VAD Professiona al Reimbursement Web Wb binar Peter K. Sm mith, MD Professor and Chief Thoracic Surgery Duke University 12/13/211
Relative Value Distribution in the Physician Fee Schedule RV PLI, 0.03 RV PE, 46% RVW, 51%
Importance of Evaluation and Management Billing in Cardiothoracic Surg gery E&M Payments 17% $110,000,000 Procedural Payments 83% $549,000,000
Length of Stay Template for E&M Services Percent of Patients 25 20 15 10 5 Mitral Repair N=7985 E&M 1 2 3 4 Median Mean 5 6 7 0 0 1 2 3 4 5 6 7 8 9 10 Length of Stay (days)
Length of Stay Template for E&M Services Percent of Patients 25 20 15 10 5 Mitral Repair N=7985 E&M 1 2 3 4 Median Mean 5 6 7 0 0 1 2 3 4 5 6 7 8 9 10 Length of Stay (days)
Payment Policy Paid for physician services that are described by CPT (Current Proceduree Terminology) and are assigned Relative Value Units (RVU) by CMS Many services are assigned Global Periods which are either 90, 10 or 0 days For many other services, no global periods are assigned. These are calle ed XXX globals Some services are intended to be add-ons to specific codes, and are called ZZZ codes
Global Period A global period is initiated when a CPT code is billed, and defines a peri iod of time where other billing related to the service described by the CPT code is prohibited. This is due to the fact that the RVU of the global code already contains th he value of the typical physician services provided during the global period.
90 Day Global This is the most common designation for surgical procedures and prohibits billing for related services 1 day before and 90 days after the procedure. For example, this is a 90 day global: 33533 Coronary artery by ypass, single, arterial
33533 RVU Build Includes Time 60 minutes of pre-service evaluation 15 minutes to position p atient in OR 20 minutes of scrub, dress and wait time 151 minutes to perform the procedure skin-to-skin 40 minutes of immediatee postop time to stabilize and transfer the patient, dictate, communicate, etc And
33533 RVU Build Includes Visits 1 X 99291 Critical Care 3 X 99233 Hospital Visit 1 X 99232 Hospital Visit 1 X 99231 Hospital Visit 1 X 99231 Hospital Visit 1 X 99238 Discharge 1 X 99212 Office Visit 1 X 99214 Office Visit
Global Period Exce eptions-additional Procedures Performed Post Op Must be performed in OR or treatment room Best example is 35820 Re-exploration exploration for Bleeding or Infection CPT modifier -78 must be appended to indicate that it is performed in the global period, related to the principal procedure. This results in a discount in payment Procedures performed by others are paid full value and not subject to global period rules
Global Period Exceptions: Evaluation and Management of a New and dunrelated ltdproblem Example: Patient has CABG with pre-existing DVT and suffers a pulmonary embolism requiring multiple days of critical care services to recover. You would bill several critical care E&M codes and append CPT modifier -24 or -25 to indicate that you are billing for a new problem wihi ithin the existing i global l period for the CABG There are few legitimate t examples of this, as most tissues that arise are related to the CABG procedure. The use of -24 and -25 modi ifiers frequently lead to audits.
CPT Modifiers -51: Another procedure performed at the same time as a higher valued procedure, pays 50% to account for overlap and duplication in global period payments. Orthotopic Heart Tx/VAD Removal Pays full value of higher valued code, Heart Tx Pays 50% of VAD Remo oval
Summary of VAD Changes VAD removal codes Global changes from 90 day to XXX global Reimbursement goes down Offset cuts by billing for E/M services VAD replacement codes Have established Values All VAD codes Have XXX global l Related E/M services should be separately billed Additional i services should be separately billed Physician Documentation of services ESSENTIAL
Impact of 5 Year Review VAD Changes 2010 Global Period Global Period Current New Current Percent CPT Descriptor 2011 2012 RVW RVW Medicare New Payment Payment Difference Freq 33975 Insert Single Extracorporeal XXX XXX 20.97 25.00 416 $296,038 $352,930 19% 33976 Insert Double Extracorporeal XXX XXX 33977 Remove Single Extracorporeal 90 XXX 33978 Remove BiVAD Extracorporeal 90 XXX 33979 Insert Single Intracorporeal XXX XXX 33980 Remove Single Intracorporeal 90 XXX 33981 Change Pump Et Extracorporeal XXX XXX 33982 Change Pump Intracorporeal XXX XXX 33983 Change Intracorporeal with CPB XXX XXX 22.97 30.75 71 $55,333 $74,075 34% 20.28 20.86 172 $118,791 $122,188 3% 22.72 25.00 39 $30,337 $33,382 10% 45.93 37.50 793 $1,237,349 $1,010,246 18% 65.19 33.50 223 $493,042 $253,365 49% NA 16.1111 8 Unknown $4,215 NA NA 37.86 3 Unknown $4,245 NA NA 44.54 21 Unknown $31,322 NA Grand Total $2,230,889 $1,885,967 15%
Ventricular Assist Devices - Replacements 33981 - Replacement of extra acorporeal ventricular assist device, single or biventricular, pump(s), single or each pump p 33982 - Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass 33983 - implantable intracorporeal, single ventricle, with cardiopulmonary bypass ALL ARE XXX GLOBAL PROCEDURES
VAD Rep lacements Procedure component in ncludes Replacement and insertion of pump ONLY Connection of new pump De-airing of new pump Initiation of new pump
Services Include ed in VAD XXX Valuation Same day pre-op E/M Procedure (insertion, rep placement or removal) Care through stabilization
VAD Removals Problem #1 You will receive less automatic payment for the procedures that have been revalued from 090 Globals to XXX codes Solution: Develop plans to capture (perform, document and bill) medically necessary E&M services for these and all l other XXX codes
33977 Remove Single VAD Extracorporeal Cd Code RVW Surveyed dvisitsit Total RVW 9291 (critical care first 30 74 mins) 4.5 2 9.00 9292 (critical care each add 30 mins) 2.2525 1 225 2.25 9233 (subsequent hospital visit) 2 5 10.00 9232 (subsequent hospital visit) 1.39 2 2.78 9231 (subsequent hospital visit) 0.76 4 3.04 9238 (discharge 30 minutes or less) 1.28 1 1.28 9239 (discharge >30 minutes 1.9 0 0.00 9214 (established patient office visit) 1.5 1 1.50 9213 (established patient office visit) 0.97 1 0.97 9212 (established patient office visit) 0.48 0 0.00 otal E&M Services RVW rocedure RVW otal Potential RVW 30.82 20.86 51.68 omparable Code 33430 Mitral Valve Replacement 50.93
Code 33978 Remove BiVAD Extracorporeal RVW 9291 (critical care first 30 74 mins) 4.5 9292 (critical i care each add 30 mins) 225 2.25 9233 (subsequent hospital visit) 2 9232 (subsequent hospital visit) 1.39 9231 (subsequent hospital visit) 0.76 9238 (discharge 30 minutes or less) 1.28 9239 (discharge >30 minutes 19 1.9 9214 (established patient office visit) 1.5 9213 (established patient office visit) 0.97 9212 (established patient office visit) 0.48 Total Surveyed Visits RVW 2 9.00 1 225 2.25 5 10.00 4 5.56 8 6.08 1 1.28 0 000 0.00 1 1.50 1 0.97 0 0.00 otal E&M Services RVW rocedure RVW otal Potential RVW omparable Code 33411 AVR with Annulus Enlargement 36.64 25.00 61.64 62.07
33980 Remove Single VAD Intracorporeal Code RVW Surveyed Visits Total RVW 99291 (critical care first 30 74 mins) 4.5 2 9.00 99292 (critical care each add 30 min ns) 225 2.25 1 225 2.25 99233 (subsequent hospital visit) 2 5 10.00 99232 (subsequent hospital visit) 1.39 5 6.95 99231 (subsequent hospital visit) 0.76 7 5.32 99238 (discharge 30 minutes or less) 1.28 1 1.28 99239 (discharge >30 minutes 1.9 0 0.00 99214 (established patient office visit) 1.5 1 1.50 99213 (established patient office visit) 0.97 1 0.97 99212 (established patient t office visi it) 048 0.48 1 048 0.48 Total E&M Services RVW Procedure RVW Total Potential RVW Comparable Code 37.75 33.50 71.25 Current Value as 090 65.20
VAD Remova al Problem #2 Value of 33976 has been reduced by 8.43 RVW or 18% Solution No solution if you are alr ready billing appropriate E&M However, value would be restored with two 99291 services (9.0 RVW) if you have not been taking advantage of the XXX global period to this point.
VAD Removal Problem #3 When VAD removal codes are performed with Heart Transplant, the reduced value will still be reduced 50%, but you will be within the Heart Transplant 090 global. This prevents billing additional E&M related to the Heart Transplant procedure Solution (minimal): Bill for new Dx related to VAD, use -24 or -25 Mo odifier
Unrelated VAD Care Examples Rare that will be able to removal care same day Wound care issues - Drive line site Bleeding related to the VAD pocket separate out VAD Residual medical compli cations from the VAD Care for embolus that occurred during explantation
Necessary Documentation To report any VAD related post op E/M Care All services MUST be cle early documented d Separate out care specific to VAD in op note and use that t documentation ti to sele ect codes Code levels and category selected based on VAD specific documentation Diagnosis for VAD should be different from 90 day global procedure diagnosi is Use appropriate modifiers to pull out of bundle
Possible E/M Codes for Follow-up VAD Care Established Patient Outpati ient Visits (99211-99215) 99215) Initial Hospital Care (99221 99223) Subsequent Hospital Care (99231-99233) Critical Care (99291 99292) VAD Interrogation Code (93750): Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report
Coding Based on Time Use instead of fkey Components ONLY WHEN OVER 50% of visit spent in face-to-face patient counseling or coordination of care Documentation includes time of overall visit Documentation includes time spent in counseling or coordination of care Documentation includes summary of the discussion Some codes are time based Follow CPT for time increments instead of component based
Critical Care Codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 99292 each additional separately in addition to 30 minutes (List 30 minutes (List code for primary service)
Critical Care Definitions Medicare and CPT Definition Care delivered directly by a physician for a critically ill or injured patient. A critically ill or injured patie ent tis defined das one that thas an illness or injury impairing one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition. Vital organ systems include (but are not limited to) failure of the central nervous system circulatory failure shock failure of the renal, metabolic, and/or respiratory systems
Critical Ca are Criteria The critical care codes are time based for each date and encounter. The critical i care time provided d to the patient does not need to be continuous; it can be cumulative over the course of the day. Time counted towards critical care must be time where the physician s s care is de evoted solely to the critically ill or injured patient. NO Care be provided to any other patients during time that is counted towards critical care.
Critical Care Considerations Considerations More than one physician can provide critical care at another time and be paid. Only one physician may bill for critical care during any single period of time, even if more than one physician i is present and providing care to a critically ill or injured patient. Use of fdifferent tdiagnosi is codes by different physicians involved in the patient s care, if appropriate, clarify that th he care does not overlap
E/M Modifiers -57 - Decision for Surgery -25 - Significant, Separa ately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service -24 - Unrelated Evaluati on and Management Service by the Same Physician During a Postoperative Period
Post-VAD Procedures No modifier necessary if not in global of another procedure Additional procedure starts new global period Once in new global, mod difiers to isolate care related to VAD if appropriate
Example - VAD Removal Patient no longer needs VAD supp port. Biventricular extracorporeal VAD is removed, The patient is moved to ICU in critical condition. Surgeon spends 90 minutes providing critical care services to patient throughout h the day and evening. Report 33978, 99291, 99292 Code 33978 would be reported extracorporeal device. for the removal of fthe biventricular i 99291 would be used for the fir rst 74 minutes of critical care services (minimum 31 minutes, otherwise use 99233) 99292 would be used for the additional 16 minutes of critical care services NOTE: documentation in coding scenario is not sufficient for reporting the critical care visits, detailed documentation must be provided
Example - VAD Removal with Transplant Implantable intracorporeal VAD removed, heart transplant performed, ASD on the donor heart repaired. Patient seen for level three subsequent hospital visit three days postop p in the ICU for bleeding along the suture line. Report 33945, 33641-51, 33980-51, 99233-24 33945 is reported at 100% for the heart transplant 33641-51 is reported with the 50% reduction for the ASD repair on the donor heart 33980-51 is reported for the intracorporeal VAD removal 99233-24 is reported for the subsequent hospital visit. A different dx from the heart transplant or ASD repair is required
Example VAD Insertion Patient has left ventricular failure, an intracorporeal VAD is placed. Patient is seen later that day in the ICU for 60 minutes of critical care. The next day the pa atient taken back to OR for bleeding. Report: First Day: 33979, 99291 Second Day: 35820
Example VAD Insertion with CABG Patient with CAD has tripl le CABG single arterial and two venous grafts. Patient has left ventricular failure and a single ventricular ex tracorporeal VAD is placed. Patient is seen later that day in the ICU for 90 minutes critical care. The next day patient is taken back to the OR for bleeding Report: First Day: 33533, 33975-51, 33518, 99291-25, 99292-25 Second Day: 35820-78 Note: Payers may not recognize the critical care isolated to VAD care on the same day, even with the -25 mo odifier since in the global of another procedure and it is related to the same organ system
You Must Develop a Plan Details of E&M coding and documentation beyond scope of our talk Work with your compliance officers and local educators Usually do not need to re-invent the wheel, as many physicians i in your organi ization derive all lltheir income from E&M Services Pay attention to other procedures and how effects VAD care and reporting Utilize modifiers to identify separately billable care