SOLITAIRE 2 REVASCULARIZATION DEVICE CODING AND REIMBURSEMENT GUIDE

Transcription

1 SOLITAIRE 2 REVASCULARIZATION DEVICE CODING AND REIMBURSEMENT GUIDE REIMBURSEMENT SUPPORT HOTLINE

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3 SOLITAIRE 2 REVASCULARIZATION DEVICE The Solitaire 2 revascularization device is a self-expanding device designed to restore blood flow in patients experiencing acute ischemic stroke due to large intracranial vessel occlusion. The device is designed for use in the neurovasculature, such as the internal carotid artery, M1 and M2 segments of the middle cerebral artery, anterior cerebral artery, basilar and the vertebral arteries. The Solitaire 2 revascularization device is comprised of a scaffolding design made of nitinol and a pushwire attached to the nitinol scaffolding. It is supplied pre-loaded into an introducer sheath. The Solitaire device is designed to be delivered through a microcatheter, deployed across the clot and removed along with the clot to enable revascularization of the occluded intracranial vessel. The revascularization procedure employs a widely accepted mode of delivery where the arterial system is accessed through the femoral artery in the groin. The device is then navigated to the brain using standard endovascular techniques. 1

4 HOSPITAL INPATIENT DIAGNOSIS CODING FOR THE SOLITAIRE REVASCULARIZATION DEVICE ICD-10-CM DIAGNOSIS S 1 effective October 1, 2015 ICD-10-CM diagnosis codes are used by both physicians and hospitals to report the indication for the procedure. 2 ISCHEMIC STROKE: PRECEREBRAL ARTERIES I63.02 I63.12 I63.22 I I I I I I I I I I I I I I I I I I I63.09 I63.19 I63.29 I63.00 I63.10 I63.20 HISTORY OF IV t-pa 3 Z92.82 Cerebral infarction due to thrombosis of basilar artery Cerebral infarction due to embolism of basilar artery Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries Cerebral infarction due to thrombosis of right carotid artery Cerebral infarction due to thrombosis of left carotid artery Cerebral infarction due to thrombosis of unspecified carotid artery Cerebral infarction due to embolism of right carotid artery Cerebral infarction due to embolism of left carotid artery Cerebral infarction due to embolism of unspecified carotid artery Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries Cerebral infarction due to thrombosis of right vertebral artery Cerebral infarction due to thrombosis of left vertebral artery Cerebral infarction due to thrombosis of unspecified vertebral artery Cerebral infarction due to embolism of right vertebral artery Cerebral infarction due to embolism of left vertebral artery Cerebral infarction due to embolism of unspecified vertebral artery Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries Cerebral infarction due to thrombosis of other precerebral artery Cerebral infarction due to embolism of other precerebral artery Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries Cerebral infarction due to thrombosis of unspecified precerebral artery Cerebral infarction due to embolism of unspecified precerebral artery Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries Status post-administration of IV t-pa (rtpa) in a different facility within the last 24 hours prior to admission to current facility The Solitaire 2 revascularization device is intended to restore blood flow by removing thrombus from a large intracranial vessel in patients experiencing ischemic stroke within 8 hours of symptom onset. Patients who are ineligible for intravenous tissue plasminogen activator (IV t-pa) or who fail IV t-pa therapy are candidates for treatment. 2

5 ICD-10-CM DIAGNOSIS S 1 effective October 1, 2015 ICD-10-CM diagnosis codes are used by both physicians and hospitals to report the indication for the procedure. 2 ISCHEMIC STROKE: CEREBRAL ARTERIES I63.30 I I I I I I I I I I I I I63.39 I63.6 I63.40 I I I I I I I I I I I I I63.50 Cerebral infarction due to thrombosis of unspecified cerebral artery Cerebral infarction due to thrombosis of right middle cerebral artery Cerebral infarction due to thrombosis of left middle cerebral artery Cerebral infarction due to thrombosis of unspecified middle cerebral artery Cerebral infarction due to thrombosis of right anterior cerebral artery Cerebral infarction due to thrombosis of right anterior cerebral artery Cerebral infarction due to thrombosis of left anterior cerebral artery Cerebral infarction due to thrombosis of unspecified anterior cerebral artery Cerebral infarction due to thrombosis of right posterior cerebral artery Cerebral infarction due to thrombosis of left posterior cerebral artery Cerebral infarction due to thrombosis of right cerebellar artery Cerebral infarction due to thrombosis of left cerebellar artery Cerebral infarction due to thrombosis of unspecified cerebellar artery Cerebral infarction due to thrombosis of other cerebral artery Cerebral infarction due to cerebral venous thrombosis, nonpyogenic Cerebral infarction due to embolism of unspecified cerebral artery Cerebral infarction due to embolism of right middle cerebral artery Cerebral infarction due to embolism of left middle cerebral artery Cerebral infarction due to embolism of unspecified middle cerebral artery Cerebral infarction due to embolism of right anterior cerebral artery Cerebral infarction due to embolism of left anterior cerebral artery Cerebral infarction due to embolism of unspecified anterior cerebral artery Cerebral infarction due to embolism of right posterior cerebral artery Cerebral infarction due to embolism of left posterior cerebral artery Cerebral infarction due to embolism of unspecified posterior cerebral artery Cerebral infarction due to embolism of right cerebellar artery Cerebral infarction due to embolism of left cerebellar artery Cerebral infarction due to embolism of unspecified cerebellar artery Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral arteries I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified 3

6 HOSPITAL INPATIENT PROCEDURE CODING AND DRG PAYMENT ICD-10-PCS PROCEDURE S 4 effective October 1, 2015 ICD-10-PCS procedure codes are used by hospitals to report surgeries and procedures performed in the inpatient setting. 5 REMOVAL OF THROMBUS 03CG3ZZ 03CH3ZZ 03CJ3ZZ 03CK3ZZ 03CL3ZZ 03CM3ZZ 03CN3ZZ 03CP3ZZ 03CQ3ZZ CEREBRAL ARTERIOGRAPHY Extirpation of Matter from Intracranial Artery, Percutaneous Approach Extirpation of Matter from Right Common Carotid Artery, Percutaneous Approach Extirpation of Matter from Left Common Carotid Artery, Percutaneous Approach Extirpation of Matter from Right Internal Carotid Artery, Percutaneous Approach Extirpation of Matter from Left Internal Carotid Artery, Percutaneous Approach Extirpation of Matter from Right External Carotid Artery, Percutaneous Approach Extirpation of Matter from Left External Carotid Artery, Percutaneous Approach Extirpation of Matter from Right Vertebral Artery, Percutaneous Approach Extirpation of Matter from Left Vertebral Artery, Percutaneous Approach B31R1ZZ Fluoroscopy of Intracranial Arteries using Low Osmolar Contrast USE OF THROMBOLYTIC (IV t-pa) 3E03317 Introduction of Other Thrombolytic into Peripheral Vein, Percutaneous Approach DRG ASSIGNMENT FY2016 effective October 1, 2015 Under Medicare s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 750 diagnosis-related groups, based on the ICD-10 codes assigned to the diagnoses and procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Implanted devices are typically included in the flat payment and are not paid separately. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. MS-DRGs shown are those typically assigned to the following scenarios. MS-DRG 6 MS-DRG TITLE 6,7 FY2016 RELATIVE GEOMETRIC SUBJECT TO MEDICARE WEIGHT MEAN LENGTH NATIONAL OF STAY PACT? 6,8 AVERAGE 9 ISCHEMIC STROKE WITH REMOVAL OF THROMBUS (SOLITAIRE DEVICE THROMBECTOMY) Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis W MCC or Chemo Implant Yes $31, Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis WO MCC Yes $22,429 ISCHEMIC STROKE WITH ADMINISTRATION OF THROMBOLYTIC ONLY 061 Acute Ischemic Stroke with Use of Thrombolytic Agent W MCC No $15, Acute Ischemic Stroke with Use of Thrombolytic Agent W CC No $11, Acute Ischemic Stroke with Use of Thrombolytic Agent WO CC/MCC No $9,000 ISCHEMIC STROKE WITH MEDICAL MANAGEMENT ONLY 064 Intracranial Hemorrhage or Cerebral Infarction W MCC Yes $10, Intracranial Hemorrhage or Cerebral Infarction W CC or IV t-pa in 24 Hrs Yes $6, Intracranial Hemorrhage or Cerebral Infarction WO CC/MCC Yes $4,473 4

7 PHYSICIAN PROCEDURE CODING AND PAYMENT PHYSICIAN PROCEDURE CODING AND PAYMENT FOR THE SOLITAIRE DEVICE Physicians use CPT codes for all services. Use of CPT codes was not impacted by implementation of ICD-10 on October 1, Physicians continue to use CPT codes to report procedures and other services. Under Medicare s Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the relative value unit (RVU), which is then converted to a flat payment amount. CPT S 11 effective January 1, 2016 CY 2016 RBRVS FACTORS 12 effective January 1, 2016 CPT MULTIPLE PROCEDURE DISCOUNTING 13 CY2016 MEDICARE RVUS (FACILITY SETTING) 14 CY2016 MEDICARE NATIONAL AVERAGE (FACILITY SETTING) 14,15 SOLITAIRE DEVICE THROMBECTOMY 16 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, No $809 and intraprocedural pharmacological thrombolytic injection(s) 16. Thrombectomy code is defined as a comprehensive procedure and includes: catheterization, diagnostic angiography in the vessel territory treated, imaging guidance, radiological supervision and interpretation, thrombolytic injection during the procedure, completion angiography, and all neurologic and hemodynamic monitoring of the patient. These components are not coded separately. Diagnostic angiography in vessel territories that were not treated can be coded separately. Code may be reported once for each intracranial vascular territory treated. There are three territories: 1) right carotid, 2) left carotid, and 3) vertebro-basilar. 5

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9 STROKE PATIENT CODING SCENARIOS The following stroke scenarios provide examples of diagnosis and procedure coding for hospitals and physicians. 7

10 TREATMENT OF ACUTE ISCHEMIC STROKE Scenario 1: The patient arrives at a primary stroke center which administers IV t-pa and admits the patient for medical care as an inpatient with no further interventions. n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 I63.00-I63.29 I63.30-I63.9 Cerebral infarction, precerebral arteries Cerebral infarction, cerebral arteries n HOSPITAL INPATIENT PROCEDURE CODING ICD-10_PCS PROCEDURE S effective January 1, 2016 ADMINISTRATION OF THROMBOLYTIC (IV t-pa) 3E03317 Introduction of other thrombolytic into peripheral vein, percutaneous approach n HOSPITAL INPATIENT PAYMENT MS-DRG PAYMENT effective October 1, 2015 MS-DRG MS-DRG TITLE RELATIVE WEIGHT GEOMETRIC MEAN LENGTH OF STAY SUBJECT TO PACT? MEDICARE NATIONAL AVERAGE 061 Acute Ischemic Stroke with Use of Thrombolytic Agent W MCC No $15, Acute Ischemic Stroke with Use of Thrombolytic Agent W CC No 063 Acute Ischemic Stroke with Use of Thrombolytic Agent WO CC/MCC No $11,173 $9,000 n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT 1 1 ADMINISTRATION OF THROMBOLYTIC (IV t-pa) CY2016 MEDICARE RVUS (FACILITY SETTING) Thrombolysis, cerebral, by intravenous infusion contractor priced CY2016 MEDICARE NATIONAL AVERAGE (FACILITY SETTING) Note: This service is usually performed by the hospital nurse, under physician supervision. The Medicare Administrative Contractor establishes RVUs and any payment to the physician only on a case-by-case basis, generally after review of documentation. EVALUATION AND MANAGEMENT Physician coding and payment are determined by the evaluation and management services provided to the patient during the inpatient admission. 8

11 Scenario 2: The patient arrives at a primary stroke center which administers IV t-pa in emergency department and then transfers the patient to a comprehensive stroke center for inpatient admission, often referred to drip-and-ship. The codes and payments shown below are for the transferring primary stroke center only. n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 I63.00-I63.29 I63.30-I63.9 Cerebral infarction, precerebral arteries Cerebral infarction, cerebral arteries n HOSPITAL OUTPATIENT PROCEDURE AND DRUG CODING AND APC PAYMENT effective January 1, 2016 CPT / HCPCS II S APC APC TITLE STATUS INDICATOR CY2016 RELATIVE WEIGHT CY2016 MEDICARE NATIONAL AVERAGE ADMINISTRATION OF THROMBOLYTIC (IV t-pa) Thrombolysis, cerebral, by intravenous infusion 5291 Thrombolysis and Other Device Revisions T $200 THROMBOLYTIC (IV t-pa) DRUG J2997 Injection, alteplase recombinant, 1 mg 7048 Alteplase recombinant K NA $74 per unit HOSPITAL EMERGENCY DEPARTMENT VISIT Critical care, evaluation and management of the critically ill or critically injured patient; first minutes 5041 Critical Care $ Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes N Note: Status Indicator shows how the code is handled for the purpose of hospital outpatient payment. Status T means the code is separately payable, though payment may be reduced by 50% when the code submitted with certain other procedures. Status K means the drug is separately payable at the rate shown, per unit. The drug rate can be revised each quarter. The rate shown is for 1st Q Status S means that the APC pays at 100% of the rate regardless of whether it is submitted with other procedures. Status N means that the code is packaged into the primary service and is not separately payable. Note that code can also be assigned to Comprehensive APC However, C-APC 8011 does not apply in this scenario because code is being submitted with code 37195, which is status T. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 80 Fed. Reg Published November 13, n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT effective January 1, 2016 CPT CY2016 CY2016 MEDICARE RVUS MEDICARE NATIONAL (FACILITY SETTING) AVERAGE (FACILITY SETTING) ADMINISTRATION OF THROMBOLYTIC (IV t-pa) Thrombolysis, cerebral, by intravenous infusion contractor price Note: This service is usually performed by the hospital nurse, under physician supervision. The Medicare Administrative Contractor establishes RVUs and any payment to the physician only on a case-by-case basis, generally after review of documentation. EVALUATION AND MANAGEMENT Critical care, evaluation and management of the critically ill or critically injured patient; first minutes 6.31 $ Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes 3.16 $113 9

12 TREATMENT OF ACUTE ISCHEMIC STROKE Scenario 3: The patient was previously treated with IV t-pa in the emergency department of a primary stroke center and was then transferred to a comprehensive stroke center. In this drip-and ship scenario, the patient is admitted to the comprehensive stroke center as an inpatient and does not undergo any further interventions or procedures. The codes and payments shown below are for the receiving comprehensive stroke center only. n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 ISCHEMIC STROKE I63.00-I63.29 I63.30-I63.9 PRIOR IV t-pa Cerebral infarction, precerebral arteries Cerebral infarction, cerebral arteries Z92.82 Status post-administration of IV t-pa (rtpa) in a different facility within the last 24 hours prior to admission to current facility n HOSPITAL INPATIENT PAYMENT MS-DRG PAYMENT effective October 1, 2015 MS-DRG MS-DRG TITLE RELATIVE WEIGHT GEOMETRIC MEAN LENGTH OF STAY 3.3 SUBJECT TO PACT? MEDICARE NATIONAL AVERAGE 065 Intracranial Hemorrhage or Cerebral Infarction W CC or IV t-pa in 24 Hours Yes $6,256 n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT Because no procedures are performed at the comprehensive stroke center, physician coding and payment are determined by the evaluation and management services provided to the patient during the inpatient admission. 10

13 Scenario 4: The patient arrives at a primary or comprehensive stroke center and is admitted for care as an inpatient. No interventions are performed and the patient is treated with medical management only. n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 ISCHEMIC STROKE I63.00-I63.29 Cerebral infarction, precerebral arteries I63.30-I63.9 Cerebral infarction, cerebral arteries n HOSPITAL INPATIENT PROCEDURE CODING Because no interventions are performed, no inpatient ICD-10-PCS procedure codes are assigned. n HOSPITAL INPATIENT PAYMENT MS-DRG PAYMENT effective October 1, 2015 MS-DRG MS-DRG TITLE RELATIVE WEIGHT GEOMETRIC MEAN LENGTH OF STAY SUBJECT TO PACT? 064 Intracranial Hemorrhage or Cerebral Infarction W MCC Yes MEDICARE NATIONAL AVERAGE $10, Intracranial Hemorrhage or Cerebral Infarction W CC or IV t-pa in 24 Hours Yes $6, Intracranial Hemorrhage or Cerebral Infarction WO CC/MCC Yes $4,473 n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT Because no procedures are performed, physician coding and payment are determined by the evaluation and management services provided to the patient during the inpatient admission. 11

14 TREATMENT OF ACUTE ISCHEMIC STROKE Scenario 5: The patient was previously treated with IV t-pa in the emergency department of a primary stroke center and was then transferred to a comprehensive stroke center. In this drip-and ship scenario, the patient is admitted to the comprehensive stroke center as an inpatient and, following diagnostic angiography, undergoes a Solitaire device thrombectomy. The codes and payments shown below are for the receiving comprehensive stroke center only. n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 ISCHEMIC STROKE I63.00-I63.29 I63.30-I63.9 PRIOR IV t-pa Cerebral infarction, precerebral arteries Cerebral infarction, cerebral arteries Z92.82 Status post-administration of IV t-pa (rtpa) in a different facility within the last 24 hours prior to admission to current facility n HOSPITAL INPATIENT PROCEDURE CODING ICD-10-PCS PROCEDURE S effective January 1, 2016 SOLITAIRE DEVICE THROMBECTOMY 16 03CG3ZZ Extirpation of matter from intracranial artery, percutaneous approach 03CH3ZZ 03CJ3ZZ 03CK3ZZ 03CL3ZZ 03CM3ZZ 03CN3ZZ 03CP3ZZ 03CQ3ZZ Extirpation of matter from right common carotid artery, percutaneous approach Extirpation of matter from left common carotid artery, percutaneous approach Extirpation of matter from right internal carotid artery, percutaneous approach Extirpation of matter from left internal carotid artery, percutaneous approach Extirpation of matter from right external carotid artery, percutaneous approach Extirpation of matter from left external carotid artery, percutaneous approach Extirpation of matter from right vertebral artery, percutaneous approach Extirpation of matter from left vertebral artery, percutaneous approach n HOSPITAL INPATIENT PAYMENT MS-DRG PAYMENT effective October 1, 2015 MS-DRG MS-DRG TITLE RELATIVE WEIGHT GEOMETRIC MEAN LENGTH OF STAY 7.9 SUBJECT TO PACT? 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis W MCC or Chemo Implant Yes 024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis WO MCC Yes MEDICARE NATIONAL AVERAGE $31,590 $22,429 12

15 n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT CPT SOLITAIRE DEVICE THROMBECTOMY 16 MULTIPLE PROCEDURE DISCOUNTING? CY2015 MEDICARE RVUS (FACILITY SETTING) CY2015 MEDICARE NATIONAL AVERAGE (FACILITY SETTING) Percutaneous arterial transluminal mechanical thrombectomy and/ or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, N and intraprocedural pharmacological thrombolytic injection(s) DIAGNOSTIC CEREBRAL ARTERIOGRAPHY (D ONLY FOR NON-TREATED TERRITORIES) Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision Y 9.43 $338 and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Y $376 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, Y 9.29 $333 includes angiography of the cervicocerebral arch, when performed Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of Y $377 the cervicocerebral arch, when performed $ Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) N 6.81 $244 Note: The arteriography codes identify the location of the catheter for injection as well as the areas that are imaged following the injection. Only one code can be used from for carotid imaging. Likewise, only one code can be used from for vertebral imaging. Add-on code for additional cerebral vessel catheterization and injection must be used together with one of the carotid or vertebral codes. Depending on the specific nature of the diagnostic angiography, the payment shown for each code may be subject to 150% increase for bilateral angiography or 50% reduction for multiple procedure discounting. When submitted with thrombectomy code 61645, the diagnostic angiography codes require a modifier, eg, -59, to indicate the distinct procedural service in a non-treated territory. EVALUATION AND MANAGEMENT Physician coding and payment are determined by the evaluation and management services provided to the patient during the inpatient admission. 13

16 TREATMENT OF ACUTE ISCHEMIC STROKE Scenario 6: The patient arrives at a comprehensive stroke center which administers IV t-pa in emergency department and then admits the patient as an inpatient for diagnostic angiography and a Solitaire device thrombectomy 16 n HOSPITAL INPATIENT DIAGNOSIS CODING ICD-10-CM DIAGNOSIS S effective October 1, 2015 ISCHEMIC STROKE I63.00-I63.29 Cerebral infarction, precerebral arteries I63.30-I63.9 Cerebral infarction, cerebral arteries n HOSPITAL INPATIENT PROCEDURE CODING ICD-10-PCS PROCEDURE S effective October 1, 2015 SOLITAIRE DEVICE THROMBECTOMY 03CG3ZZ Extirpation of matter from intracranial artery, percutaneous approach 03CH3ZZ 03CJ3ZZ 03CK3ZZ 03CL3ZZ 03CM3ZZ 03CN3ZZ 03CP3ZZ Extirpation of matter from right common carotid artery, percutaneous approach Extirpation of matter from left common carotid artery, percutaneous approach Extirpation of matter from right internal carotid artery, percutaneous approach Extirpation of matter from left internal carotid artery, percutaneous approach Extirpation of matter from right external carotid artery, percutaneous approach Extirpation of matter from left external carotid artery, percutaneous approach Extirpation of matter from right vertebral artery, percutaneous approach 03CQ3ZZ Extirpation of matter from left vertebral artery, percutaneous approach CEREBRAL ARTERIOGRAPHY B31R1ZZ Fluoroscopy of intracranial arteries using low osmolar contrast ADMINISTRATION OF THROMBOLYTIC (IV t-pa) 3E03317 Introduction of other thrombolytic into peripheral vein, percutaneous approach n HOSPITAL INPATIENT MS-DRG PAYMENT effective October 1, 2015 MS-DRG MS-DRG TITLE RELATIVE WEIGHT GEOMETRIC MEAN LENGTH OF STAY SUBJECT TO PACT? MEDICARE NATIONAL AVERAGE 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis W MCC or Chemo Implant Yes $31, Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis WO MCC Yes $22,429 14

17 n PHYSICIAN PROCEDURE CODING AND RBRVS PAYMENT CPT SOLITAIRE DEVICE THROMBECTOMY MULTIPLE PROCEDURE DISCOUNTING? CY2015 MEDICARE RVUS (FACILITY SETTING) CY2015 MEDICARE NATIONAL AVERAGE (FACILITY SETTING) Percutaneous arterial transluminal mechanical thrombectomy and/ or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, N and intraprocedural pharmacological thrombolytic injection(s) DIAGNOSTIC CEREBRAL ARTERIOGRAPHY (D ONLY FOR NON-TREATED TERRITORIES) Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision Y 9.43 $338 and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Y $376 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, Y 9.29 $333 includes angiography of the cervicocerebral arch, when performed Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of Y $377 the cervicocerebral arch, when performed $ Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) N 6.81 $244 Note: The arteriography codes identify the location of the catheter for injection as well as the areas that are imaged following the injection. Only one code can be used from for carotid imaging. Likewise, only one code can be used from for vertebral imaging. Add-on code for additional cerebral vessel catheterization and injection must be used together with one of the carotid or vertebral codes. Depending on the specific nature of the diagnostic angiography, the payment shown for each code may be subject to 150% increase for bilateral angiography or 50% reduction for multiple procedure discounting. When submitted with thrombectomy code 61645, the diagnostic angiography codes require a modifier, eg, -59, to indicate the distinct procedural service in a non-treated territory. ADMINISTRATION OF THROMBOLYTIC (IV t-pa) Thrombolysis, cerebral, by intravenous infusion contractor priced Note: This service is usually performed by the hospital nurse, under physician supervision. The Medicare Administrative Contractor establishes RVUs and any payment to the physician only on a case-by-case basis, generally after review of documentation. EVALUATION AND MANAGEMENT Physician coding and payment are determined by the evaluation and management services provided to the patient during the inpatient admission. 15

18 REFERENCES 1. ICD-10-CM: Department of Health and Human Services, Centers for Medicare & Medicaid Services and Centers for Disease Control and Prevention. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) For the I63.-- codes for ischemic stroke, note that the first digit is the letter I, not the number ICD-10-CM code Z92.82 is used to indicate the history for a patient who received IV t-pa at one facility and has been transferred to another facility. The code is assigned by the receiving hospital and is always used as an additional diagnosis (not primary). See code first note on code Z92.82 in the ICD-10-CM Tabular. 4. ICD-10-CM: Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) Root Operation C-Extirpation is defined as taking or cutting out solid matter from a body part. The solid matter may be imbedded in a body part or may be in the lumen of a tubular body part. Thrombectomy and embolectomy are coded to this root operation. CMS ICD-10-PCS Reference Manual 2016, p Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2016 Rates Final Rule, 80 Fed. Reg Published August 17, W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs WO CC/MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay. 8. Post-Acute Care Transfer (PACT) status refers to selected DRGs in which payment to the hospital may be reduced when the patient is discharged by being transferred out. The DRGs impacted are those marked Yes and the patient must be transferred out before the geometric mean length of stay to certain post-acute care providers, including rehabilitation hospitals, long term care hospitals, skilled nursing facilities, or to home under the care of a home health agency. When these conditions are met, the DRG payment is converted to a per diem and payment is made as double the per diem rate for the first day plus the per diem rate for each remaining day up to the full DRG payment. 9. Payment is based on the average standardized operating amount ($5,467.39) plus the capital standard amount ($438.75). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2016 Rates; Correction, 80 Fed. Reg Tables 1A-1D. Published October 5, The payment rate shown is the standardized amounts for facilities with a wage index greater than one. The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 10. All ischemic stroke codes are classified as acute complex central nervous system diagnoses in DRG logic. 11. CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 12. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 Final Rule; 80 Fed. Reg Published November 16, For codes marked Y, multiple procedure discounting indicates that when a procedure code is reported on the same day as another higher-weighted procedure code, the highest-weighted code is paid at 100% of the fee schedule amount and additional codes are paid at 50% of the fee schedule amount. Procedure codes marked N are always paid at 100% of the fee schedule amount regardless of whether they are submitted with other procedure codes. January 2016 release of the PFS Relative Value File RVU16A at The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU. RVUs and the Medicare National Average are shown for the facility setting only because the Onyx embolization procedure is always performed in the hospital, rather than the non-facility (physician office) setting. 15. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. Effective January 1, 2016, the conversion factor for CY 2016 is $ per 80 Fed. Reg Published November 16, See also the January 2016 release of the PFS Relative Value File RVU16A at Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown. 16. These instructions are according to CPT manual instructions (Surgery section, Nervous System, Endovascular Therapy). 16

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