2014 Procedural Reimbursement Guide for Endoscopy

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1 2014 Procedural Reimbursement Guide for Endoscopy

2 2014 Procedural Reimbursement Guide For THIS PROCEDURAL REIMBURSEMENT GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, provides coding and reimbursement information for physicians and facilities. The Medicare payment amounts shown are national average payments. Actual reimbursement will vary for each provider and institution based on geographic differences in costs, hospital teaching status, and proportion of low-income patients. Please feel free to contact the Boston Scientific reimbursement department if you have any questions: x 54145, or DESCRIPTION OF PAYMENT METHODS PHYSICIAN BILLING AND PAYMENT: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to CODES. CPT Codes are published by the American Medical Association and are used to report medical services and procedures performed by or under the direction of physicians. HOSPITAL OUTPATIENT BILLING AND PAYMENT: Medicare reimburses hospitals for outpatient stays (typically stays of less than 24 hours) under AMBULATORY PAYMENT CLASSIFICATION GROUPS (APCS). Medicare assigns a procedure to an APC based on the billed CPT Code. s may receive separate APC payments for each procedure done during the same outpatient visit. Many APCs are subject to reduced payment when multiple procedures are performed on the same day. In most cases, the highest valued procedure is paid at 100% and all other procedures are subject to a 50% payment reduction. HOSPITAL INPATIENT BILLING AND PAYMENT: Many insurers, including Medicare, define inpatient hospital care as an admission (typically stays of greater than 24 hours). An MS-DRG (MEDICARE SEVERITY DIAGNOSIS-RELATED GROUP) is a system of classifying patients, based on their diagnoses and the procedures performed during their hospital stay. The Center for Medicare and Medicaid Services, which runs the Medicare program, uses MS-DRGs to determine how much to pay hospitals for treating Medicare patients who receive inpatient care. Private payers may also pay hospitals using MS-DRG-based systems for providing inpatient services. Each of Medicare s 700+ MS-DRGs is assigned a single, fixed payment rate. That payment rate reflects the average cost of caring for patients with similar clinical characteristics who require similar resources (services, supplies, devices, etc.) for their treatment during their hospital stay. One single MS-DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of professional (e.g., physician) charges associated with performing medical procedures. FREE-STANDING CLINIC/AMBULATORY SURGICAL CENTER BILLING AND PAYMENT: Many procedures are performed outside of the hospital in free-standing clinics. s made to free-standing clinics from private insurers depend on the contract the clinic has with the payer. Medicare payments to free-standing clinics are determined in part, by the licensing status of the clinic. If a free-standing clinic is licensed by Medicare as an AMBULATORY SURGICAL CENTER () it is eligible to be reimbursed for select procedures provided in this setting. Not all procedures that Medicare covers in the hospital setting are eligible for payment in s. Medicare has approved over 3,000 procedures (as defined by CPT Code), for which it will pay the a facility fee. Effective: 1-JAN-2014 Expires: 31-DEC Page 1

3 2014 Procedural Reimbursement Guide THIS GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, PROVIDES CODING AND REIMBURSEMENT INFORMATION FOR PHYSICIANS AND FACILITIES. THE CODES INCLUDED IN THIS GUIDE ARE INTENDED TO REPRESENT TYPICAL ENDOSCOPY PROCEDURES WHERE THERE IS: 1) At least one device approved or cleared by the U.S. Food and Drug Administration (FDA) for use in the listed procedure; and 2) Specific procedural coding guidance provided by a recognized coding or reimbursement authority such as the American Medical Association (AMA) or the Centers for Medicare and Medicaid Services (CMS). This guide is in no way intended to promote the off label use of medical devices. PLEASE NOTE: While these materials are intended to provide coding information for a full range of endoscopy procedures, the FDA approved/cleared labeling for all products will not be consistent with all uses described in these materials. Some payers, including some Medicare contractors, may treat a procedure which is not specifically covered by a product s FDA-approved labeling as a non-covered service. THE MEDICARE REIMBURSEMENT AMOUNTS SHOWN ARE CURRENTLY PUBLISHED NATIONAL AVERAGE PAYMENTS. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic difference in labor and non-labor costs, hospital teaching status, and/or proportion of lowincome patients. On average, private payers pay significantly more than Medicare. 8 Please feel free to contact Boston Scientific reimbursement department if you have any questions. Rates referenced in these guides do not reflect Sequestration, automatic reductions in federal spending that will result in a 2% across-the-board reduction to ALL Medicare rates on January 1, 2014, unless Congress passes legislation to stop the sequester. You can find reimbursement updates on our website: Effective: 1-JAN-2014 Expires: 31-DEC-2014 Page 2

4 Biliary Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged RVUs Physician ⱡ $352 $352 $1,934 $1, $370 $370 $1,934 $1, $390 $390 $1,934 $1, $390 $390 $1,934 $1, $398 $398 $1,934 $1, $472 $472 $1,934 $1, $413 $413 $1,934 $1, $470 $470 $1,934 $1, $498 $498 $1,934 $1, $411 $411 $1,934 $1, $518 $518 $1,934 $1,068 Inpatient Coding Inpatient Medicare Possible ICD-9-CM Procedure Codes Code Description Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiography (ERC) Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi Other percutaneous procedures on biliary tract MS- DRG 435 Inpatient Medicare National Average 4 Description Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of pancreas except malignancy with MCC 5 $9, Disorders of pancreas except malignancy with CC 5 $5, Disorders of pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $10, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,349 See important information about the uses and limitations of this document on pages 1 and 2 Page 3

5 Biopsy Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Cold Biopsy Inpatient Coding and Medicare RVUs Physician ⱡ Esophagoscopy, flexible, transoral; with biopsy, single or multiple $368 $114 $670 $ Esophagoscopy, rigid, transoral; with biopsy, single or multiple $185 $185 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple $406 $152 $670 $ Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple $370 $370 $1,934 $1, not including ileum; with biopsy, single or multiple $176 $176 $837 $ including ileum; with biopsy, single or multiple $327 $327 $1,233 $ Ileoscopy, through stoma; with biopsy, single or multiple $84 $84 $837 $ Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple $358 $131 $737 $ Colonoscopy through stoma; with biopsy, single or multiple $402 $190 $737 $ Proctosigmoidoscopy, rigid; with biopsy, single or multiple $199 $82 $779 $ Sigmoidoscopy, flexible; with biopsy, single or multiple $166 $77 $461 $ Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Hot Biopsy Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $470 $265 $737 $ $466 $187 $1,013 $ $200 $200 $1,233 $ $446 $226 $737 $ $221 $90 $779 $ $301 $113 $461 $ $471 $277 $737 $407 Inpatient payment information not shown because the biopsy procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 1 and 2 Page 4

6 Dilation Procedural Reimbursement Guide Medicare Physician,, and s 1 Code Description Work Code Balloon Inpatient Coding and Medicare RVUs Physician ⱡ Esophagoscopy, rigid, transoral; with balloon dilation (less than 30 mm diameter) $186 $186 $1,013 $ Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) $203 $203 $1,013 $ Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter) $1,021 $131 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) $241 $241 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) $1,067 $169 $1,013 $ Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures $494 $119 $779 $ Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures $676 $272 $737 $407 Balloon or Rigid Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire $203 $203 $1,013 $ Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed) $1,253 $281 $1,013 $ Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire $388 $144 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) $627 $193 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire $419 $184 $670 $ Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) $954 $95 $779 $431 Balloon w/ another therapeutic Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes preand post-dilation and guide wire passage, when performed) $200 $200 $2,371 $1, Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) $241 $241 $2,371 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, $498 $498 $1,934 $1,068 each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, $518 $518 $1,934 $1,068 each stent exchanged Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including $413 $413 $1,934 $1,068 sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, $470 $470 $1,934 $1,068 when performed not including ileum; with transendoscopic stent placement (includes predilation) $291 $291 $2,371 $1, including ileum; with transendoscopic stent placement (includes predilation) $446 $446 $2,371 $1, Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) $168 $168 $2,371 $1, Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) $280 $280 $2,371 $1, Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) $125 $125 $2,371 $1, Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) $178 $178 $2,371 $1, Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) $354 $354 $2,371 $1,310 Inpatient payment information not shown because the dilation procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 1 and 2 Page 5

7 Enteral Feeding Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Gastrostomy Tube Initial Placement Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Gastrostomy Tube Replacement/Reposition Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition Jejunostomy Tube Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Other Procedures Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Inpatient Coding and Medicare RVUs Physician ⱡ $221 $221 $1,013 $ $1,063 $233 $1,013 $ $493 $49 $184 $ $677 $69 $466 $ $121 $107 $670 $ $916 $147 $466 $ $1,016 $170 $1,013 $ $210 $210 $1,233 $ $1,063 $233 $1,013 $ $749 $50 $466 $258 Inpatient payment information not shown because the enteral feeding procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 1 and 2 Page 6

8 Hemostasis Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Inpatient Coding and Medicare RVUs Physician ⱡ2 3 Control of bleeding Esophagoscopy, flexible, transoral; with control of bleeding, any method $403 $183 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method $441 $221 $1,013 $ not including ileum; with control of bleeding (eg, injection, bipolar cautery, $264 $264 $1,233 $681 unipolar cautery, laser, heater probe, stapler, plasma coagulator) including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar $420 $420 $1,233 $681 cautery, laser, heater probe, stapler, plasma coagulator) Colonoscopy through stoma; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) $504 $257 $737 $ Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) $167 $167 $779 $ Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma $611 $336 $737 $407 coagulator) 6 Ligation Esophagoscopy, flexible, transoral; with band ligation of esophageal varices $155 $155 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices $269 $269 $1,013 $ Hemorrhoidectomy, internal, by rubber band ligation(s) $272 $196 $473 $127 Injection Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance $280 $114 $1,013 $ Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance $155 $155 $1,013 $ Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices $150 $150 $670 $ Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance $396 $153 $670 $ Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices $260 $260 $670 $ Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance $278 $95 $461 $ Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance $472 $251 $737 $407 MS- DRG Inpatient Medicare National Average 4 Description 377 Hemorrhage with Major Complication or Comorbidity (MCC 5 ) $10, Hemorrhage with Complication or Comorbidity (CC 5 ) $5, Hemorrhage without CC/MCC $4, Cirrhosis & alcoholic hepatitis with MCC 5 $9, Cirrhosis & alcoholic hepatitis with CC 5 $5, Cirrhosis & alcoholic hepatitis without CC/MCC $3,570 See important information about the uses and limitations of this document on pages 1 and 2 Page 7

9 Polypectomy Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Inpatient Coding and Medicare RVUs Physician ⱡ2 3 Hot Biopsy Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $466 $187 $1,013 $ not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot $200 $200 $1,233 $681 biopsy forceps or bipolar cautery Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $446 $226 $737 $ Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery $221 $90 $779 $ Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $301 $113 $461 $ Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $471 $277 $737 $407 Snare Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $456 $178 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $513 $216 $1,013 $ not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by $225 $225 $1,233 $681 snare technique Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $504 $263 $737 $ Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique $227 $95 $779 $ Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $323 $145 $779 $ Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $531 $315 $737 $407 Hot Biopsy or Snare Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique $234 $115 $779 $431 Other Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Foreign Body Removal Esophagoscopy, flexible, transoral; with removal of foreign body $413 $154 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body $414 $193 $670 $ $739 $215 $1,969 $1, not including ileum; with removal of foreign body $211 $211 $837 $ Proctosigmoidoscopy, rigid; with removal of foreign body $234 $107 $1,657 $ Sigmoidoscopy, flexible; with removal of foreign body $296 $114 $779 $ Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body $508 $278 $737 $ Esophagoscopy, rigid, transoral; with removal of foreign body $168 $168 $1,013 $560 Endoscopic Mucosal Resection Esophagoscopy, flexible, transoral; with endoscopic mucosal resection $253 $253 $670 $ Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection $291 $291 $670 $370 Inpatient payment information not shown because the polypectomy procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 1 and 2 Page 8

10 Pulmonary Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work RVUs Physician ⱡ2 3 Biopsy performed; with bronchial or endobronchial biopsy(s), single or multiple sites $339 $176 $952 $ performed; with transbronchial lung biopsy(s), single lobe $381 $196 $952 $ performed; with transbronchial lung biopsy(s), each additional lobe (List $72 $51 $0 $0 separately in addition to code for primary procedure)* Cytology and Brush performed; diagnostic, with cell washing, when performed (separate $316 $152 $952 $526 procedure) performed; with brushing or protected brushings $335 $152 $952 $ performed; with bronchial alveolar lavage $315 $153 $952 $526 Foreign Body Removal (Stent Removal) performed; with removal of foreign body $352 $195 $952 $526 Needle Aspiration performed; with transbronchial needle aspiration biopsy(s), trachea, main stem $600 $211 $2,000 $1,105 and/or lobar bronchus(i) performed; with transbronchial needle aspiration biopsy(s), each additional $90 $65 $0 $0 lobe (List separately in addition to code for primary procedure)* performed; with therapeutic aspiration of tracheobronchial tree, initial (eg, $323 $167 $952 $526 drainage of lung abscess) Stenting performed; with placement of tracheal stent(s) (includes tracheal/bronchial $238 $238 $2,000 $1,105 dilation as required) performed; with placement of bronchial stent(s) (includes tracheal/bronchial $230 $230 $2,000 $1,105 dilation as required), initial bronchus performed; each additional major bronchus stented (List separately in addition $76 $76 $0 $0 to code for primary procedure)* performed; with revision of tracheal or bronchial stent inserted at previous $264 $264 $2,000 $1,105 session (includes tracheal/bronchial dilation as required) Balloon Dilation performed; with tracheal/bronchial dilation or closed reduction of fracture $208 $208 $2,000 $1,105 Bronchial Thermoplasty performed; with bronchial thermoplasty, 1 lobe $218 $218 $2, performed; with bronchial thermoplasty, 2 or more lobes $230 $230 $2,000 - See important information about the uses and limitations of this document on pages 1 and 2 Page 9

11 Pulmonary Procedural Reimbursement Guide Bronchial Thermoplasty C Code Inpatient Coding C1886: Catheter, extravascular tissue ablation, any modality (insertable) Alair Bronchial Thermoplasty Catheter C1886 Possible ICD-9-CM Procedure Codes Code Description Endoscopic excision or destruction of lesion or tissue of bronchus Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle Other bronchoscopy Closed endoscopic biopsy of bronchus; bronchoscopy (fiber-optic) with brush biopsy of lung, brushing or washing for specimen collection, excision (bite) biopsy Closed endoscopic biopsy of lung; Fiber-optic bronchoscopy with fluoroscopic guidance with biopsy, transbronchial lung biopsy Replacement of laryngeal or tracheal stent Other operations on trachea Removal of intraluminal foreign body from trachea and bronchus without incision Inpatient Medicare Inpatient Medicare National MS- DRG Description Average Respiratory neoplasms with Major Complication or Comorbidity (MCC 5 ) $9, Respiratory neoplasms pancreas with Complication or Comorbidity (CC 5 ) $6, Respiratory neoplasms without CC/MCC $4, Pulmonary edema & respiratory failure $7, Simple pneumonia & pleurisy with MCC 5 $8, Simple pneumonia & pleurisy with CC 5 $5, Simple pneumonia & pleurisy without CC/MCC $4, Interstitial lung disease with MCC 5 $9, Interstitial lung disease with CC 5 $6, Interstitial lung disease without CC/MCC $4, Respiratory signs & symptoms $3, Other respiratory system diagnoses with MCC 5 $8, Other respiratory system diagnoses without CC/MCC $4, Major Chest Procedures with MCC 7 $29, Major Chest Procedures with Complication or Comorbidity (CC 5 ) $15, Major Chest Procedures without CC/MCC $10,406 See important information about the uses and limitations of this document on pages 1 and 2 Page 10

12 Stenting Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Biliary Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged Esophageal Stenting Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Colonic and Duodenal Stenting Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) not including ileum; with transendoscopic stent placement (includes predilation) including ileum; with transendoscopic stent placement (includes predilation) Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) Tracheobronchial Stenting performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus performed; each additional major bronchus stented (List separately in addition to code for primary procedure) RVUs Physician ⱡ $498 $498 $1,934 $1, $411 $411 $1,934 $1, $518 $518 $1,934 $1, $200 $200 $2,371 $1, $241 $241 $2,371 $1, $241 $241 $2,371 $1, $291 $291 $2,371 $1, $446 $446 $2,371 $1, $168 $168 $2,371 $1, $280 $280 $2,371 $1, $125 $125 $2,371 $1, $178 $178 $2,371 $1, $354 $354 $2,371 $1, $238 $238 $2,000 $1, $230 $230 $2,000 $1, $76 $76 $0 $0 See important information about the uses and limitations of this document on pages 1 and 2 Page 11

13 Stenting Procedural Reimbursement Guide Medicare Physician,, and s RVUs Physician ⱡ2 3 Code1 Inpatient Coding Code Description Work Foreign Body Removal (Stent Removal) Esophagoscopy, flexible, transoral; with removal of foreign body $413 $154 $1,013 $ Esophagoscopy, rigid, transoral; with removal of foreign body $168 $168 $1,013 $ Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body $414 $193 $670 $ Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) $411 $411 $1,934 $1, not including ileum; with removal of foreign body $211 $211 $837 $ Proctosigmoidoscopy, rigid; with removal of foreign body $234 $107 $1,657 $ Sigmoidoscopy, flexible; with removal of foreign body $296 $114 $779 $ Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body $508 $278 $737 $407 Possible ICD-9-CM Procedure Codes Insertion of permanent tube into esophagus Endoscopic insertion of colonic stent(s) Endoscopic insertion of stent (tube) into bile duct Replacement of stent (tube) in biliary or pancreatic duct Code Description Inpatient Medicare Inpatient Medicare National MS- DRG Description Average Digestive malignancy with Major Complication or Comorbidity (MCC 5 ) $12, Digestive malignancy with Complication or Comorbidity (CC 5 ) $7, Digestive malignancy without CC/MCC $5, GI obstruction with MCC 5 $9, GI obstruction with CC 5 $5, GI obstruction without CC/MCC $3, Other digestive system diagnoses with MCC 5 $9, Other digestive system diagnoses with CC 5 $5, Other digestive system diagnoses without CC/MCC $3, Malignancy of hepatobiliary system or pancreas with MCC 5 $10, Malignancy of hepatobiliary system or pancreas with CC 5 $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $10, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,349 See important information about the uses and limitations of this document on pages 1 and 2 Page 12

14 SpyGlass Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Cholangioscopy Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure* CPT Code is an add-on code and must be reported with at least one of the following ERCP codes: Medicare Physician,, and s Code 1 Code Description Work RVUs Physician ⱡ $129 $129 $0 $0 RVUs Physician ⱡ2 3 Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed $352 $352 $1,934 $1,068 (separate procedure) Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple $370 $370 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy $390 $390 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi $390 $390 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) $398 $398 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) $472 $472 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla $413 $413 $1,934 $1,068 (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide $470 $470 $1,934 $1,068 wire passage, when performed Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when $498 $498 $1,934 $1,068 performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) $411 $411 $1,934 $1, Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged $518 $518 $1,934 $1,068 See important information about the uses and limitations of this document on pages 1 and 2 Page 13

15 SpyGlass Procedural Reimbursement Guide Inpatient Coding Possible ICD-9-CM Procedure Codes Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiography (ERC) Code Description Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi Inpatient Medicare MS- DRG Description Inpatient Medicare National Average Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of the pancreas except malignancy with MCC 5 $9, Disorders of the pancreas except malignancy with CC 5 $5, Disorders of the pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $10, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,349 See important information about the uses and limitations of this document on pages 1 and 2 Page 14

16 Transendoscopic Ultrasound-Guided Fine Needle Aspiration Procedural Reimbursement Guide Medicare Physician,, and s Code 1 Code Description Work Upper Gastrointestinal Procedures Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) Lower Gastrointestinal Procedures Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Inpatient Coding and Medicare RVUs Physician ⱡ $487 $212 $1,013 $ $246 $246 $1,013 $ $280 $280 $1,013 $ $244 $244 $779 $ $388 $388 $737 $407 Inpatient payment information not shown because the transendoscopic ultrasound-guided fine needle aspiration procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 1 and 2 Page 15

17 Footnotes: ⱡ The 2014 National Average Medicare physician payment rates have been calculated using a 2014 conversion factor of $ which reflects the 0.5 percent update for January 1, 2014 through March 31, N/A* = Medicare has not developed a rate for the setting as the procedure is typically performed in the hospital setting. *Add-on codes are always listed in addition to the primary procedure code. **WallFlex, Percuflex C-Flex and Flexima Biliary RX Stent Systems as well as WALLSTENT Biliary Endoprostheses are not FDAcleared for use in the pancreatic ducts. Boston Scientific does not have a biliary stenting device that is FDA- cleared for use in the pancreatic ducts. 1 CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2 PFS Relative Value File Source: CMS Physician Fee Schedule December 27, 2013 revised release, RVU14A file. 3 Source: November 27, 2013 Federal Register CMS-1601-FC. 4 National average (wage index greater than one) DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5,799.59). Source: August 19, 2013 Federal Register. 5 The patient s medical record must support the existence and treatment of the complication or comorbidity. 6 May include but is not limited to one of the following hemostasis techniques: injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator. 7 Likely to pertain to bronchial thermoplasty only. 8 Based on estimate that non-medicare payment for outpatient hospital services is 2.17 times Medicare payment. Source: High and Varying Prices for Privately Insured Patients Underscore Market Power by Chapin White, Amelia M. Bond and James D. Reschovsky. See important information about the uses and limitations of this document on pages 1 and 2 Page 16

18

19 Endoscopy C-Code Summary C-code C-code Description Devices Impacted 1 C1726 Catheter, balloon dilation, non-vascular CRE Single-Use Fixed Wire Esophageal Balloon Dilators CRE Single-Use Pulmonary Balloon Dilators CRE Single-Use Wireguided Esophageal/Pyloric/Biliary Balloon Dilators CRE Single-Use Wireguided Esophageal/Pyloric/Colonic/Biliary Balloon Dilators CRE Single-Use Wireguided Biliary Balloon Dilators Hurricane RX Single-Use Biliary Dilatation Balloon Catheters MaxForce Biliary Balloon Dilatation Catheters MaxForce TTS Single-Use Balloon Dilators Rigiflex II Single-Use Achalasia Balloon Dilators C1769 Guide wire All BSC guide wires used in GI procedures: Dreamwire Guidewire, Hydra Jagwire Guidewire, Jagwire Guidewire, NaviPro Guidewire, Pathfinder Guidewire Hydratome RX Cannulating Sphincterotomes Jagtome RX Cannulating Sphincterotomes Dreamtome RX Cannulating Sphincterotomes C1874 Stent, coated/covered, with delivery system Polyflex Single-Use Esophageal Stent System Polyflex Single-Use Self-Expanding Silicone Airway Stent System Ultraflex Single-Use Covered Esophageal NG Stent System Distal Release Ultraflex Single-Use Covered Esophageal NG Stent System Proximal Release Ultraflex Single-Use Covered Large Esophageal NG Stent System Distal Release Ultraflex Single-Use Covered Large Esophageal NG Stent System Proximal Release WallFlex Biliary RX Fully Covered Stent System WallFlex Biliary RX Partially Covered Stent System WallFlex Fully Covered Esophageal Stent WallFlex Partially Covered Esophageal Stent WallFlex Partially Covered Esophageal Stent System WALLSTENT Endoscopic Biliary Endoprosthesis Stents C1875 Stent, coated/covered without delivery system Dynamic (Y) Stent C1876 Stent, non-coated/non-covered, with delivery system Ultraflex Precision Single-Use Colonic Stent System Ultraflex Single-Use Uncovered Esophageal NG Stent System Distal Release Ultraflex Single-Use Uncovered Esophageal NG Stent System Proximal Release Ultraflex Single-Use Uncovered Tracheobronchial Stent System Distal Release Ultraflex Single-Use Uncovered Tracheobronchial Stent System Proximal Release WallFlex Single-Use Colonic Stent System WallFlex Single-Use Duodenal Stent System WallFlex Biliary RX Uncovered Stent System WALLSTENT RX Biliary Endoprosthesis Stent System WALLSTENT Endoscopic Biliary Endoprosthesis Stents WALLSTENT Single-Use Colonic and Duodenal Endoprosthesis with UniStep Plus Delivery System C2617 Stent, non-coronary, temporary, without delivery system C-Flex Single-Use Pigtail Biliary Stent Percuflex Amsterdam Single-Use Biliary Stent w/out Introducer Kit Advanix Biliary Stent C2625 Stent, non-coronary, temporary, with delivery system Advanix Preloaded Biliary Stent Systems Flexima Biliary Stent Systems Percuflex Biliary Stent with Introducer Kits1 RX Biliary Stents with RX Delivery System C1886 Catheter, extravascular tissue ablation, any modality (insertable) Alair Bronchial Thermoplasty Catheter 1 For devices packaged in kits, hospitals may bill for the components of the kits that individually qualify for C-codes. Facilities should bill for the estimated proportion of the kit that the C-code eligible device comprises. See important information about the uses and limitations of this document on pages 1 and 2 Page 17

20 Boston Scientific Corporation One Boston Scientific Place Natick, MA CRE, Hurricane, MaxForce, MaxForce TTS, Rigiflex, Dreamwire, Hydra Jagwire, Jagwire, NaviPro, Pathfinder, Hydratome, Jagtome, Dreamtome, Polyflex, Ultraflex, WALLSTENT, Permalume, WallFlex, Dynamic, UniStep, Percuflex, Advanix, Flexima and Alair are registered or unregistered trademarks of Boston Scientific Corporation or its affiliates. All other trademarks are property of their respective owners Boston Scientific Corporation or its affiliates. All rights reserved. Effective: 1JAN2014 Expires: 31DEC2014 MS-DRG Rates Expire: 30SEP2014 See important information about the uses and limitations of this document on pages 1 and 2

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