procedures. These codes can apply to both coronary and peripheral vessels, and should be used in conjunction with other therapeutic procedure codes to provide additional information on the number of vessels upon which a procedure was performed and/or the number of stents inserted. As appropriate, code both the number of vessels operated upon and the number of stents inserted. If a case involves a combination of coronary and non-coronary vessels, report the grand total number of vessels/stents treated during the admission. 7 Note that insertion of drug-eluting peripheral vessel stents and insertion of stents into extracranial vessels other than the carotid artery are still considered investigational by Medicare and are not covered. Medicare covers only those repair devices that are FDA approved. There are other devices which may be under investigational development. If a device is listed on the Category B device exemption lists, special procedures must be followed to receive payment by Medicare.

8 7 Procedure Code Table 5: Common ICD-9-CM Procedure Codes -- Adjunct Vascular System Procedures Description Procedure on single vessel Procedure on two vessels Procedure on three vessels Procedure on four or more vessels Procedure on vessel bifurcation Insertion of a single stent Insertion of two stents Insertion of three stents Insertion of four or more stents Note that ICD-9-CM procedure code is used to describe the performance of a procedure across or involving a vessel bifurcation; it does not indicate a specific bifurcation stent or other device. This code is typically reported only once per operative session, regardless of the number of vessel bifurcations. Revenue Codes Revenue codes allow hospitals to categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. Sample revenue codes that hospital facilities may use to track costs for services associated with endovascular, non-vascular procedures are listed in the following table: Revenue Code 8 Description Accommodations, Coronary Care Table 6: Common Revenue Codes 0278 Medical/Surgical Supplies and Devices, Other Implant 0321 Diagnostic Radiology - Angiocardiography 0323 Diagnostic Radiology Arteriography 0360 Operating Room Services, General Classification 0481 Cardiac Catheterization Lab Supplies Incident to Radiology / Other Diagnostic Services 0732 Electrocardiogram - Telemetry 0921 Peripheral Vascular Lab 8 Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set, Form Locator 42;

9 8 Hospital Inpatient Reimbursement Medicare beneficiaries who are admitted into hospital inpatient settings typically have coverage through Medicare Part A. Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on diagnosis-related groups (DRGs), now MS-DRGs. The MS-DRG payment system groups similar diagnoses into a single payment level, and reimburses the hospital according to the extent of resources typically required to treat patients with similar diagnoses undergoing similar treatments. All services and supplies provided during the inpatient admission are bundled into a single MS-DRG reimbursement rate, regardless of the length of the inpatient stay, the intensity of treatments, or the number of procedures performed for the specific individual. Hospitals will receive one global MS-DRG payment rate per patient admission, and the MS-DRG assignment is primarily determined by the patient s principle diagnosis and/or principal procedure performed. Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) Beginning October 1, 2007, Medicare revised the entire DRG system to better reflect the severity levels of inpatient treatments. Hospitals performing procedures for Medicare patients now receive payment under the new MS-DRG assignments and MS-DRGs are now distinguished between encounters with or without CCs or MCCs. MCCs better recognize hospital resource use based on secondary diagnoses. These conditions generally correspond to longer and more complicated inpatient stays due to a need for services such as intensive monitoring, expensive and technically complex procedures, and/or extensive nursing care. Secondary conditions documented in a patient s medical record may impact the reimbursement a hospital receives. While there are typically only two levels of MS-DRG for coronary procedures, with or without MCC, some endovascular MS-DRGs include reference to CCs. Under the MS-DRG system, a CC or MCC must represent a secondary diagnosis in combination with the principal diagnosis. Beginning with FY 2013, documenting and reporting the diagnosis of chronic total occlusion (CTO) of artery of the extremities (ICD-9-CM code 440.4) can significantly affect reimbursement to the hospital for peripheral interventions, as this is now recognized as a CC. The following two tables provide diagnosis codes that may be cormorbidities in cardiovascular patients, which have been identified as CCs or MCCs and may therefore affect MS-DRG assignment.

10 9 Table 7: Partial List of ICD-9-CM Codes Complications and Cormorbidities (CCs) 9 Diagnosis Code 10 Description 263.0, Malnutrition of moderate or mild degree 263.8, Other and unspecified protein-calorie malnutrition Hypernatremia, hyponatremia, acidosis, alkalosis Malignant essential hypertension , Malignant hypertensive heart disease, with or without heart failure , Hypertensive chronic kidney disease, malignant , Hypertensive chronic kidney disease, benign or unspecified, with chronic kidney disease stage V or end stage renal disease Hypertensive heart and chronic kidney disease, malignant , Hypertensive heart and chronic kidney disease, benign or unspecified, with heart failure and/or chronic kidney disease stage V or end stage renal disease , Malignant renovascular or other secondary hypertension Other acute and subacute forms of ischemic heart disease Primary pulmonary hypertension Chronic pulmonary embolism Cardiomyopathy Paroxysmal supraventricular tachycardia Paroxysmal ventricular tachycardia Atrial flutter Left heart failure , , Unspecified or chronic systolic, diastolic, or combined systolic and diastolic heart failure , , , , 435.1, 435.2, Basilar artery syndrome, vertebral artery syndrome, subclavian steal syndrome, or vertebrobasilar artery syndrome 435.8, Other specified or unspecified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease Other generalized ischemic cerebrovascular disease Atherosclerosis of native arteries of the extremities with gangrene Chronic total occlusion of artery of the extremities Arterial embolism and thrombosis of aorta, artery of upper or lower extremity, iliac artery, other specified artery, or unspecified artery Atheroembolism Rupture of artery Acute / chronic venous embolism and thrombosis of vessels of specified sites , , , , Extrinsic or intrinsic or chronic obstructed or unspecified asthma with status asthmaticus or (acute) exacerbation , , , Chronic respiratory failure Acute kidney failure, unspecified 585.4, Chronic kidney disease, Stage IV or V Urinary tract infection, site not specified Cellulitis and abscess of various specified sites Ulcer of lower limb Jaundice, unspecified, not of newborn Mechanical complication of other vascular device, implant, and graft Infection and inflammatory reaction due to other vascular device, implant, and graft Other complications due to other vascular device, implant, and graft 997.1, Cardiac or peripheral vascular complications, not elsewhere classified V85.0, V85.4X Body Mass Index less than 19, or 40 and over, adult 9 Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 6J - CC List; (under Acute Inpatient Files for Download) 10 Ibid; International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD- 9-CM Tabular Addenda, National Center for Health Statistics, June 10, 2011.

11 10 Table 8: Partial List of ICD-9-CM Codes Major Complications and Cormorbidities (MCCs) 11 Diagnosis Code 12 Description Secondary diabetes mellitus with ketoacidosis, hyperosmolality or other coma Diabetes mellitus with ketoacidosis, hyperosmolality or other coma 410.X1 Acute myocardial infarctions, initial episode of care Dissection of coronary artery 415.1X Pulmonary embolism and infarction Ventricular fibrillation, ventricular flutter Cardiac arrest , Acute or acute on chronic systolic heart failure , Acute or acute on chronic diastolic heart failure , Acute or acute on chronic combined systolic and diastolic heart failure Dissection of aorta, unspecific site or thoracic , , Occlusion and stenosis of precerebral arteries with cerebral infarction , , , , , Dissection of aorta, unspecified site, thoracic, abdominal, or thoracoabdominal , , , Dissection of artery: carotid, iliac, renal, vertebral, or other artery , , Other venous embolism and thrombosis of inferior vena cava End stage renal disease Peripartum cardiomyopathy , Pressure ulcer, stage III or stage IV Cardiogenic, septic, or other shock without mention of trauma Traumatic injuries to specified blood vessels Sepsis, severe sepsis, systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Postoperative shock, cardiogenic Five diagnoses which are closely associated with patient mortality are assigned different CC subclasses, depending upon whether the patient is discharged alive or deceased. These diagnoses are: Ventricular fibrillation Cardiac arrest Cardiogenic shock Other shock without mention of trauma Respiratory arrest These diagnoses are assigned an MCC subclass for patients who are discharged alive, and a non-cc subclass for patients who expire. Table 9 below lists common MS-DRGs which may be assigned when conducting endovascular procedures, including peripheral angioplasty and/or stenting or placing a vena cava filter, in the inpatient setting. 11 Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 6I - MCC List; (under Acute Inpatient Files for Download) 12 Ibid; International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD- 9-CM Tabular Addenda, National Center for Health Statistics, June 10, 2011.

12 11 MS-DRG Description Table 9: Common MS-DRGs for Endovascular Procedures Relative Weight 2014 National Average Payment Carotid artery stent procedure with MCC $19, Carotid artery stent procedure with CC $12, Carotid artery stent procedure without CC/MCC $9, Other respiratory system O.R. procedures with MCC $21, Other respiratory system O.R. procedures with CC $11, Other respiratory system O.R. procedures without CC/MCC $7, Other vascular procedures with MCC $18, Other vascular procedures with CC $14, Other vascular procedures without CC/MCC $9, Peripheral vascular disorders with MCC $7, Peripheral vascular disorders with CC $5, Peripheral vascular disorders without CC/MCC $3, Other kidney and urinary tract procedures with MCC $18, Other kidney and urinary tract procedures with CC $12, Other kidney and urinary tract procedures without CC/MCC $8,007 Table 10 below lists common MS-DRGs which may be assigned when conducting coronary procedures or inserting coronary devices in the inpatient setting: MS-DRG Description Table 10: Common MS-DRGs for Coronary Procedures 2014 Relative Weight 2014 National Average Payment 246 Percutaneous cardiovascular procedure with drug-eluting stent with MCC or 4+ vessels/stents $18, Percutaneous cardiovascular procedure with drug-eluting stent without MCC $11, Percutaneous cardiovascular procedure with non-drug-eluting stent with MCC or 4+ vessels/stents $17, Percutaneous cardiovascular procedure with non-drug-eluting stent without MCC $10, Percutaneous cardiovascular procedure without coronary artery stent with MCC $17, Percutaneous cardiovascular procedure without coronary artery stent without MCC $11, Circulatory disorders except acute myocardial infarction, with cardiac catheterization with MCC $12, Circulatory disorders except acute myocardial infarction, with cardiac catheterization without MCC $6, Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 5 - List of Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay; (under Acute Inpatient Files for Download) 14 MS-DRG national average payments were calculated with a base rate of $ using the national adjusted operating standardized amounts and the capital standard federal payment rate as issued in the Medicare Inpatient Prospective Payment System Final Rule issued by CMS on August 2, 2013 [CMS-1599-F] and published in the Federal Register on August 19, 2013; Tables 1A and 1D, Table 5, and assume that all hospitals are receiving the full 1.7% quality reporting update. Actual payment may vary based on various hospital-specific factors not reflected in the source data.

13 12 HOSPITAL OUTPATIENT ISSUES Introduction to the 2014 Outpatient Prospective Payment System (OPPS) Final Rule On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) released the 2014 Final Rule updating the hospital outpatient prospective payment system (OPPS) 15. Medicare reimburses outpatient hospital services under the OPPS, which bases payment on Ambulatory Payment Classifications (APCs), groups of clinical services, supplies, drugs, and devices that are similar clinically and in terms of resource costs. CMS mandated several changes in the OPPS beginning in 2008, including bundling of imaging and ancillary services into an intervention payment and new hospital outpatient quality measures; these initiatives are continuing for CY Expanded Bundling of Services In order to encourage the efficient use of resources, CMS has continued to extend the packaging approach to reimbursement in the hospital outpatient setting. Since January 1, 2008, CMS has been bundling payment for items and services that are usually ancillary and supportive into payment for the primary diagnostic or therapeutic outpatient services. This was considered by Medicare as a first step toward additional service bundling and creation of larger payment groups for hospital outpatient care in future years. For 2014, CMS finalizes five new categories of supporting items and services rather than the seven proposed. These categories are: Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure; Drugs and biologicals that function as supplies; when used in a surgical procedure, including skin substitutes. Skin substitutes will be classified as either high cost or low cost and will be packaged into the associated surgical procedures with other skin substitutes of the same class; Certain clinical diagnostic laboratory tests; Certain procedures described by add-on codes; Device removal procedures. In addition to packaging these five categories, CMS finalizes its proposal to create 29 comprehensive APCs to replace 29 existing device-dependent APCs, but with a modification to apply a complexity adjustment for the most complex multiple device claims. CMS is delaying the implementation of these comprehensive APCs until CY In 2008, Medicare reclassified nearly 200 procedures as always or frequently bundled into reimbursement for another procedure. Due to these changes, guidance imaging for implantation of Cordis products is not reimbursed separately. Reimbursement for the surgical Ambulatory Payment Classifications (APCs) now includes payment for these supportive services, including intravascular ultrasound (IVUS), angiography, and other types of radiology supervision and interpretation. Beginning in 2009, CMS changed how it pays for imaging services when two or more imaging procedures from certain imaging families are provided in one session. The final rule created five imaging composite APCs (such as multiple computed tomography (CT) procedures) performed in a single hospital session. The change applies to certain ultrasound procedures, CT and computed tomographic angiography (CTA) scans with or without contrast, and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) scans with or without contrast. Collapsing Five Levels of Visits to One. The 2014 final rule streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits. CMS did not finalize the proposal to replace the current five levels of codes for each type of emergency department visits, but intends to consider options to revise the codes for these services in future rulemaking. 15 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHF) Incentive Program; Provider Reimbursement Determinations and Appeals [CMS-1601-FC] was published in the December 10, 2013, Federal Register.

14 13 Hospital Outpatient Quality Data Reporting Program (HOP QDRP) The Tax Relief and Health Care Act of 2006 (TRHCA) required the Secretary of Health and Human Services to develop measures in order to assess the quality of care furnished by hospitals in outpatient settings. For services furnished on or after April 1, 2008, Medicare has required most hospitals to report data on hospital outpatient department quality measures. Similar to existing quality reporting requirements in the inpatient setting, hospitals that do not report these outpatient data points will not receive complete payments updates in The final 2014 Outpatient Prospective Payment System / Ambulatory Surgical Center Payment System (OPPS/ASC) rule includes a 1.7% annual inflation update for hospital outpatient departments (HOPDs); and adopts changes to payment policies for HOPDs and Ambulatory Surgical Centers (ASCs) beginning on January 1, The rule finalizes four new measures for the OQR program, affecting the CY 2016 payment determination and subsequent years, with data collection beginning in CY 2014 (OP-27, OP-29, OP-30, and OP-31 below). The final rule also removes two measures for the CY 2015 payment determination and subsequent years: Transition Record with Specified Elements Received by Discharged ED Patients (OP-19; and Cardiac Rehabilitation Measure: Patient Referral from an Outpatient Setting (OP-24) (NQF# 0643). OP-1 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-15 OP-17 OP-18 OP-20 OP-21 OP-22 OP-23 OP-25 OP-26 OP-27 OP-29 OP-30 OP-31 Table 11: Outpatient Quality Measures 17 Median Time to Fibrinolysis Fibrinolytic Therapy Received Within 30 Minutes of Arrival Median Time to Transfer for Primary Percutaneous Coronary Intervention (PCI) Aspirin at Arrival Median Time to Electrocardiogram (ECG) Timing of Antibiotic Prophylaxis Selection of Perioperative Antibiotic MRI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT Use of Contrast Material Thorax CT Use of Contrast Material The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache Tracking Clinical Results Between Visits Median Time from ED Arrival to ED Departure for Discharged ED Patients Door to Diagnostic Evaluation by a Qualified Medical Professional ED Median Time to Pain Management for Long Bone Fracture ED Patient Left without Being Seen Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stoke Who Received Head CT Scan Interpretation within 45 Minutes of Arrival Safe Surgery Checklist Use Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures Influenza Vaccination Coverage Among Healthcare Personnel Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average- Risk Patients Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use Cataracts Improvement in Patient s Visual Function within 90 Days Following Cataract Surgery 16 Centers for Medicare and Medicaid Services Fact Sheet: CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 2014, November 27, 2013; 17 Hospital Outpatient Quality Reporting Specifications Manual, v6.0b; Hospitals-Outpatient, Specifications Manual.

15 14 The seven claims-based imaging measures are calculated by CMS using Medicare Part B claims data without imposing on hospitals the burden of additional chart abstraction. Although these measures may not be directly related to implantation of Cordis vascular products or other percutaneous vascular procedures, we felt it important to include discussion of them as hospitals that choose not to report on these measures will ultimately receive reduced payment for all procedures in 2014 and subsequent years. CMS has implemented a policy to not pay for medical care that harms patients or leads to complications that could have been prevented; this policy also affects service reporting for outpatient services. For dates of service on or after January 15, 2009, append one of the following applicable HCPCS modifiers to all lines related to the surgical error. PA PB PC Surgical or other invasive procedure on wrong body part Surgical or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient Hospital Outpatient Reimbursement Medicare beneficiaries who receive services in the hospital outpatient setting typically have coverage through Medicare Part B. Current Procedural Terminology 18 (CPT ) and Healthcare Common Procedure Coding System (HCPCS) codes map to APCs which assign a Medicare hospital outpatient payment rate for the service as illustrated in the example below: CPT Code APC maps to maps to 2014 Estimated National Average Allowable 19 $ 9,120 Depending upon the services provided, hospitals may receive payment for more than one APC per patient encounter. If a claim contains services that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC. However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting. Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged Current Procedural Terminology (CPT ), 2013 American Medical Association. CPT is a registered trademark of the American Medical Association. 19 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHF) Incentive Program; Provider Reimbursement Determinations and Appeals; Addendum B; CMS-1601-FC.

16 15 Device C-Codes In 2004, CMS reinstated the use of device C-codes for cost tracking purposes. 20 device C-codes that may apply to Cordis Corporation vascular products: The following table lists relevant Code Description C1714 Catheter, transluminal atherectomy, directional C1724 Catheter, transluminal atherectomy, rotational C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion / perfusion capability C1753 Catheter, intravascular ultrasound C1757 Catheter, thrombectomy / embolectomy C1760 Closure device, vascular (implantable / insertable) C1874 Stent, coated/covered, with delivery system 21 C1875 Stent, coated/covered, without delivery system C1876 Stent, non-coated/non-covered, with delivery system C1877 Stent, non-coated/non-covered, without delivery system C1880 Vena cava filter C1885 Catheter, transluminal angioplasty, laser C1884 Embolization protection system C1887 Catheter, guiding (may include infusion / perfusion capability) C1888 Catheter, ablation, non-cardiac, endovascular (implantable) C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Continuing in 2014, CMS requires hospitals to report C-codes on claims for devices used in procedures that are reimbursed under certain device-dependent APCs. This requirement is intended to allow CMS to better calculate the correct relative costs of device-dependent APCs in relation to other OPPS services. For example, the following endovascular and cardiovascular procedure codes require related device C-codes to be reported on the same claim: Endovascular revascularization of lower extremities ( ) Transluminal balloon angioplasty, open ( ) Transluminal balloon angioplasty, percutaneous ( ) Transluminal atherectomy; open ( ) Transluminal balloon angioplasty, percutaneous ( ) Transcatheter retrieval of intravascular foreign body (37197) Transcatheter occlusion or embolization ( ) Transcatheter placement of non-coronary stent(s) ( ) Transcatheter placement of carotid artery stent with embolic protection (37215) Transluminal coronary balloon angioplasty ( ) Transcatheter placement of intracoronary stent ( ) Transcatheter coronary atherectomy ( ) Transcatheter coronary atherectomy plus stent placement ( ) Revascularization of or through a coronary artery bypass ( ) Revascularization of acute total/subtotal occlusion during acute myocardial infarction (92941) Revascularization of a chronic total occlusion of coronary artery ( ) Coronary interventions with drug-eluting intracoronary stent (G9600 G9608) 20 Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS), 61 - Billing for Devices Under the OPPS; 21 Medicare instructions indicate that drug-eluting stents should be reported using C1874. (Personal communication Cordis Corporation on file).

17 16 CMS will continue to review procedures to determine whether additional device-dependent edits are necessary, and may update the edits on a quarterly basis. 22 Hospitals are not required to report C-codes when performing procedures for non-device-dependent APCs, but they are encouraged to report the corresponding C-codes to support cost tracking and more appropriate APC payment in coming years. For vascular closure devices (VCDs), there is also a companion code for the act of placement: G0269 Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure, which accompanies the device code C1760. There is not a device-dependent edit for C1760 with any procedure, as a VCD is not always used. Hospital reimbursement for fixed fee payers (Medicare), incremental reimbursement for the use of the device is not available. Established rates of reimbursement are based on historical costs and therefore include the cost of these devices. Hospitals should bill payers when a VCD is used. Medicare establishes rates based upon the estimated cost of care rendered to a population of patients. Private payers contracting with hospitals are permitted to provide incremental reimbursement for the use of VCDs. The hospital must make a request with the payer. Although there is no separate payment available under the OPPS for most device C-codes, it is important for hospitals to report the C-code and an appropriate charge on their claims for each item provided. This claims data will be used by CMS to determine future APC payment rates and to ensure that the cost of associated devices is appropriately accounted for in each APC. Revenue Codes Hospitals must continue to assign a revenue code in addition to the C-code for each device reported on a claim. 23 Revenue codes which may be relevant for vascular procedures include: Code Description 0278 Medical/Surgical Supplies: Other Implants 0279 Medical/Surgical Supplies: Other Supplies/Devices 0321 Radiology - Diagnostic: Angiocardiography 0323 Radiology - Diagnostic: Arteriography 0481 Cardiology: Cardiac Catheterization Laboratory 0489 Cardiology: Other Cardiology Supplies Incident to Radiology / Other Diagnostic Services 0921 Other Diagnostic Services: Peripheral Vascular Lab 22 A complete listing of the current procedure-to-device and device-to-procedure edits may be downloaded from the CMS website: 23 A revenue code to cost center crosswalk is available on the CMS website at: Annual Policy Files.

18 17 Status Indicators OPPS payment status indicators (SIs) indicate whether a service represented by a HCPCS or CPT code is payable under the OPPS or another payment system, and also whether particular OPPS policies apply to the code (eg, multiple procedure discounts or other payment reductions, full separate payment, or is a service packaged with another procedure). A total of twenty-three SIs are listed in the calendar year 2014 OPPS Final Rule; several relating to the hospital outpatient case examples provided in this guide are included below for reference. A complete list of SIs can be found in Addendum D1 of the CY 2014 OPPS Final Rule. 24 Common OPPS Status Indicators Indicator Item/Code/Service OPPS Payment Status C Inpatient Procedures Not paid under OPPS. Admit patient. Bill as inpatient. G Pass-Through Drugs and Biologicals Paid under OPPS; separate APC payment. H Pass-Through Device Categories Separate cost-based pass-through payment; not subject to copayment. K Non-Pass-Through Drugs and Nonimplantable Biologicals Paid under OPPS; separate APC payment. N Items and Services Packaged into APC Rates Paid under OPPS; payment is packaged into payment for other services, including outliers. Therefore, there is no separate APC payment. Q1 STVX-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, V, or X. (2) In all other circumstances, payment is made through a separate APC payment. Q2 T-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In all other circumstances, payment is made through a separate APC payment. Q3 Codes That May Be Paid Through a Composite APC Paid under OPPS; Addendum B displays APC assignments when services are separately payable. Addendum M displays composite APC assignments when codes are paid through a composite APC. (1) Composite APC payment based on OPPS compositespecific payment criteria. Payment is packaged into a single payment for specific combinations of service. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. Paid under OPPS; separate APC payment. S Significant Procedure, Not Discounted when Multiple T Significant Procedure, Multiple Paid under OPPS; separate APC payment. Reduction Applies V Clinic or Emergency Department Visit Paid under OPPS; separate APC payment. X Ancillary Services Paid under OPPS; separate APC payment. For codes with a SI of Q1, Q2, and Q3, the APC assignment is the standard APC to which the code would be assigned if it is paid separately when these procedures are performed in circumstances which do not meet the criteria of the package, reimbursement will be guided by the default status of the applicable APC. If there are multiple STVX and/or T packaged HCPCS codes on a specific date and no service with which the codes would be packaged on the same date, the code assigned to the APC with the highest payment rate will be paid. All other codes are packaged. 24 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum D1; CMS-1601-FC.

19 18 AMBULATORY SURGERY CENTER AND INDEPENDENT DIAGNOSTIC TESTING FACILITY ISSUES Introduction to the 2014 Ambulatory Surgery Center (ASC) Final Rule Since January 1, 2008, ambulatory surgery centers (ASCs) have been paid under a revised ASC payment system that aligns payment rates to those rates for similar services in the Hospital Outpatient Prospective Payment System (HOPPS) Ambulatory Payment Classifications (APCs) and extended payment to more surgical services in ASCs. To minimize the impact of the revised payment system, the revised ASC payment rates were phased in over four years, with CY 2011 being the final year of the transition. In general, the ASC payment rate for services is set at approximately 65% of the payment rate for the same service under the HOPPS, with some exceptions. For example, for device-intensive services (where device costs account for more than 50 percent of the total cost of the service), ASCs receive the same payment rate for the device cost as under the HOPPS, with payment for the service portion of the ASC rate calculated at the usual percentage rate of the corresponding OPPS service payment. ASCs will not typically bill separately for these devices. For ASC services that are predominantly performed in physicians offices, the ASC payment is capped at the amount the physician is paid under the MPFS for practice expenses for providing the same service in an office. CMS has assigned APC-based payment rates in an Ambulatory Surgery Center only to surgical procedure codes CPT codes in the range , plus a few Category III codes and so does not include cardiac catheterization codes. Radiology procedures, supplies, and devices are considered ancillary to the surgical procedure; while some are reimbursed additionally, no separate payment is made for angiographic imaging procedures. CMS continues to add or revise services in the list of ASC procedures for which payment may be made. However, those surgical procedures that would be expected to pose a significant safety risk to beneficiaries or that would be expected to require an overnight stay following the procedure are excluded from the ASC list. Therefore, there are certain procedures which may be considered appropriate for performance in a hospital outpatient setting, but for which Medicare does not provide reimbursement in an ASC for 2014, this includes certain endovascular interventional procedures. 25 PLEASE NOTE that some commercial insurers are still utilizing the former nine groupers for ASC payment calculations, or have devised their own groupers, and have not converted to the Medicare methodology. 25 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum EE -- Surgical Procedures to be Excluded from Payment in ASCs for CY 2014; CMS-1601-FC, Addenda.

20 19 ASC Quality Measure Reporting Program The 2012 Final Rule implemented a new quality reporting program for ASCs. To allow CMS and ASCs to more effectively plan for future measurement requirements, this final rule adopts measures for three subsequent payment determinations. Specifically, CMS is adopting five quality measures to be reported by ASCs beginning October 1, 2012, for CY 2014 payment determination. These measures included four outcome and one surgical infection control measures to be reported by ASCs on Medicare claims using quality data codes. CMS added two structural measures: safe surgical checklist use and ASC facility volume data on selected ASC surgical procedures, beginning with reporting in CY 2013 for the CY 2015 payment determination; and one NHSN infection control measure: Influenza Vaccination Coverage among Healthcare Personnel, beginning with reporting in CY 2014 for the CY 2016 payment determinations. The 2014 Final Rule adopts the same two colonoscopy measures, as well as the cataract measure, for the ASCQR Program as were added to the Hospital Outpatient Quality Reporting Program for the CY 2016 payment determination and subsequent years. ASC-1: ASC-2: ASC-3: ASC-4: ASC-5: ASC-6: ASC-7: ASC-11: ASC Quality Measures for the CY 2016 Payment Determinations 26 Patient Burn* Patient Fall* Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant* Hospital Transfer/Admission* Prophylactic Intravenous IV Antibiotic Timing* Safe Surgery Checklist Use** ASC Facility Volume Data on Selected ASC Surgical Procedures*** Influenza Vaccination Coverage among Healthcare Personnel*** * Final new measure for the CY 2014 payment determination. ** Final new measure for the CY 2015 payment determination. *** Final new measure for CY 2016 payment determination. (Note: The selected ASC procedures identified in the 2012 Final Rule do not include any cardiovascular system codes ( ). Ambulatory Surgical Center Measure G-Codes (QDCS) Measure Measure Description QDC ASC-1 Patient Burn G8908: Patient documented to have received a burn prior to discharge G8909: Patient documented not to have received a burn prior to discharge ASC-2 Patient Fall G8910: Patient documented to have experienced a fall within the ASC G8911: Patient documented not to have experienced a fall within the ASC ASC-3 ASC-4 ASC-5 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant Hospital Transfer/Admission Prophylactic IV Antibiotic Timing G8912: Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event G8913: Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event G8914: Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC G8915: Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC G8916: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time G8917: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time G8918: Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis G8907: Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event; or a hospital transfer or hospital admission upon discharge from the facility. Note: This code may be used in lieu of reporting individual codes for ASC-1 through ASC-4 if all are negative. 26 Centers for Medicare and Medicaid Services Fact Sheet: CMS Issues Outpatient Policy and Payment Changes;