2016 Procedural Reimbursement Guide Select Percutaneous Coronary Interventions

Transcription

1 2016 Procedural Reimbursement Guide Select Percutaneous Coronary Interventions This Procedural Payment Guide for interventional cardiology procedures provides coding and reimbursement information for physicians and healthcare facilities. The codes included in this guide are intended to represent typical interventional cardiology procedures where there is: 1) at least one product approved 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 that while these materials are intended to provide coding information for a range of interventional cardiology procedures, the FDA approved/cleared labeling for all products may 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 differences in labor and non labor costs, hospital teaching status, proportion of low income patients, coverage, and/or payment rules. Please feel free to contact the Boston Scientific reimbursement department at CARDIAC if you have any questions about the information in these materials. You can also find reimbursement updates on our website, Billing and Payment: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to Current Procedural Terminology 1 (CPT ) codes. CPT codes are published by the AMA and used to report medical services and procedures performed by or under the direction of physicians. payment for procedures performed in an outpatient or inpatient hospital or Ambulatory Surgical Center (ASC) setting is described as an in facility fee payment (listed as In in document) while payment for procedures performed in the physician office is described as an in office payment. In facility payments reflect modifier 26 as applicable. Billing and Payment: Medicare reimburses hospitals for outpatient stays (typically stays that do not span 2 midnights) under Ambulatory Payment Classification () groups. Medicare assigns an to a procedure based on the billed CPT/HCPCS (Healthcare Common Procedural Coding System) code. (Note that private insurers may require other procedure codes for outpatient payment.) While it is possible that separate payments may be deemed appropriate where more than one procedure is done during the same outpatient visit, many s are subject to reduced payment when multiple procedures are performed on the same day. Comprehensive s (J1 status indicator) can impact total payment received for outpatient services. Billing and Payment: Medicare reimburses hospital inpatient procedures based on the Medicare Severity Diagnosis Related Group (MS DRG). The MS DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS DRGs closely calibrate payment to the severity of a patient s illness. 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. Private payers may also use MS DRG based systems or other payer specific system to pay hospitals for providing inpatient services. : Potential procedure codes are included within this guide. Due to the number of potential codes within the system, the codes included in this document do not fully account for all procedure code options. Some codes outlined in this guide include an " _" symbol. For example, 027_34Z is listed as a potential code for reporting a coronary drug eluting stent procedure. In this example, the "_" character could be 0, 1, 2 or 3, depending on the number of sites treated. The "_" symbol is not a recognized character within the system. ASC Billing and Payment: Many elective procedures are performed outside of the hospital in Medicare certified facilities also known as Ambulatory Surgical Centers (ASCs). Not all procedures that Medicare covers in the hospital setting are eligible for payment in an ASC. Medicare has a list of all services (as defined by CPT/HCPCs codes), generally nonsurgical, that it covers when offered in an ASC. ASC allowed procedures can be found at Payments made to ASCs from private insurers depend on the contract the facility has with the payer. Disclaimer Please note: this coding information may include codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved. Health economics and reimbursement information provided by Boston Scientific Corporation is gathered from third party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is provided for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider's responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA approved label. coding or site of service requirements. The coding options listed within this guide are commonly relevant manuals for appropriate coding options. 1 CPT Copyright 2015 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. Boston Scientific does not promote the use of its products outside their FDA approved label. See Page 9 for Sources and Footnotes See page 1 for important information about the uses and limitations of this document IC AA Dec of 11

2 and ASC information effective through December 31, 2016 Diagnostic Cardiac Catheterization Average Payment 3 Medicare Cardiac valve & other major cardiothoracic proc with cardiac catheterization without CC/ MCC Cardiac defibrillator implant with cardiac catheterization with AMI/HF/Shock with MCC 6 Cardiac defibrillator implant with cardiac catheterization with AMI/HF/Shock without MCC 6 Cardiac defibrillator implant with cardiac cath without AMI/HF/Shock with MCC Catheter placement in coronary artery(s) for coronary angiography, including $ $44,959 placement intraprocedural injection(s) for coronary angiography, imaging supervision and : interpretation; with right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including $ Cardiac defibrillator implant with cardiac catheterization without placement intraproceduralinjection(s) for coronary angiography, imaging supervision and AMI/HF/Shock without MCC interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free $34,579 arterial, venous grafts) including intraprocedural injection(s) for bypass graft 233: angiography and right heart catheterization Coronary bypass with cardiac cath with MCC Catheter placement in coronary artery(s) for coronary angiography, including $ $43,448 placement intraprocedural injection(s) for coronary angiography, imaging supervision and : interpretation; with left heart catheterization including intraprocedural injection(s) Coronary bypass with cardiac for left ventriculography, when performed catheterization without MCC Catheter placement in coronary artery(s) for coronary angiography, including $ $28,978 placement intraprocedural injection(s) for coronary angiography, imaging supervision and : interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculogr+b13aphy, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography $12, Catheter placement in coronary artery(s) for coronary angiography, including $ : placement intraproceduralinjection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed cardiac catheterization without MCC $6, Catheter placement in coronary artery(s) for coronary angiography, including $ : placement intraproceduralinjection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft Atherosclerosis with MCC $6, : Atherosclerosis without MCC angiography $3,795 In Facility Right heart catheterization including measurement(s) of oxygen saturation and $ A023N6 216: right cardiac output, when performed 4.16 Diagnostic cardiac 4A020N Right heart catheterization, for congenital cardiac anomalies $ catheterization right Left heart catheterization including intraprocedural injection(s) for left $ $2,549 4A023N7 $55,884 left ventriculography, imaging supervision and interpretation, when performed A020N7 217: Left heart catheterization by transseptal puncture through intact septum or by $ left transapical puncture (List separately in addition to code for primary procedure) $36, Combined right heart catheterization and left heart catheterization including $ A023N8 218: combined intraprocedural injection(s) for left ventriculography, imaging supervision and A020N interpretation, when performed Combined right heart catheterization and retrograde left heart catheterization, for $ combined congenital cardiac anomalies $32, Combined right heart catheterization and transseptal left heart catheterization $ : combined through intact septum, with or without retrograde left heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and transseptal left heart catheterization $ combined through existing septal opening, with or without retrograde left heart $50, catheterization, for congenital cardiac anomalies) 223: Catheter placement in coronary artery(s) for coronary angiography, including $ B21 ZZ placement intraprocedural injection(s) for coronary angiography, imaging S&I Catheter placement in coronary artery(s) for coronary angiography, including $ $37,806 placement intraprocedural injection(s) for coronary angiography, imaging supervision and : interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography Total Cardiac valve & other major cardiothoracic procedures with cardiac catheterization with MCC Cardiac valve & other major cardiothoracic procedures with cardiac catheterization with CC cardiac catheterization with MCC IC AA Dec of 11

3 and ASC information effective through December 31, 2016 Average Payment 3 Medicare Injection Diagnostic Cardiac Catheterization Each site may be injected multiple times, only report each code once Injection procedure during cardiac catheterization including imaging supervision, $ Status N, items and 3E053KZ NA interpretation, and report; for selective coronary angiography during congenital 1.69 services packaged 3E063KZ heart catheterization (List separately in addition to code for primary procedure) into primary procedure rate Injection procedure during cardiac catheterization including imaging supervision and $ No separate payment 3E053KZ interpretation, and report; for selective opacification of aortocoronary venous or E063KZ arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and $ E073KZ interpretation, and report; for selective left ventricular or left arterial angiography E083KZ (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective right ventricular or right atrial angiography $ (List separately in addition to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and $ E053KZ interpretation, and report; for supravalvular aortography (List separately in addition E063KZ to code for primary procedure) Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for pulmonary angiography (List separately in addition to $ code for primary procedure) Miscellaneous Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of $ Status N, items and 3E073KZ NA 7 nitroprusside, dobutamine, milrinone, or other agent) including assessing 2.81 services packaged 3E083KZ hemodynamic measurements before, during, after and repeat pharmacologic agent into primary administration, when performed (List separately in addition to code for primary procedure rate. procedure) No separate payment Physiologic exercise study (eg, bicycle or arm ergometry) including assessing $ A1335C hemodynamic measurements before and after (List separately in addition to code for 2.48 primary procedure) Coronary Angioplasty (PTCA), without stent (See page 10 for Complexity Adjustment Code Combinations) Billed in conjunction with Procedure Code. Use physician modifier 26 as appropriate Percutaneous transluminal coronary angioplasty; single major coronary $ _3ZZ 250: artery or branch Level I Endovascular 027_3Z6 Percutaneous cardiovascular procedures without coronary artery stent with MCC $4,592 $15, Percutaneous transluminal coronary angioplasty; each additional branch of $ NA 251: a major coronary artery (list separately in addition to code for primary 0.00 Complexity Percutaneous cardiovascular procedure) adjustment may procedures without coronary artery apply stent without MCC Coronary Atherectomy, without stent (See page 10 for Complexity Adjustment Code Combinations) Percutaneous transluminal coronary atherectomy, with coronary $ C_3ZZ 250: angioplasty when performed; single major coronary artery or branch Level II Endovascular Percutaneous cardiovascular procedures without coronary artery stent with MCC $9,542 $15, Percutaneous transluminal coronary atherectomy, with coronary $ NA 251: angioplasty when performed; each additional branch of a major coronary 0.00 Percutaneous cardiovascular procedures artery (list separately in addition to code for primary procedure) without coronary artery stent without MCC $9,957 $9,957 IC AA Dec of 11

4 and ASC information effective through December 31, 2016 Average Payment 3 Medicare Non Drug Eluting Stent with Angioplasty (PTCA) (See page 10 for Complexity Adjustment Code Combinations) Percutaneous transcatheter placement of intracoronary stent(s), with $ _3DZ 248: coronary angioplasty when performed; single major coronary artery or Level II Endovascular 027_3D6 branch $9,542 $18, : Percutaneous transcatheter placement of intracoronary stent(s), with coronary $ NA Percutaneous cardiovascular proc w angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) 0.00 non drug eluting stent without MCC Drug Eluting Stent with Angioplasty (PTCA) (See page 10 for Complexity Adjustment Code Combinations) C9600 Percutaneous transcatheter placement of drug eluting intracoronary NA _34Z 246: stent(s), with coronary angioplasty when performed; single major Level II Endovascular 027_346 coronary artery or branch C9602 Percutaneous transluminal coronary atherectomy, with drug eluting NA _34Z 246: intracoronary stent, with coronary angioplasty when performed; single Level III Endovascular 027_346 major coronary artery or branch 02C_3ZZ Non Drug Eluting Stent Coronary Revascularization Bypass Graft s use codes 92928/ $9,542 $19,187 +C9601 Percutaneous transcatheter placement of drug eluting intracoronary NA 247: stent(s), with coronary angioplasty when performed; each additional branch of major coronary artery Complexity adjustment may apply Percutaneous cardiovascular proc w drug eluting stent without MCC Non Drug Eluting Stent with Atherectomy Percutaneous transluminal coronary atherectomy, with intracoronary $ _3DZ 248: stent, with coronary angioplasty when performed; single major coronary artery or branch Level III Endovascular 027_3D6 02C_3ZZ Percutaneous cardiovascular proc w $14,612 $18, Percutaneous transluminal coronary atherectomy, with intracoronary $ NA 249: stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary #N/A Percutaneous cardiovascular proc w non drug eluting stent without MCC procedure Drug Eluting Coronary Stent with Atherectomy s use codes 92928/ $14,612 $19,187 +C9603 Percutaneous transluminal coronary atherectomy, with drug eluting NA 247: intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery drug eluting stent without MCC Percutaneous transluminal revascularization of or through coronary artery bypass $ _3DZ 248: graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; Level II Endovascular 027_3D6 02C_3ZZ single vessel $9,542 $18, Percutaneous transluminal revascularization of or through coronary artery $ NA 249: bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection 0.00 non drug eluting stent without MCC when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) IC AA Dec of 11

5 and ASC information effective through December 31, 2016 Average Payment 3 Medicare Non Drug Eluting Stent Coronary Revascularization (continued) Acute Myocardial Infarction Percutaneous transluminal revascularization of acute total/subtotal $ _3DZ 248: Level II Endovascular 027_3D6 02C_3ZZ occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel $9,542 $18,125 Chronic Total Occlusion 249: Percutaneous transluminal revascularization of chronic total occlusion, $ _3DZ coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; Level II Endovascular 027_3D6 02C_3ZZ single vessel $9, Percutaneous transluminal revascularization of chronic total occlusion, $ NA coronary artery, coronary artery branch, or coronary artery bypass graft, 0.00 any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) Drug Eluting Stent Coronary Revascularization Bypass Graft (See page 10 for Complexity Adjustment Code Combinations) C9604 Percutaneous transluminal revascularization of or through coronary artery NA _34Z 246: Level II Endovascular 027_346 02C_3ZZ bypass graft (internal mammary, free arterial, venous), any combination of s use drug eluting intracoronary stent, atherectomy and angioplasty, including codes distal protection when performed; single vessel 92928/ $9,542 $19,187 +C9605 Percutaneous transluminal revascularization of or through coronary artery NA 247: bypass graft (internal mammary, free arterial, venous), any combination of drugeluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft Acute Myocardial Infarction C9606 Percutaneous transluminal revascularization of acute total/subtotal NA 5193 Level III Endovascular 027_34Z 027_346 02C_3ZZ occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel Drug Eluting Stent Coronary Revascularization (continued) Chronic Total Occlusion Percutaneous transluminal revascularization of chronic total occlusion, BSC currently has no stents FDA approved for CTOs s use codes 92928/ $14,612 drug eluting stent without MCC C9607 NA _34Z 246: Level III Endovascular 02C_3ZZ coronary artery, coronary artery branch, or coronary artery bypass graft, s use any combination of drug eluting intracoronary stent, atherectomy and codes angioplasty; single vessel 92928/ $14,612 $19,187 +C9608 Percutaneous transluminal revascularization of chronic total occlusion, NA 027_ : 027_34Z coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft Complexity adjustment may apply non drug eluting stent without MCC drug eluting stent without MCC IC AA Dec of 11

6 and ASC information effective through December 31, 2016 Average Medicare Payment 3 Intravascular Ultrasound (Use physician modifier 26 as appropriate) Intravascular ultrasound (coronary vessel or graft) during diagnostic $ Status N, items and B240ZZ3 231: evaluation and/or therapeutic intervention including imaging supervision, 2.77 services packaged B241ZZ3 Coronary bypass with PTCA with MCC interpretation and report; initial vessel (List separately in addition to code into primary for primary procedure) procedure rate. $46,090 No separate payment 232: Coronary bypass with PTCA without MCC Intravascular ultrasound (coronary vessel or graft) during diagnostic $ evaluation and/or therapeutic intervention including imaging supervision, 2.22 $34, : interpretation and report; each additional vessel (List separately in addition to code for primary procedure) Fractional Flow Reserve (FFR) $19, Intravascular Doppler velocity and/or pressure derived coronary flow $ Status N, items and 4A033BC 247: reserve measurement (coronary vessel or graft) during coronary 2.77 services packaged angiography including pharmacologically induced stress; initial vessel (List into primary procedure rate. separately in addition to code for primary procedure) No separate payment Intravascular Doppler velocity and/or pressure derived coronary flow $ reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure) 248: $18, : non drug eluting stent without MCC 250: $15, : Percutaneous cardiovascular procedures without coronary artery stent without MCC $9, : cardiac catheterization with MCC Intravascular Ultrasound (Peripheral Interventions) Use physician modifier 26 as appropriate Intravascular ultrasound (non coronary vessel) during diagnostic $ Status N, items and B44_ZZ3 252: evaluation and/or therapeutic intervention; initial vessel (List separately in 2.70 services packaged B54_ZZ3 addition to code for primary procedure) into rate. No separate payment. drug eluting stent without MCC Percutaneous cardiovascular procedures without coronary artery stent with MCC $12, : cardiac catherization without MCC $6,827 Other vascular procedures w/mcc $19, : Other vascular procedures w/cc Intravascular ultrasound (non coronary vessel) during diagnostic $ $15,369 evaluation and/or therapeutic intervention; each additional vessel (List separately in addition to code for primary procedure) : Other vascular procedures without CC/MCC $10,175 IC AA Dec of 11

7 and ASC information effective through December 31, 2016 Average Payment 3 Medicare Thrombectomy Percutaneous transluminal coronary thrombectomy mechanical (List $ NA 02C_3ZZ 246: separately in addition to code for primary procedure) 5.15 Percutaneous Balloon Valvuloplasty; Aortic Valve $19, : drug eluting stent without MCC 248: $18, : non drug eluting stent without MCC 250: Percutaneous cardiovascular procedures without coronary artery stent with MCC $15, : Percutaneous cardiovascular procedures without coronary artery stent without MCC $9, : cardiac catheterization with MCC $12, : cardiac catherization without MCC Percutaneous balloon valvuloplasty; aortic valve $1, F3ZZ 273: Level I Endovascular 027F4ZZ Percutaneous intracardiac procedures with MCC $20,961 $4, : Percutaneous balloon valvuloplasty; mitral valve $1, G3ZZ Percutaneous intracardiac procedures Level II Endovascular 027G4ZZ without MCC $14,288 $9, Percutaneous balloon valvuloplasty; pulmonary valve $1, H3ZZ H4ZZ $6,827 IC AA Dec of 11

8 and ASC information effective through December 31, 2016 Endovascular or Transthoracic Valves In Facility Total Average Payment 3 Medicare Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, NA 02RF37Z 266: Aortic percutaneous femoral artery approach Only 02RF38Z Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, Procedure 02RF3JZ Aortic open femoral artery approach RF3KZ $50, Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, : Aortic open axillary artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, Aortic open iliac artery approach $38, Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, Aortic transaortic approach (e.g., median sternotomy, mediastinotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $2, RF3JH Aortic transapical exposure (eg, left thoracotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $ RF3_Z Aortic cardiopulmonary bypass support with percutaneous peripheral arterial A1221Z and venous cannulation (e.g., femoral vessels) (list separately in addition to code for primary procedure) Endovascular cardiac valve replacement with MCC Endovascular cardiac valve replacement without MCC Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $ RF0_Z Aortic cardiopulmonary bypass support with open peripheral arterial and venous A1221Z cannulation (e.g., femoral, iliac, axillary vessels) (list separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; $1, RF3JZ Aortic cardiopulmonary bypass support with central arterial and venous A1221Z cannulation (e.g., aorta, right atrium, pulmonary artery) (list separately in addition to code for primary procedure) 0262T Implantation of catheter delivered prosthetic pulmonary valve, Carrier RH3_Z Pulmonary endovascular approach priced Unlisted procedure, cardiac surgery 02RH3_H Transcatheter mitral valve repair, percutaneous approach, including $1, UG3JZ 273: transseptal puncture when performed; initial prosthesis Percutaneous intracardiac procedures Transcatheter mitral valve repair, percutaneous approach, including $ with MCC $20,961 transseptal puncture when performed; additional prosthesis(es) during : same session (List separately in addition to code for primary procedure) Percutaneous intracardiac procedures without MCC $14,288 IC AA Dec of 11

9 and ASC information effective through December 31, 2016 Average Payment 3 Medicare WATCHMAN TM Left Atrial Appendage Closure (LAAC) Procedure 0281T L73DK 273: Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s) left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation Carrier Priced WATCHMAN is a registered or unregistered trademark of Boston Scientific Corporation NA Only Procedure Percutaneous intracardiac procedures with MCC $20, : Percutaneous intracardiac procedures without MCC $14, Current Procedural Terminology (CPT) 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. 2. Source: CMS website. Fee Schedule 2016 National Fee Schedule Relative Value File: Fee for Service Payment/FeeSched/PFS Relative Value Files.html 3. Source: CMS website OPPS Addendum B: Fee for Service Payment/PPS/ Regulationsand Notices.html 4. Source: CMS ICD 10 CM/PCS MS DRG v33 Definitions Manual fullcode cms/fullcode_cms/p0001.html 5. Source: Data tables (FY2016 IPPS Final Rule). CMS Website. National average (wage index greater than one) MS DRG rates calculated using the national adjusted full update standardized labor, non labor and capital amounts. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic differences in labor and non labor costs, hospital teaching status, and/or proportion of low income patients). Fee for Service Payment/AcutePPS/FY2016 IPPS Final Rule Home Page.html 6. Not intended as an all inclusive list of MS DRGs. 7. MS DRG grouping is driven by other primary procedures that are performed in conjunction with this procedure. 8. Total RVU is the relative value unit total for In Facility calculation 0 0 $ IC AA Dec of 11

10 Description 2016Complexity Adjustment Interventional Cardiology Code Combinations for Comprehensive s (c s) 5191, 5192 and 5193 CY 2016 Final Payment 5191 Level I Endovascular $4, Level II Endovascular $9, Level III Endovascular $14,612 Interventional Cardiology PCI Complexity Adjustment CPT Combinations (5191 base code plus second CPT equals 5192 payment) Primary HCPCS Code Primary Short Descriptor Primary SI Primary Code Base Secondary or Device Add on HCPCS Code Secondary Short Descriptor Secondary SI Secondary Code Base Complexity Adjusted Prq cardiac angioplast 1 art J Prq cardiac angioplast 1 art J Prq cardiac angioplast 1 art J Cath place cardio brachytx N 5192 Complexity Adjustment CPT Combinations (5192 base code plus second CPT equals 5193 payment) Primary HCPCS Code Interventional Cardiology PCI Base s and Payment Primary Short Descriptor Primary SI Primary Code Base Secondary or Device Add on HCPCS Code Secondary Short Descriptor Secondary SI Secondary Code Base Complexity Adjusted Prq card angio/athrect 1 art J C9600 Perc drug el cor stent sing J Prq card stent w/angio 1 vsl J Iliac revasc w/stent J Prq card stent w/angio 1 vsl J C9601 Perc drug el cor stent bran N 5193 C9600 Perc drug el cor stent sing J Insrt heart pm atrial & vent J C9600 Perc drug el cor stent sing J Insert electrd/pm cath sngl J C9600 Perc drug el cor stent sing J Implant pat active ht record J C9600 Perc drug el cor stent sing J Iliac revasc w/stent J C9600 Perc drug el cor stent sing J Open/perq place stent 1st J C9600 Perc drug el cor stent sing J Prq revasc byo graft 1 vsl J C9600 Perc drug el cor stent sing J C9600 Perc drug el cor stent sing J C9600 Perc drug el cor stent sing J C9601 Perc drug el cor stent bran N 5193 C9604 Perc d e cor revasc t cabg s J C9600 Perc drug el cor stent sing J C9604 Perc d e cor revasc t cabg s J C9604 Perc d e cor revasc t cabg s J C9604 Perc d e cor revasc t cabg s J C9605 Perc d e cor revasc tcabg b N is Highest Level in the Vascular family, payment is capped at the 5193 level Complexity Adjustment Combinations (CMS Defined Combination based on Cost) are Two CPT combinations identified that high cost results in next highest vascular family payment when billed together Note: 1. All complexity adjustment stay in the same "Comprehensive" family 2. IC and PI s 5191, 5192 and 5193 are in the same Comprehensive family defined as Vascular (VASCX) payment adjustments are two CPT code combinations (complexity adjustments) pre defined by CMS based on cost 4. The highest payment, even with Complexity Adjustments is Base codes in 5193 are at the highest vascular family c payment level, no additional complexity adjustments apply. 1 CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2 Source: CMS Medicare Fee for Service Payment_ PPS CY2016 OPPS Addendums J found at Fee for Service Payment/PPS/ Regulations and Notices Items/CMS 1633 FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending IC AA Dec of 11

11 Category C Code Reference Guide 2016 Interventional Cardiology Quarterly updates can be found on the Medicare website ( Background: C Codes are used for hospital outpatient device reporting for Medicare and some private payers. A limited number of C Codes are eligible for additional pass through payment from Medicare for the associated device. Device dependent s may be denied without applicable C Codes. C Codes are VERY important to future reimbursement. Use of all applicable C Codes on a claim allows identification of device(s) utilized in a procedure and may affect future payment rates. CORONARY Category C Code C1724 C1725 C1753 C1757 C1769 C1874 C1876 C1884 C1887 C1894 Category C Code Description Catheter, transluminal atherectomy, rotational Catheter, transluminal angioplasty, non laser (may include guidance, infusion/perfusion capability) Catheter, intravascular ultrasound Catheter, Embolectomy/thrombectomy Guide Wire Stent, coated/covered, with delivery system Stent, noncoated/noncovered, with delivery system Embolization protective system Catheter, guiding (may include infusion/perfusion capability) Introducer/sheath, other than guiding, other than intracardiac electrophysiological, nonlaser Disclaimer Please note: This coding information may include some codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved. Health economics and reimbursement information provided by Boston Scientific Corporation is gathered from third party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is provided for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider's responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDAapproved label. coding or site of service requirements. The coding options listed within this guide are commonly relevant manuals for appropriate coding options. coding or site of service requirements. The coding options listed within this guide are commonly relevant manuals for appropriate coding options. CPT Disclaimer CPT copyright 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. We welcome your feedback. Please send comments to [email protected] 1 CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. IC AA Dec of 11