Solitaire FR Revascularization Device CODING AND REIMBURSEMENT GUIDE REIMBURSEMENT SUPPORT HOTLINE

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1 Solitaire FR Revascularization Device TM CODING AND GUIDE

2 INTRODUCTION: HOSPITAL INPATIENT CODING SOLITAIRE FR REVASCULARIZATION DEVICE DESCRIPTION The Solitaire FR revascularization device is a self-expanding device designed to restore blood flow in patients experiencing 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 FR revascularization system 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 FR revascularization device is designed to be delivered through a micro catheter, 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. HOSPITAL INPATIENT CODING AND GUIDE Medicare assigns a hospital inpatient admission to a Medicare Severity- Diagnosis Related Group (MS-DRG) based on the ICD-9 diagnoses and procedure codes. Hospitals generally receive an all-inclusive payment for each MS-DRG. This payment will vary based on several adjustments: outlier payments, new technology add-ons, wage index, disproportionate share, indirect medical education and geographic. Based on the hospital s contract with insurers, there may be separate payments for devices. Device-specific C-codes or HCPCS codes were established by Medicare for outpatient procedures and pass-through payments (April 1, 2001). C-codes are not used to submit inpatient claims to Medicare. However, hospitals often request C-codes for internal tracking purposes. CODING AND GUIDE PAGE 1

3 HOSPITAL INPATIENT CODING AND GUIDE DISCLAIMER Possible DRGs will vary based on the principal and secondary diagnosis codes as well as the primary procedure code. MS- DRG 1 Mechanical Thrombectomy/Embolectomy 1, Relative Weight 2 Average Length of Stay Medicare Average Base Payment Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant $30, Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC or Chemo Implant $20,371 MS- DRG 1 Thrombolytics for Acute Ischemic Stroke 1, Medicare Relative Weight 2 Average Length of Stay 2 Average Base Payment Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC $16, Acute Ischemic Stroke with Use of Thrombolytic Agent with CC $11, Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC $8,873 MS- DRG 1 Medical Management of Acute Ischemic Stroke Medicare Relative Weight 2 Average Length of Stay 2 Average Base Payment Intracranial Hemorrhage or Cerebral Infarction with MCC $10, Intracranial Hemorrhage or Cerebral Infarction with CC $6, Intracranial Hemorrhage or Cerebral Infarction without CC/MCC $4,564 MCC = MAJOR COMPLICATION AND COMORBIDITY CC = COMPLICATION AND COMORBIDITY ICD-9 CM Diagnosis Code 2, Occlusion and stenosis of basilar artery, with cerebral infarction Occlusion of cerebral arteries, cerebral thrombosis, with cerebral infarction Occlusion and stenosis of carotid artery, with cerebral infarction Occlusion of cerebral arteries, cerebral embolism, with cerebral infarction Occlusion and stenosis of vertebral artery, with cerebral infarction Occlusion of cerebral arteries, unspecified, with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries, with cerebral infarction Occlusion and stenosis of other specified precerebral arteries, with cerebral infarction Occlusion and stenosis of unspecified precerebral artery, with cerebral infarction V45.88* Status post-administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to current facility. * To indicate the history for a patient who has received IV tpa at one facility and has been transferred to another facility, report V45.88 as an additional diagnosis (not primary). MORE CODING AND GUIDE PAGE 2

4 HOSPITAL INPATIENT CODING AND GUIDE CONTINUED ICD-9 CM Procedure Code Endovascular removal of obstruction from head and neck vessel(s): - Endovascular embolectomy - Endovascular thrombectomy of pre-cerebral and cerebral vessels - Mechanical embolectomy or thrombectomy Arteriography of cerebral arteries EXCLUDES: Open embolectomy or thrombectomy of intracranial vessels Open embolectomy or thrombectomy of other vessels of head and neck Endarterectomy of intracranial vessels Endarterectomy of other vessels of head and neck Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils CODE ALSO: Any injection or infusion of thrombolytic agent. Subsequent or prior continuous infusion of a thrombolytic is not an included service of mechanical thrombectomy and is separately reportable using Procedure on single vessel Procedure on two vessels Procedure on three vessels Procedure on four or more vessels Procedure on vessel bifurcation. Use this code only once per operative episode, irrespective of the number of bifurcation in vessels. C1757 HCPCS or C - Codes Revenue Codes 5 Catheter, thrombectomy/embolectomy. (Solitaire FR Revascularization Device) Medical/Surgical Supply C1769 Guidewire. (Avigo Hydrophilic Guidewire, X-Pedion Guidewire) 272 Sterile Supply C1884 C1887 Embolization protective system - a system designed and marketed for use to trap, pulverize and remove atheromatous or thrombotic debris from the vascular system during an angioplasty, atherectomy or stenting procedure. (SpiderFX Embolic Protection Device) Catheter, guiding (may include infusion/perfusion capability) intended for the introduction of interventional/diagnostic devices into the coronary or peripheral vascular system. (Cello Balloon Guide Catheter, Rebar Reinforced Micro Catheter, Orion Micro Catheter, Marksman Micro Catheter) 624 FDA Investigational Devices (if used during a clinical trial) CODING AND GUIDE PAGE 3

5 INTRODUCTION: PHYSICIAN CODING PHYSICIAN CODING AND GUIDE Following are the commonly billed codes associated with reporting endovascular procedures. Refer to the American Medical Association for specific guidelines on the use of these codes. There are a few CPT coding changes in 2013: Carotid angiography codes (75650, 75660, 75662, 75665, 75671, 75676, and 75685) were deleted and bundled into the interventions to move away from component coding. This is comparable to what occurred with lower limb revascularization codes in The impact was budget neutral for the 2013 revisions in the neurovascular codes. New codes (36224, and 36228) were created as a result of the elimination of component coding and have been revised to clarify that thrombolytic infusions is not in inclusive service and is separately reportable with the new combined transcatheter services (report once per date of treatment). CPT codes for thrombectomy include intraprocedural fluoroscopic radiological supervision and interpretation services for guidance (76000, 76001) of the procedure. Intraprocedural injection(s) of a thromboloytic agent is an included service and not separately reportable in conjunction with mechanical thrombectomy (96374, 96375). CODING AND GUIDE PAGE 4

6 PHYSICIAN CODING AND GUIDE CPT Codes 6, 7 Description 2013 Medicare National Average 8 CATHETERIZATION AND DIAGNOSTIC IMAGING NEW in 2013 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 $ NEW in 2013 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed $ New in 2013 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) (List separately in addition to code for primary procedure) $223 TEMPORARY BALLOON OCCLUSION Endovascular temporary balloon arterial occlusion, head or neck (extracranial/ intracranial) including selected catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion $552 If selective catheterization and angiography of arteries other than artery to be occluded is performed, use appropriate catheterization and radiologic supervision and interpretation codes If complete diagnostic angiography of the artery to be occluded is performed immediately prior to temporary occlusion, use appropriate radiologic supervision and interpretation codes MECHANICAL THROMBECTOMY Primary, percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural thrombolytic injection(s); initial vessel $ Second and subsequent vessel(s) within the same vascular family (list separately in addition to code for primary procedure) $ Secondary percutaneous transluminal thrombectomy (e.g. nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (list separately in addition to code for primary procedure) $256 MORE CODING AND GUIDE PAGE 5

7 PHYSICIAN CODING AND GUIDE CONTINUED THROMBOLYSIS CPT Codes 6, 7 Description 2013 Medicare National Average New in 2013 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day $ New in 2013 Transcatheter therapy, venous infusion for thrombolysis, any method, including supervision and interpretation, initial treatment day $ New in 2013 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed $ New in 2013 Cessation of thrombolysis including removal of catheter and vessel closure by any method $147 DIAGNOSTIC CODING RULES Diagnostics should not be reported on the same date of service as an intervention unless: There is no previous diagnostic study available The decision to intervene is based on this study The patient s condition has changed with respect to the clinical indication since the prior study There is inadequate visualization of the anatomy and/or pathology There is a clinical change during the procedure If diagnostic imaging is determined to be separately reportable, append the -59 modifier to the angiography CPT code to distinguish the service. PRIMARY VERSUS SECONDARY THROMBECTOMY CODING Primary arterial thrombectomy is performed when there is a known thrombus and removal of the thrombus is the planned procedure. There may be other interventions performed during the same session but they are not planned as the definitive treatment. Secondary arterial thrombectomy is performed as an adjunct to another procedure, such as removal of short segments of thrombus before or following vascular stent placement. Primary arterial thrombectomies are further differentiated by vascular family. Code is used for a thrombectomy in the initial vessel of a vascular family. Code is used for any subsequent thrombectomy in a different vessel in that same vascular family. As with other interventions, thrombectomy is coded once per vessel treated. If a different vascular family is treated during the same session, code would be repeated for the initial vessel treated in the new vascular family. Code would be used for any additional vessel treated in the new vascular family. CODING AND GUIDE PAGE 6

8 REFERENCES REFERENCES DRG Expert. Ingenix, St. Anthony Publishing/Medicode. Salt Lake City, FY13 IPPS Final Rule Home Page Fee-for-Service-Payment/AcuteInpatientPPS/FY-2013-IPPS-Final-Rule- Home-Page.html. Complete list of MCC/CC can be found in Tables 6G-6K at IPPS Final Rule, Federal Register (77 Fed Reg, No. 170, August 31, AcuteInpatientPPS/FY-2013-IPPS-Final-Rule-Home-Page-Items/ FY2013-Final-Rule-Tables.html 3. Ingenix ICD-9-CM for Hospitals Volumes 1, 2 & 3: Expert HCPCS or C-Codes may be found at: List of Pass through Payment Device Category Codes - Updated: November HospitalOutpatientPPS/passthrough_payment.html 5. Revenue Codes UB-04 Editor. 6. Current Procedural Terminology 2013 American Medical Association. Chicago, IL CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT ) is copyright 2011 American Medical Association. All rights reserved. Applicable FARS/ DFARS apply. 7. Multiple procedure modifier (-51) applies to catheterization (36216, 36217) and embolization (61624). The most significant procedure (embolization) should be listed first on the claim, followed by modifier -51 for subsequent codes. 8. Medicare Physician Fee Schedule Final Rule, Federal Register, 77 Fed Reg, No. 222 Nov 16, The MPFS Conversion Factor for CY 2013 is $ , which reflects the zero percent update for calendar year 2013 adopted by section 601(a) of the American Taxpayer Relief Act of 2012 and MPFS payment rates reflecting policies adopted in the CY 2013 Medicare Physician Fee Schedule Final Rule that appeared in the Federal Register on November 16, 2012, as subsequently corrected by a CY 2013 Medicare Physician Fee Schedule Final Rule Correction Notice. PhysicianFeeSched/index.html CODING AND GUIDE PAGE 7

9 DRIP AND SHIP When an Acute Ischemic Stroke patient receives IV t-pa therapy in an OP setting at Hospital A and is then transferred to Hospital B for interventional treatment, the potential coding and payment for Hospital A is included in the table below. CPT 2013 Description HCPCS 1 SI 2 APC 3 1 Relative Weight Medicare Average Payment New in 2013 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day T $ New in 2013 Transcatheter therapy, venous infusion for thrombolysis, any method, including supervision and interpretation, initial treatment day T $ New in 2013 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed (N/A since patients are transferred same day) New in 2013 Cessation of thrombolysis including removal of catheter and vessel closure by any method (Code is not applicable since providers can only report one code per day) T $1,754 T $1,754 J Injection of tpa (Alteplase recombinant) 1MG K 7048 N/A $ Emergency department visit Level V V $ Emergency department visit Level IV V $ Emergency department visit Level III V $ Emergency department visit Level II V $ Emergency department visit Level I V $52 NOTES: TRANSCATHETER PROCEDURES New 2013 codes for catheter placement and the radiologic supervision and interpretation should also be reported, in addition to the code(s) for the therapeutic aspect of the procedure change: Report once per date of treatment. CODING AND GUIDE PAGE 8

10 REFERENCES REFERENCES: 1. Current Procedural Terminology 2013 American Medical Association. Chicago, IL CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is 2012 American Medical Association. All rights reserved. Applicable FARS/DFARS apply Rates: Effective January 1, 2013, CMS-1589-FC, Federal Register, Vol. 77, No. 221/Thursday, November 15, 2012/Rules and Regulations Rules available at: Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and- Notices.html The complete list of the status indicators (SI) and their definitions is displayed in Addendum D1: a. T: Significant Procedure, Multiple Reduction Applies b. K: Nonpass-Through Drugs and Nonimplantable Biologicals, including Therapeutic Radiopharmaceuticals. Separate APC payment. c. V: Clinic or Emergency Department Visit. Separate APC payment Outpatient Prospective Payment System Fee Schedule. Addendum B Release Date January 2013 at: Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/ HospitalOutpatientPPS/AU/list.asp#TopOfPage. Downloaded on January 14, Medicare Part B Drug Average Sales Price, 2013 ASP Drug Pricing Files. McrPartBDrugAvgSalesPrice/index.html. Downloaded January 14, Effective January 1, 2013 through March 31, J2997 1MG $ DISCLAIMER Covidien provides this information for your convenience only. This information cannot guarantee coverage or reimbursement and should not replace internal policies, decision making or billing standards. It is the provider s responsibility to code and submit appropriate claims for the services rendered. Before filing any claims, providers should verify current requirements and policies with the payer. FDA LABELING Indications for Use: The Solitaire FR 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. Indications, contraindications, warnings and instructions for use can be found on the product labeling supplied with each device. CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician. CODING AND GUIDE PAGE 9

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