2014 Cordis Cardiac & Vascular Procedures Reimbursement Guide

2014 Cordis Cardiac & Vascular Procedures Reimbursement Guide

Table of Contents Description Page 1 Hospital Inpatient Issues 2 Hospital Inpatient Coding 4 Hospital Inpatient Reimbursement 8 Hospital Outpatient Issues 12 Hospital Outpatient Reimbursement 14 Ambulatory Surgery Center and Independent Diagnostic Testing Facility Issues 18 Physician Reimbursement Issues 22 Bundling NCCI and OCE Issues 23 CPT Coding Updates in Recent Years 25 Modifiers 29 Case Study Payment Examples 31 Disclaimer The information contained in this guide is provided to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Cordis Corporation concerning levels of reimbursement, payment or charge. Similarly, all CPT and HCPCS codes are supplied for information purposes only and represent no statement, promise or guarantee by Cordis Corporation that these codes will be appropriate or that reimbursement will be made. It is important to research coverage and payment for procedures on a payer-specific basis as coverage policies and guidelines vary by payer. The information in this guide is broad-based and intended to address a wide range of reimbursement situations that you may encounter. It references many different procedures and types of devices. Such a broad discussion is not intended to suggest or imply that Cordis offers products for every use or procedure discussed. As always, please refer to the package insert for a complete description of indications and contraindications for any medical device type mentioned in these materials prior to use. The case study examples are provided only to illustrate a possible reimbursement scenario. It is not intended as direction on how to conduct or code for a procedure. Individual procedures and corresponding codes will vary based on the physician s medical judgment and circumstances of the case. We trust you will find this guide useful. The guide is an example of the commitment of Cordis Corporation to providing quality products and services to our customers. For more information about Cordis Corporation, please visit us at www.cordis.com or contact our Customer Service department at 1-800-327-7714. Cordis Corporation 2014

2 HOSPITAL INPATIENT ISSUES Introduction to the 2014 Hospital Inpatient Prospective Payment System (IPPS) Final Rule On August 2, 2013, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for acute inpatient hospital services, detailing changes to Medicare payment rates and policies for fiscal year 20141. The final rule appeared in the August 19th Federal Register and will be effective for discharges on or after October 1, 2013. 1 Medicare previously adopted the Medicare Severity Diagnosis Related Group (MS-DRG) system to better account for patient severity of illness, expanding the number of payment groups from 538 to 745; there are now 751 MS-DRGs. The intent of the MS-DRG system is to more accurately stratify groups of Medicare patients with varying levels of severity than the prior DRG system by better aligning payments with the anticipated costs of care, and are assigned based upon the presence or absence of specific ICD-9-CM diagnosis codes indicating complications or comorbidities (CCs) and/or major complications or comorbidities (MCCs). Complications include all conditions that develop after inpatient admission which affect treatment and/or length of stay; cormorbidities are conditions which pre-exist at the time of admission. While most commercial insurers are also following MS-DRGs, some may utilize other reimbursement methods. 2 Among other key changes in the IPPS for FY 2014 are the following: 2 1) FY 2014 Inpatient Hospital Update: The final rule updates IPPS payment rates by 1.7% for hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program, which reflects a market basket increase of 2.5% reduced by several adjustment factors. 2) Quality Measure Reporting for 2014 Updates: Under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU), in effect since 2004, hospitals that choose not to participate or fail to meet criteria for successful reporting in a given year received the annual payment update (APU) reduced by 2.0%. The 2013 final rule reduced the number of measures in the IQR program from 72 to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination. 3 3) Hospital Readmissions Reduction Program: The Affordable Care Act established this program, under which payments to certain hospitals will be reduced to account for excess readmissions. Two new measures bring the total to five: acute myocardial infarction (AMI) or heart attack, heart failure, pneumonia, hip/knee arthroplasty, and chronic obstructive pulmonary disease. 4) Other Payment Policy Updates: The Final Rule also addresses operational details regarding: The Hospital Value-Based Purchasing (VBP) Program; Admissions and Medical Review Criteria for Inpatient Services; Part B Rebilling for Inpatient Services in Hospitals later determined to be outpatient stays; Medicare Disproportionate Share Hospitals (DSH) payments; and Direct Graduate Medical Education (DGME). Expiring provisions include: the Medicare-Dependent Hospital (MDH) Program, and Affordable Care Act changes to the Low-Volume Hospital Payment Adjustment. 1 October 1, 2013 through September 30, 2014. 2 Centers for Medicare and Medicaid Services Fact Sheet: CMS Finalizes FY 2014 Policy and Payment Changes for Inpatient Stays in Acute-Care and Long-Term Hospitals; August 2, 2013; http://www.cms.gov/newsroom/mediareleasedatabase/fact- Sheets. 3 Centers for Medicare and Medicaid Services Fact Sheet: CMS Final Rule to Improve Quality of Care During Hospital Inpatient Stays; August 2, 2013; http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets.

3 5) Quality Reporting Programs: The Affordable Care Act called for CMS to create new quality reporting programs for two types of hospitals that are exempt from payment under the IPPS. The Hospital IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups. By statute, annual payment updates for hospitals that do not participate successfully in the Hospital IQR program are reduced by 2.0 percentage points. Beginning with fiscal year 2015, hospitals that do not participate will lose one-quarter of the percentage increase in their payment updates. Since the implementation of this financial penalty, hospital participation has increased to well over 99 percent. For the FY 2016 payment determination and subsequent years, CMS will remove six chart abstracted measures and one structural measure. We will suspend one chart-abstracted measure and adopt five new claims-based measures: (1) 30-day risk-standardized COPD Readmission; (2) 30-day risk standardized COPD mortality; (3) 30- day risk standardized stroke readmission; (4) 30-day risk standardized stroke mortality; and (5) AMI payment per episode of care. In the final rule, CMS finalizes a policy to validate two new chart- abstracted Healthcare Associated Infections measures: hospital-onset methicillin-resistant staphylococcus aureas (MRSA) bacteremia, and clostridium difficile. CMS is also finalizing a proposal to reduce the number of records used for HAI validation from 48 records per year to 36 records per year beginning with the FY 2015 payment determination and to provide hospitals with the option to transmit secure electronic versions of medical information to meet validation requirements. 6) Hospital Acquired Conditions: The FY 2014 hospital payment rule finalizes the general framework for the Hospital- Acquired Condition (HAC) Reduction Program for the FY 2015 implementation. Section 3008 of the Affordable Care Act requires CMS to establish a program for IPPS hospitals to improve patient safety, by imposing financial penalties on hospitals that perform poorly with regard to hospital-acquired conditions. HACs are conditions that patients did not have when they were admitted to the hospital, but which developed during the hospital stay. Under the HAC Reduction Program, hospitals that rank in the lowest-performing quartile of hospital-acquired conditions will be paid 99 percent of what otherwise would have been paid under IPPS, beginning in FY 2015. The rule finalizes the quality measures and the scoring methodology to determine this quartile, as well as the process hospitals will use to review and correct their data. In the first year of the program, FY 2015, CMS will use measures that are part of the IQR program. The HAC measures will consist of two domains of measure sets. Domain 1 will include the Agency for Health Care Research and Quality (AHRQ) composite PSI #90. This measure includes the following indicators: Pressure ulcer rate (PSI 3); Iatrogenic pneumothorax rate (PSI 6); Central venous catheter-related blood stream infection rate (PSI 7); Postoperative hip fracture rate (PSI 8); Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12); Postoperative sepsis rate (PSI 13); Wound dehiscence rate (PSI 14); and Accidental puncture and laceration rate (PSI 15). Domain 2 measures consist of two healthcare-associated infection measures developed by the Centers for Disease Control and Prevention s (CDC) National Health Safety Network: Central Line-Associated Blood Stream Infection and Catheter-Associated Urinary Tract Infection. Hospitals will be given a score for each measure within the two domains. A domain score will be calculated with Domain 1 weighted at 35 percent and Domain 2 weighted at 65 percent to determine a total score under the program. Risk factors such as the patient s age, gender, and comorbidities will be considered in the calculation of the measure rates so that hospitals serving a large proportion of sicker patients will not be penalized unfairly. Hospitals will be able to review and correct their information. 7) Never Events: CMS has also implemented a policy to not pay for medical care that harms patients or leads to complications that could have been prevented involving three identified Never Events. For dates of service on or after January 15, 2009, hospitals should submit the non-covered TOB 110, clearly indicating in Remarks one of the applicable 2-digit surgical error codes: MX: MY: MZ: Wrong Surgery on Patient Surgery on Wrong Body Part Surgery on Wrong Patient

4 Hospital Inpatient Coding Medicare uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify diagnoses and procedures in the hospital inpatient setting. Hospitals must report the principal diagnosis using an appropriate ICD-9-CM code, as well as any secondary diagnoses some of which may be considered CCs or MCCs for MS-DRG assignment. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The circumstances of inpatient admission always govern the selection of principal diagnosis. 4 Diagnosis codes should be reported to the highest level of specificity available a code is invalid if it has not been coded to the full number of digits required for that code. A minimum of one diagnosis code is required on all claims, and it is possible to report up to eighteen. Medicare may require additional clinical information specific to each patient to determine coverage and payment for the reported procedure. Table 1 includes ICD-9-CM diagnosis codes commonly used to report peripheral vascular and cerebrovascular conditions: Table 1: Common ICD-9-CM Diagnosis Codes Peripheral Vascular Conditions Diagnosis Code 5 Description 415.19 Pulmonary embolism and infarction, other 416.2 Chronic pulmonary embolism 433.10 Occlusion and stenosis of carotid artery, without mention of cerebral infarction 433.11 Occlusion and stenosis of carotid artery, with cerebral infarction 433.30 Occlusion and stenosis of precerebral arteries, multiple and bilateral, without mention of cerebral infarction 433.31 Occlusion and stenosis of precerebral arteries, multiple and bilateral, with cerebral infarction 440.0 Atherosclerosis of aorta 440.1 Atherosclerosis of renal artery 440.20 440.29 Atherosclerosis of native arteries of the extremities 440.4 Chronic total occlusion of artery of the extremities 440.8 Atherosclerosis of other specified vessels 443.9 Peripheral vascular disease, unspecified 444.21 444.22 Arterial embolism and thrombosis of the extremities 444.81 444.89 Arterial embolism and thrombosis of other specified arteries 445.01 445.89 Atheroembolism 447.1 Stricture of artery 447.3 Hyperplasia of renal artery 453.40 453.89 Acute / chronic venous embolism and thrombosis of vessels of various specified sites 459.0 Hemorrhage, unspecified 4 The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40. 5 International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD-9-CM Tabular Addenda, National Center for Health Statistics, June 10, 2011. Note that there are no ICD-9-CM diagnosis code changes or relevant ICD-9-CM procedure code changes for FY 2014, reflecting the partial code freeze in preparation for transition ICD-10-CM and ICD-10-PCS in October 2014.

5 Table 2 includes ICD-9-CM diagnosis codes commonly used to report cardiac conditions: Table 2: Common ICD-9-CM Diagnosis Codes Cardiac Conditions Diagnosis Code Description 410.00-410.92 Acute myocardial infarction 411.0-411.89 Other acute and subacute forms of ischemic heart disease 413.0-413.9 Angina pectoris 414.00-414.05 Coronary atherosclerosis 414.2 Chronic total occlusion of coronary artery 414.3 Coronary atherosclerosis due to lipid rich plaque 414.4 Coronary atherosclerosis due to calcified coronary lesion 414.8 Other specified forms of ischemic heart disease 414.9 Chronic ischemic heart disease, unspecified For inpatient admissions involving procedures, hospitals must also report ICD-9-CM procedure code(s) for the surgical and other procedures, up to six procedures on a claim. Medicare recognizes certain ICD-9-CM procedure codes used in the inpatient setting to report percutaneous angiography, angioplasty, stenting, and other procedures. The following two tables list some of the most commonly used codes for cardiovascular diagnostic and therapeutic procedures. Table 3: Common ICD-9-CM Procedure Codes Diagnostic Procedures Procedure Code 6 Description Head and Neck Vessels 88.41 Arteriography of cerebral arteries 88.61 Phlebography of veins of head and neck using contrast material Peripheral Vascular 00.67 Intravascular pressure measurement of intrathoracic arteries 00.68 Intravascular pressure measurement of peripheral arteries 00.69 Intravascular pressure measurement, other specified and unspecified vessels 38.25 Intravascular imaging of non-coronary vessel(s) by optical coherence tomography 88.40 Arteriography using contrast material, unspecified site 88.42 Aortography 88.43 Arteriography of pulmonary arteries 88.44 Arteriography of other intrathoracic vessels 88.45 Arteriography of renal arteries 88.47 Arteriography of other intra-abdominal arteries 88.48 Arteriography of femoral and other lower extremity arteries 88.49 Arteriography of other specified sites 88.60 Phlebography using contrast material, unspecified site 88.62 Phlebography of pulmonary veins using contrast material 88.63 Phlebography of other intrathoracic veins using contrast material 88.65 Phlebography of other intra-abdominal veins using contrast material 88.66 Phlebography of femoral and other lower extremity veins using contrast material 88.67 Phlebography of other specified sites using contrast material Coronary Vessels and Cardiac Imaging 37.21 Right heart cardiac catheterization 37.22 Left heart cardiac catheterization 37.23 Combined right and left heart cardiac catheterization 38.24 Intravascular imaging of coronary vessel(s) by optical coherence tomography 88.50 88.57 Angiocardiography using contrast material 6 Ibid.

6 Table 4: Common ICD-9-CM Procedure Codes -- Cardiovascular Interventional Procedures and IVUS Procedure Code Description Head and Neck Vessels 00.21 Intravascular imaging of extracranial cerebral vessels 00.61 Percutaneous angioplasty of extracranial vessel(s) 00.63 Percutaneous insertion of carotid artery stent(s) 00.64 Percutaneous insertion of other extracranial artery stent(s) 17.53 Percutaneous atherectomy of extracranial vessel(s) 39.74 Endovascular removal of obstruction from head and neck vessel(s) 39.79 Other endovascular procedures on other vessels 39.90 Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Peripheral Vascular 00.22 Intravascular imaging of intrathoracic vessels 00.23 Intravascular imaging of peripheral vessels 00.25 Intravascular imaging of renal vessels 00.28 Intravascular imaging, other specified vessel(s) 00.55 7 Insertion of drug-eluting stent(s) of other peripheral vessel(s) 00.60 Insertion of drug-eluting stent(s) of superficial femoral artery 17.56 Atherectomy of other non-coronary vessels 38.7 Interruption of the vena cava 39.50 Angioplasty of other non-coronary vessel(s) 39.90 Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Coronary Vessels 00.24 Intravascular imaging of coronary vessels 00.49 Super-saturated oxygen therapy 00.59 Intravascular pressure measurement of coronary arteries 00.66 Percutaneous transluminal coronary angioplasty [PTCA] 17.55 Transluminal intracoronary atherectomy 36.04 Intracoronary artery thrombolytic infusion 36.06 Insertion of non-drug-eluting coronary artery stent(s) 36.07 Insertion of drug-eluting coronary artery stent(s) 36.09 Other removal of coronary artery obstruction Injections / Infusions and Other Supportive Therapies 37.61 Insertion of pulsation balloon 37.68 Insertion of percutaneous external heart assist device 99.10 Injection or infusion of thrombolytic agent 99.19 Injection of anticoagulant 99.20 Injection or infusion of platelet inhibitor 97.44 Nonoperative removal of heart assist system Additional procedure codes relevant to vascular procedures are the adjunct vascular system procedure codes, which indicate multi-vessel and multi-stent procedures. These codes can apply to both coronary and peripheral vessels, and should be used in conjunction with other therapeutic procedure codes to provide additional information on the number of vessels upon which a procedure was performed and/or the number of stents inserted. As appropriate, code both the number of vessels operated upon and the number of stents inserted. If a case involves a combination of coronary and non-coronary vessels, report the grand total number of vessels/stents treated during the admission. 7 Note that insertion of drug-eluting peripheral vessel stents and insertion of stents into extracranial vessels other than the carotid artery are still considered investigational by Medicare and are not covered. Medicare covers only those repair devices that are FDA approved. There are other devices which may be under investigational development. If a device is listed on the Category B device exemption lists, special procedures must be followed to receive payment by Medicare.

7 Procedure Code Table 5: Common ICD-9-CM Procedure Codes -- Adjunct Vascular System Procedures Description 00.40 Procedure on single vessel 00.41 Procedure on two vessels 00.42 Procedure on three vessels 00.43 Procedure on four or more vessels 00.44 Procedure on vessel bifurcation 00.45 Insertion of a single stent 00.46 Insertion of two stents 00.47 Insertion of three stents 00.48 Insertion of four or more stents Note that ICD-9-CM procedure code 00.44 is used to describe the performance of a procedure across or involving a vessel bifurcation; it does not indicate a specific bifurcation stent or other device. This code is typically reported only once per operative session, regardless of the number of vessel bifurcations. Revenue Codes Revenue codes allow hospitals to categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. Sample revenue codes that hospital facilities may use to track costs for services associated with endovascular, non-vascular procedures are listed in the following table: Revenue Code 8 Description 0210 0219 Accommodations, Coronary Care Table 6: Common Revenue Codes 0278 Medical/Surgical Supplies and Devices, Other Implant 0321 Diagnostic Radiology - Angiocardiography 0323 Diagnostic Radiology Arteriography 0360 Operating Room Services, General Classification 0481 Cardiac Catheterization Lab 0621 0622 Supplies Incident to Radiology / Other Diagnostic Services 0732 Electrocardiogram - Telemetry 0921 Peripheral Vascular Lab 8 Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set, 75.4 - Form Locator 42; http://www.cms.gov/manuals/downloads/clm104c25.pdf.

8 Hospital Inpatient Reimbursement Medicare beneficiaries who are admitted into hospital inpatient settings typically have coverage through Medicare Part A. Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on diagnosis-related groups (DRGs), now MS-DRGs. The MS-DRG payment system groups similar diagnoses into a single payment level, and reimburses the hospital according to the extent of resources typically required to treat patients with similar diagnoses undergoing similar treatments. All services and supplies provided during the inpatient admission are bundled into a single MS-DRG reimbursement rate, regardless of the length of the inpatient stay, the intensity of treatments, or the number of procedures performed for the specific individual. Hospitals will receive one global MS-DRG payment rate per patient admission, and the MS-DRG assignment is primarily determined by the patient s principle diagnosis and/or principal procedure performed. Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) Beginning October 1, 2007, Medicare revised the entire DRG system to better reflect the severity levels of inpatient treatments. Hospitals performing procedures for Medicare patients now receive payment under the new MS-DRG assignments and MS-DRGs are now distinguished between encounters with or without CCs or MCCs. MCCs better recognize hospital resource use based on secondary diagnoses. These conditions generally correspond to longer and more complicated inpatient stays due to a need for services such as intensive monitoring, expensive and technically complex procedures, and/or extensive nursing care. Secondary conditions documented in a patient s medical record may impact the reimbursement a hospital receives. While there are typically only two levels of MS-DRG for coronary procedures, with or without MCC, some endovascular MS-DRGs include reference to CCs. Under the MS-DRG system, a CC or MCC must represent a secondary diagnosis in combination with the principal diagnosis. Beginning with FY 2013, documenting and reporting the diagnosis of chronic total occlusion (CTO) of artery of the extremities (ICD-9-CM code 440.4) can significantly affect reimbursement to the hospital for peripheral interventions, as this is now recognized as a CC. The following two tables provide diagnosis codes that may be cormorbidities in cardiovascular patients, which have been identified as CCs or MCCs and may therefore affect MS-DRG assignment.

9 Table 7: Partial List of ICD-9-CM Codes Complications and Cormorbidities (CCs) 9 Diagnosis Code 10 Description 263.0, 263.1 Malnutrition of moderate or mild degree 263.8, 263.9 Other and unspecified protein-calorie malnutrition 276.0 276.3 Hypernatremia, hyponatremia, acidosis, alkalosis 401.0 Malignant essential hypertension 402.00, 402.01 Malignant hypertensive heart disease, with or without heart failure 403.00, 403.01 Hypertensive chronic kidney disease, malignant 403.11, 403.91 Hypertensive chronic kidney disease, benign or unspecified, with chronic kidney disease stage V or end stage renal disease 404.00 404.03 Hypertensive heart and chronic kidney disease, malignant 404.11 404.13, 404.91 404.93 Hypertensive heart and chronic kidney disease, benign or unspecified, with heart failure and/or chronic kidney disease stage V or end stage renal disease 405.01, 405.09 Malignant renovascular or other secondary hypertension 411.0 411.89 Other acute and subacute forms of ischemic heart disease 416.0 Primary pulmonary hypertension 416.2 Chronic pulmonary embolism 425.0 425.9 Cardiomyopathy 427.0 Paroxysmal supraventricular tachycardia 427.1 Paroxysmal ventricular tachycardia 427.32 Atrial flutter 428.1 Left heart failure 428.20, 428.22, Unspecified or chronic systolic, diastolic, or combined systolic and diastolic heart failure 428.30, 428.32, 428.40, 428.42 435.0, 435.1, 435.2, 435.3 Basilar artery syndrome, vertebral artery syndrome, subclavian steal syndrome, or vertebrobasilar artery syndrome 435.8, 435.9 Other specified or unspecified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437.1 Other generalized ischemic cerebrovascular disease 440.24 Atherosclerosis of native arteries of the extremities with gangrene 440.4 Chronic total occlusion of artery of the extremities 444.0 440.9 Arterial embolism and thrombosis of aorta, artery of upper or lower extremity, iliac artery, other specified artery, or unspecified artery 445.01 445.89 Atheroembolism 447.2 Rupture of artery 453.40 453.89 Acute / chronic venous embolism and thrombosis of vessels of specified sites 493.01, 493.02, 493.11, 493.12, Extrinsic or intrinsic or chronic obstructed or unspecified asthma with status asthmaticus or (acute) exacerbation 493.21, 493.22, 493.91, 493.92 518.83 Chronic respiratory failure 584.9 Acute kidney failure, unspecified 585.4, 585.5 Chronic kidney disease, Stage IV or V 599.0 Urinary tract infection, site not specified 682.0 682.9 Cellulitis and abscess of various specified sites 707.10 707.19 Ulcer of lower limb 782.4 Jaundice, unspecified, not of newborn 996.1 Mechanical complication of other vascular device, implant, and graft 996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft 996.74 Other complications due to other vascular device, implant, and graft 997.1, 997.2 Cardiac or peripheral vascular complications, not elsewhere classified V85.0, V85.4X Body Mass Index less than 19, or 40 and over, adult 9 Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 6J - CC List; http://www.cms.gov/acuteinpatientpps/ (under Acute Inpatient Files for Download) 10 Ibid; International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD- 9-CM Tabular Addenda, National Center for Health Statistics, June 10, 2011.

10 Table 8: Partial List of ICD-9-CM Codes Major Complications and Cormorbidities (MCCs) 11 Diagnosis Code 12 Description 249.10-249.31 Secondary diabetes mellitus with ketoacidosis, hyperosmolality or other coma 250.10 250.33 Diabetes mellitus with ketoacidosis, hyperosmolality or other coma 410.X1 Acute myocardial infarctions, initial episode of care 414.12 Dissection of coronary artery 415.1X Pulmonary embolism and infarction 427.41 427.42 Ventricular fibrillation, ventricular flutter 427.5 Cardiac arrest 428.21, 428.23 Acute or acute on chronic systolic heart failure 428.31, 428.33 Acute or acute on chronic diastolic heart failure 428.41, 428.43 Acute or acute on chronic combined systolic and diastolic heart failure 441.00-441.01 Dissection of aorta, unspecific site or thoracic 433.01, 433.11, Occlusion and stenosis of precerebral arteries with cerebral infarction 433.21, 433.31, 433.81, 433.91 441.00, 441.01, Dissection of aorta, unspecified site, thoracic, abdominal, or thoracoabdominal 441.02, 441.03 443.21, 443.22, Dissection of artery: carotid, iliac, renal, vertebral, or other artery 443.23, 443.24, 443.29 453.2 Other venous embolism and thrombosis of inferior vena cava 585.6 End stage renal disease 674.50 674.54 Peripartum cardiomyopathy 707.23, 707.24 Pressure ulcer, stage III or stage IV 785.51 785.59 Cardiogenic, septic, or other shock without mention of trauma 901.0 904.42 Traumatic injuries to specified blood vessels 995.91 995.94 Sepsis, severe sepsis, systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction 998.01 Postoperative shock, cardiogenic Five diagnoses which are closely associated with patient mortality are assigned different CC subclasses, depending upon whether the patient is discharged alive or deceased. These diagnoses are: 427.41 -- Ventricular fibrillation 427.5 -- Cardiac arrest 785.51 -- Cardiogenic shock 785.59 -- Other shock without mention of trauma 799.1 -- Respiratory arrest These diagnoses are assigned an MCC subclass for patients who are discharged alive, and a non-cc subclass for patients who expire. Table 9 below lists common MS-DRGs which may be assigned when conducting endovascular procedures, including peripheral angioplasty and/or stenting or placing a vena cava filter, in the inpatient setting. 11 Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 6I - MCC List; http://www.cms.hhs.gov/acuteinpatientpps/ (under Acute Inpatient Files for Download) 12 Ibid; International Classification of Diseases, Ninth Revision, Clinical Modification, 2012 Professional, Ingenix, 2011; and ICD- 9-CM Tabular Addenda, National Center for Health Statistics, June 10, 2011.

11 MS-DRG Description Table 9: Common MS-DRGs for Endovascular Procedures 13 2014 Relative Weight 2014 National Average Payment 14 034 Carotid artery stent procedure with MCC 3.4145 $19,803 035 Carotid artery stent procedure with CC 2.1781 $12,632 036 Carotid artery stent procedure without CC/MCC 1.7224 $9,989 166 Other respiratory system O.R. procedures with MCC 3.6741 $21,308 167 Other respiratory system O.R. procedures with CC 1.9860 $11,518 168 Other respiratory system O.R. procedures without CC/MCC 1.3101 $7,598 252 Other vascular procedures with MCC 3.1477 $18,255 253 Other vascular procedures with CC 2.5172 $14,599 254 Other vascular procedures without CC/MCC 1.7012 $9,866 299 Peripheral vascular disorders with MCC 1.3647 $7,915 300 Peripheral vascular disorders with CC 0.9666 $5,606 301 Peripheral vascular disorders without CC/MCC 0.6681 $3,875 673 Other kidney and urinary tract procedures with MCC 3.1150 $18,066 674 Other kidney and urinary tract procedures with CC 2.2378 $12,978 675 Other kidney and urinary tract procedures without CC/MCC 1.3807 $8,007 Table 10 below lists common MS-DRGs which may be assigned when conducting coronary procedures or inserting coronary devices in the inpatient setting: MS-DRG Description Table 10: Common MS-DRGs for Coronary Procedures 2014 Relative Weight 2014 National Average Payment 246 Percutaneous cardiovascular procedure with drug-eluting stent with MCC or 4+ vessels/stents 3.1830 $18,460 247 Percutaneous cardiovascular procedure with drug-eluting stent without MCC 2.0408 $11,836 248 Percutaneous cardiovascular procedure with non-drug-eluting stent with MCC or 4+ vessels/stents 2.9479 $17,097 249 Percutaneous cardiovascular procedure with non-drug-eluting stent without MCC 1.8245 $10,581 250 Percutaneous cardiovascular procedure without coronary artery stent with MCC 2.9881 $17,330 251 Percutaneous cardiovascular procedure without coronary artery stent without MCC 1.9737 $11,447 286 Circulatory disorders except acute myocardial infarction, with cardiac catheterization with MCC 2.1058 $12,213 287 Circulatory disorders except acute myocardial infarction, with cardiac catheterization without MCC 1.0866 $6,302 13 Centers for Medicare and Medicaid Services, FY14 Final Notice Data, Table 5 - List of Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay; http://www.cms.gov/acuteinpatientpps/ (under Acute Inpatient Files for Download) 14 MS-DRG national average payments were calculated with a base rate of $5.799.59 using the national adjusted operating standardized amounts and the capital standard federal payment rate as issued in the Medicare Inpatient Prospective Payment System Final Rule issued by CMS on August 2, 2013 [CMS-1599-F] and published in the Federal Register on August 19, 2013; Tables 1A and 1D, Table 5, and assume that all hospitals are receiving the full 1.7% quality reporting update. Actual payment may vary based on various hospital-specific factors not reflected in the source data.

12 HOSPITAL OUTPATIENT ISSUES Introduction to the 2014 Outpatient Prospective Payment System (OPPS) Final Rule On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) released the 2014 Final Rule updating the hospital outpatient prospective payment system (OPPS) 15. Medicare reimburses outpatient hospital services under the OPPS, which bases payment on Ambulatory Payment Classifications (APCs), groups of clinical services, supplies, drugs, and devices that are similar clinically and in terms of resource costs. CMS mandated several changes in the OPPS beginning in 2008, including bundling of imaging and ancillary services into an intervention payment and new hospital outpatient quality measures; these initiatives are continuing for CY 2014. Expanded Bundling of Services In order to encourage the efficient use of resources, CMS has continued to extend the packaging approach to reimbursement in the hospital outpatient setting. Since January 1, 2008, CMS has been bundling payment for items and services that are usually ancillary and supportive into payment for the primary diagnostic or therapeutic outpatient services. This was considered by Medicare as a first step toward additional service bundling and creation of larger payment groups for hospital outpatient care in future years. For 2014, CMS finalizes five new categories of supporting items and services rather than the seven proposed. These categories are: Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure; Drugs and biologicals that function as supplies; when used in a surgical procedure, including skin substitutes. Skin substitutes will be classified as either high cost or low cost and will be packaged into the associated surgical procedures with other skin substitutes of the same class; Certain clinical diagnostic laboratory tests; Certain procedures described by add-on codes; Device removal procedures. In addition to packaging these five categories, CMS finalizes its proposal to create 29 comprehensive APCs to replace 29 existing device-dependent APCs, but with a modification to apply a complexity adjustment for the most complex multiple device claims. CMS is delaying the implementation of these comprehensive APCs until CY 2015. In 2008, Medicare reclassified nearly 200 procedures as always or frequently bundled into reimbursement for another procedure. Due to these changes, guidance imaging for implantation of Cordis products is not reimbursed separately. Reimbursement for the surgical Ambulatory Payment Classifications (APCs) now includes payment for these supportive services, including intravascular ultrasound (IVUS), angiography, and other types of radiology supervision and interpretation. Beginning in 2009, CMS changed how it pays for imaging services when two or more imaging procedures from certain imaging families are provided in one session. The final rule created five imaging composite APCs (such as multiple computed tomography (CT) procedures) performed in a single hospital session. The change applies to certain ultrasound procedures, CT and computed tomographic angiography (CTA) scans with or without contrast, and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) scans with or without contrast. Collapsing Five Levels of Visits to One. The 2014 final rule streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits. CMS did not finalize the proposal to replace the current five levels of codes for each type of emergency department visits, but intends to consider options to revise the codes for these services in future rulemaking. 15 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHF) Incentive Program; Provider Reimbursement Determinations and Appeals [CMS-1601-FC] was published in the December 10, 2013, Federal Register.

13 Hospital Outpatient Quality Data Reporting Program (HOP QDRP) The Tax Relief and Health Care Act of 2006 (TRHCA) required the Secretary of Health and Human Services to develop measures in order to assess the quality of care furnished by hospitals in outpatient settings. For services furnished on or after April 1, 2008, Medicare has required most hospitals to report data on hospital outpatient department quality measures. Similar to existing quality reporting requirements in the inpatient setting, hospitals that do not report these outpatient data points will not receive complete payments updates in 2014. The final 2014 Outpatient Prospective Payment System / Ambulatory Surgical Center Payment System (OPPS/ASC) rule includes a 1.7% annual inflation update for hospital outpatient departments (HOPDs); and adopts changes to payment policies for HOPDs and Ambulatory Surgical Centers (ASCs) beginning on January 1, 2014 16. The rule finalizes four new measures for the OQR program, affecting the CY 2016 payment determination and subsequent years, with data collection beginning in CY 2014 (OP-27, OP-29, OP-30, and OP-31 below). The final rule also removes two measures for the CY 2015 payment determination and subsequent years: Transition Record with Specified Elements Received by Discharged ED Patients (OP-19; and Cardiac Rehabilitation Measure: Patient Referral from an Outpatient Setting (OP-24) (NQF# 0643). OP-1 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-15 OP-17 OP-18 OP-20 OP-21 OP-22 OP-23 OP-25 OP-26 OP-27 OP-29 OP-30 OP-31 Table 11: Outpatient Quality Measures 17 Median Time to Fibrinolysis Fibrinolytic Therapy Received Within 30 Minutes of Arrival Median Time to Transfer for Primary Percutaneous Coronary Intervention (PCI) Aspirin at Arrival Median Time to Electrocardiogram (ECG) Timing of Antibiotic Prophylaxis Selection of Perioperative Antibiotic MRI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT Use of Contrast Material Thorax CT Use of Contrast Material The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache Tracking Clinical Results Between Visits Median Time from ED Arrival to ED Departure for Discharged ED Patients Door to Diagnostic Evaluation by a Qualified Medical Professional ED Median Time to Pain Management for Long Bone Fracture ED Patient Left without Being Seen Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stoke Who Received Head CT Scan Interpretation within 45 Minutes of Arrival Safe Surgery Checklist Use Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures Influenza Vaccination Coverage Among Healthcare Personnel Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average- Risk Patients Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use Cataracts Improvement in Patient s Visual Function within 90 Days Following Cataract Surgery 16 Centers for Medicare and Medicaid Services Fact Sheet: CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 2014, November 27, 2013; http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets 17 Hospital Outpatient Quality Reporting Specifications Manual, v6.0b; https://www.qualitynet.org, Hospitals-Outpatient, Specifications Manual.

14 The seven claims-based imaging measures are calculated by CMS using Medicare Part B claims data without imposing on hospitals the burden of additional chart abstraction. Although these measures may not be directly related to implantation of Cordis vascular products or other percutaneous vascular procedures, we felt it important to include discussion of them as hospitals that choose not to report on these measures will ultimately receive reduced payment for all procedures in 2014 and subsequent years. CMS has implemented a policy to not pay for medical care that harms patients or leads to complications that could have been prevented; this policy also affects service reporting for outpatient services. For dates of service on or after January 15, 2009, append one of the following applicable HCPCS modifiers to all lines related to the surgical error. PA PB PC Surgical or other invasive procedure on wrong body part Surgical or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient Hospital Outpatient Reimbursement Medicare beneficiaries who receive services in the hospital outpatient setting typically have coverage through Medicare Part B. Current Procedural Terminology 18 (CPT ) and Healthcare Common Procedure Coding System (HCPCS) codes map to APCs which assign a Medicare hospital outpatient payment rate for the service as illustrated in the example below: CPT Code APC maps to 37221 0229 maps to 2014 Estimated National Average Allowable 19 $ 9,120 Depending upon the services provided, hospitals may receive payment for more than one APC per patient encounter. If a claim contains services that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC. However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting. Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged. 18 2014 Current Procedural Terminology (CPT ), 2013 American Medical Association. CPT is a registered trademark of the American Medical Association. 19 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHF) Incentive Program; Provider Reimbursement Determinations and Appeals; Addendum B; http://www.cms.gov/hospitaloutpatientpps, CMS-1601-FC.

15 Device C-Codes In 2004, CMS reinstated the use of device C-codes for cost tracking purposes. 20 device C-codes that may apply to Cordis Corporation vascular products: The following table lists relevant Code Description C1714 Catheter, transluminal atherectomy, directional C1724 Catheter, transluminal atherectomy, rotational C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion / perfusion capability C1753 Catheter, intravascular ultrasound C1757 Catheter, thrombectomy / embolectomy C1760 Closure device, vascular (implantable / insertable) C1874 Stent, coated/covered, with delivery system 21 C1875 Stent, coated/covered, without delivery system C1876 Stent, non-coated/non-covered, with delivery system C1877 Stent, non-coated/non-covered, without delivery system C1880 Vena cava filter C1885 Catheter, transluminal angioplasty, laser C1884 Embolization protection system C1887 Catheter, guiding (may include infusion / perfusion capability) C1888 Catheter, ablation, non-cardiac, endovascular (implantable) C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Continuing in 2014, CMS requires hospitals to report C-codes on claims for devices used in procedures that are reimbursed under certain device-dependent APCs. This requirement is intended to allow CMS to better calculate the correct relative costs of device-dependent APCs in relation to other OPPS services. For example, the following endovascular and cardiovascular procedure codes require related device C-codes to be reported on the same claim: Endovascular revascularization of lower extremities (37220 37235) Transluminal balloon angioplasty, open (35458 35460) Transluminal balloon angioplasty, percutaneous (35470 35476) Transluminal atherectomy; open (35484 35485) Transluminal balloon angioplasty, percutaneous (35490 35495) Transcatheter retrieval of intravascular foreign body (37197) Transcatheter occlusion or embolization (37241 37244) Transcatheter placement of non-coronary stent(s) (37236 37239) Transcatheter placement of carotid artery stent with embolic protection (37215) Transluminal coronary balloon angioplasty (92920 92921) Transcatheter placement of intracoronary stent (92928 92929) Transcatheter coronary atherectomy (92924 92925) Transcatheter coronary atherectomy plus stent placement (92933 92934) Revascularization of or through a coronary artery bypass (92937 92938) Revascularization of acute total/subtotal occlusion during acute myocardial infarction (92941) Revascularization of a chronic total occlusion of coronary artery (92943 92944) Coronary interventions with drug-eluting intracoronary stent (G9600 G9608) 20 Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS), 61 - Billing for Devices Under the OPPS; http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf. 21 Medicare instructions indicate that drug-eluting stents should be reported using C1874. (Personal communication Cordis Corporation on file).

16 CMS will continue to review procedures to determine whether additional device-dependent edits are necessary, and may update the edits on a quarterly basis. 22 Hospitals are not required to report C-codes when performing procedures for non-device-dependent APCs, but they are encouraged to report the corresponding C-codes to support cost tracking and more appropriate APC payment in coming years. For vascular closure devices (VCDs), there is also a companion code for the act of placement: G0269 Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure, which accompanies the device code C1760. There is not a device-dependent edit for C1760 with any procedure, as a VCD is not always used. Hospital reimbursement for fixed fee payers (Medicare), incremental reimbursement for the use of the device is not available. Established rates of reimbursement are based on historical costs and therefore include the cost of these devices. Hospitals should bill payers when a VCD is used. Medicare establishes rates based upon the estimated cost of care rendered to a population of patients. Private payers contracting with hospitals are permitted to provide incremental reimbursement for the use of VCDs. The hospital must make a request with the payer. Although there is no separate payment available under the OPPS for most device C-codes, it is important for hospitals to report the C-code and an appropriate charge on their claims for each item provided. This claims data will be used by CMS to determine future APC payment rates and to ensure that the cost of associated devices is appropriately accounted for in each APC. Revenue Codes Hospitals must continue to assign a revenue code in addition to the C-code for each device reported on a claim. 23 Revenue codes which may be relevant for vascular procedures include: Code Description 0278 Medical/Surgical Supplies: Other Implants 0279 Medical/Surgical Supplies: Other Supplies/Devices 0321 Radiology - Diagnostic: Angiocardiography 0323 Radiology - Diagnostic: Arteriography 0481 Cardiology: Cardiac Catheterization Laboratory 0489 Cardiology: Other Cardiology 0621 0622 Supplies Incident to Radiology / Other Diagnostic Services 0921 Other Diagnostic Services: Peripheral Vascular Lab 22 A complete listing of the current procedure-to-device and device-to-procedure edits may be downloaded from the CMS website: http://www.cms.gov/hospitaloutpatientpps/02_device_procedure.asp#topofpage. 23 A revenue code to cost center crosswalk is available on the CMS website at: http://www.cms.gov/hospitaloutpatientpps, Annual Policy Files.

17 Status Indicators OPPS payment status indicators (SIs) indicate whether a service represented by a HCPCS or CPT code is payable under the OPPS or another payment system, and also whether particular OPPS policies apply to the code (eg, multiple procedure discounts or other payment reductions, full separate payment, or is a service packaged with another procedure). A total of twenty-three SIs are listed in the calendar year 2014 OPPS Final Rule; several relating to the hospital outpatient case examples provided in this guide are included below for reference. A complete list of SIs can be found in Addendum D1 of the CY 2014 OPPS Final Rule. 24 Common OPPS Status Indicators Indicator Item/Code/Service OPPS Payment Status C Inpatient Procedures Not paid under OPPS. Admit patient. Bill as inpatient. G Pass-Through Drugs and Biologicals Paid under OPPS; separate APC payment. H Pass-Through Device Categories Separate cost-based pass-through payment; not subject to copayment. K Non-Pass-Through Drugs and Nonimplantable Biologicals Paid under OPPS; separate APC payment. N Items and Services Packaged into APC Rates Paid under OPPS; payment is packaged into payment for other services, including outliers. Therefore, there is no separate APC payment. Q1 STVX-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, V, or X. (2) In all other circumstances, payment is made through a separate APC payment. Q2 T-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In all other circumstances, payment is made through a separate APC payment. Q3 Codes That May Be Paid Through a Composite APC Paid under OPPS; Addendum B displays APC assignments when services are separately payable. Addendum M displays composite APC assignments when codes are paid through a composite APC. (1) Composite APC payment based on OPPS compositespecific payment criteria. Payment is packaged into a single payment for specific combinations of service. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. Paid under OPPS; separate APC payment. S Significant Procedure, Not Discounted when Multiple T Significant Procedure, Multiple Paid under OPPS; separate APC payment. Reduction Applies V Clinic or Emergency Department Visit Paid under OPPS; separate APC payment. X Ancillary Services Paid under OPPS; separate APC payment. For codes with a SI of Q1, Q2, and Q3, the APC assignment is the standard APC to which the code would be assigned if it is paid separately when these procedures are performed in circumstances which do not meet the criteria of the package, reimbursement will be guided by the default status of the applicable APC. If there are multiple STVX and/or T packaged HCPCS codes on a specific date and no service with which the codes would be packaged on the same date, the code assigned to the APC with the highest payment rate will be paid. All other codes are packaged. 24 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum D1; http://www.cms.gov/hospitaloutpatientpps, CMS-1601-FC.

18 AMBULATORY SURGERY CENTER AND INDEPENDENT DIAGNOSTIC TESTING FACILITY ISSUES Introduction to the 2014 Ambulatory Surgery Center (ASC) Final Rule Since January 1, 2008, ambulatory surgery centers (ASCs) have been paid under a revised ASC payment system that aligns payment rates to those rates for similar services in the Hospital Outpatient Prospective Payment System (HOPPS) Ambulatory Payment Classifications (APCs) and extended payment to more surgical services in ASCs. To minimize the impact of the revised payment system, the revised ASC payment rates were phased in over four years, with CY 2011 being the final year of the transition. In general, the ASC payment rate for services is set at approximately 65% of the payment rate for the same service under the HOPPS, with some exceptions. For example, for device-intensive services (where device costs account for more than 50 percent of the total cost of the service), ASCs receive the same payment rate for the device cost as under the HOPPS, with payment for the service portion of the ASC rate calculated at the usual percentage rate of the corresponding OPPS service payment. ASCs will not typically bill separately for these devices. For ASC services that are predominantly performed in physicians offices, the ASC payment is capped at the amount the physician is paid under the MPFS for practice expenses for providing the same service in an office. CMS has assigned APC-based payment rates in an Ambulatory Surgery Center only to surgical procedure codes CPT codes in the range 10000 69999, plus a few Category III codes and so does not include cardiac catheterization codes. Radiology procedures, supplies, and devices are considered ancillary to the surgical procedure; while some are reimbursed additionally, no separate payment is made for angiographic imaging procedures. CMS continues to add or revise services in the list of ASC procedures for which payment may be made. However, those surgical procedures that would be expected to pose a significant safety risk to beneficiaries or that would be expected to require an overnight stay following the procedure are excluded from the ASC list. Therefore, there are certain procedures which may be considered appropriate for performance in a hospital outpatient setting, but for which Medicare does not provide reimbursement in an ASC for 2014, this includes certain endovascular interventional procedures. 25 PLEASE NOTE that some commercial insurers are still utilizing the former nine groupers for ASC payment calculations, or have devised their own groupers, and have not converted to the Medicare methodology. 25 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum EE -- Surgical Procedures to be Excluded from Payment in ASCs for CY 2014; http://www.cms.hhs.gov/hospitaloutpatientpps/, CMS-1601-FC, Addenda.

19 ASC Quality Measure Reporting Program The 2012 Final Rule implemented a new quality reporting program for ASCs. To allow CMS and ASCs to more effectively plan for future measurement requirements, this final rule adopts measures for three subsequent payment determinations. Specifically, CMS is adopting five quality measures to be reported by ASCs beginning October 1, 2012, for CY 2014 payment determination. These measures included four outcome and one surgical infection control measures to be reported by ASCs on Medicare claims using quality data codes. CMS added two structural measures: safe surgical checklist use and ASC facility volume data on selected ASC surgical procedures, beginning with reporting in CY 2013 for the CY 2015 payment determination; and one NHSN infection control measure: Influenza Vaccination Coverage among Healthcare Personnel, beginning with reporting in CY 2014 for the CY 2016 payment determinations. The 2014 Final Rule adopts the same two colonoscopy measures, as well as the cataract measure, for the ASCQR Program as were added to the Hospital Outpatient Quality Reporting Program for the CY 2016 payment determination and subsequent years. ASC-1: ASC-2: ASC-3: ASC-4: ASC-5: ASC-6: ASC-7: ASC-11: ASC Quality Measures for the CY 2016 Payment Determinations 26 Patient Burn* Patient Fall* Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant* Hospital Transfer/Admission* Prophylactic Intravenous IV Antibiotic Timing* Safe Surgery Checklist Use** ASC Facility Volume Data on Selected ASC Surgical Procedures*** Influenza Vaccination Coverage among Healthcare Personnel*** * Final new measure for the CY 2014 payment determination. ** Final new measure for the CY 2015 payment determination. *** Final new measure for CY 2016 payment determination. (Note: The selected ASC procedures identified in the 2012 Final Rule do not include any cardiovascular system codes (30000-39999). Ambulatory Surgical Center Measure G-Codes (QDCS) Measure Measure Description QDC ASC-1 Patient Burn G8908: Patient documented to have received a burn prior to discharge G8909: Patient documented not to have received a burn prior to discharge ASC-2 Patient Fall G8910: Patient documented to have experienced a fall within the ASC G8911: Patient documented not to have experienced a fall within the ASC ASC-3 ASC-4 ASC-5 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant Hospital Transfer/Admission Prophylactic IV Antibiotic Timing G8912: Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event G8913: Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event G8914: Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC G8915: Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC G8916: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time G8917: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time G8918: Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis G8907: Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event; or a hospital transfer or hospital admission upon discharge from the facility. Note: This code may be used in lieu of reporting individual codes for ASC-1 through ASC-4 if all are negative. 26 Centers for Medicare and Medicaid Services Fact Sheet: CMS Issues Outpatient Policy and Payment Changes; http:/www.cms.gov/apps/media/fact_sheets.asp.

20 Status Indicators ASC payment status indicators (SIs) indicate whether a service represented by a HCPCS or CPT code is payable under the ASC or another payment system, and also whether particular ASC policies apply to the code (eg, multiple procedure discounts or other payment reductions, full separate payment, or is a service packaged with another procedure). A total of eighteen SIs are listed in the calendar year 2014 ASC Final Rule. A complete list of SIs can be found in Addendum DD1 of the CY 2014 OPPS Final Rule. 27 Common ASC Status Indicators Indicator A2 G2 J7 J8 K2 N1 P2 P3 R2 Z2 Z3 ASC Payment Indicator Definition Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced. Device-intensive procedure; paid at adjusted rate. Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate. Packaged service/item; no separate payment made. Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight. Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS nonfacility PE RVUs. 27 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum DD1; http://www.cms.gov/hospitaloutpatientpps, CMS-1601-FC.

21 Independent Diagnostic Testing Facilities (IDTFs) A freestanding Cardiac Catheterization Clinic or Laboratory may be categorized as an Independent Diagnostic Testing Facility (IDTF). An IDTF is not allowed to bill Medicare for any CPT or HCPCS codes that are solely therapeutic. Therefore, interventional procedures are not appropriate to or covered when performed in an IDTF, which is more typically a setting for lower-risk, elective diagnostic procedures. Diagnostic catheterization procedures are often combined with PCI procedures during the same encounter if the diagnostic catheterization indicates a need for intervention. The alternative is a staged approach where the PCI is scheduled for a later visit. Patients who go to freestanding clinics or diagnostic-only hospitals do not have the option of a combined procedure, because the PCI must be performed at a different institution. However, not all patients are considered good candidates for a combined procedure. Although combined procedures may be less costly, they may place certain patients at higher risk of complications. 28 Physician treatment decisions should be made according to the most clinically appropriate choice for the individual patient. Medicare reimbursement to IDTFs will be according to the Medicare Physician Fee Schedule (MPFS) for the technical component of the procedure. 29 Although Independent Diagnostic Testing Facilities are not presently required to report quality measures, CMS has identified a set of Performance Standards which IDTFs must meet in order to maintain Medicare billing privileges. Among these standards is the requirement that the facility be truly independent both of an attending or consulting physician s office and of a hospital, and states, with the exception of hospital-based and mobile IDTFs, a fixed base IDTF does not include the following: (i) (ii) (iii) Sharing a practice location with another Medicare-enrolled individual or organization. Leasing or subleasing its operations or its practice location to another Medicare enrolled individual or organization. Sharing diagnostic testing equipment using in the initial diagnostic test with another Medicare-enrolled individual or organization. 30 The supervisory physician for the IDTF, whether or not for a mobile unit, may not order tests to be performed by the IDTF, unless the supervisory physician is the patient s treating physician and is not otherwise prohibited from referring to the IDTF. If a physician working for an IDTF (or a physician financially related to the IDTF through common ownership or control) orders a diagnostic test payable under the Medicare Physician Fee Schedule, the antimarkup payment limitation may apply. 31 28 Technology Assessment Report: Cardiac Catheterization in Freestanding Clinics; Agency for Healthcare Research and Quality (AHRQ); September 7, 2005; https://www.cms.gov/determinationprocess/downloads/id28ta.pdf. Referencing: Blankenship JC. Ethics in Interventional Cardiology: Combining Coronary Intervention with Diagnostic Catheterization. Am Heart Hosp J 2004 Winter;2(1):52-4. Kimmel SE, Berlin JA, Hennessy S, Strom BL, Krone RJ, Laskey WK. Risk of Major Complications from Coronary Angioplasty Performed Immediately after Diagnostic Coronary Angiography: Results from the Registry of the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol 1997 Jul;30(1):193-200. 29 Medicare Claims Processing Manual, Chapter 35 Independent Diagnostic Testing Facility (IDTF); http://www.cms.gov/manuals/downloads/clm104c35.pdf. 30 Independent Diagnostic Testing Facility (IDTF) Performance Standards; http://www.cms.gov. 31 Medicare Claims Processing Manual, Chapter 35 Independent Diagnostic Testing Facility (IDTF); http://www.cms.gov/manuals/downloads/clm104c35.pdf.

22 PHYSICIAN REIMBURSEMENT ISSUES Medicare Part B pays for physician services based upon the Medicare Physician Fee Schedule (MPFS). Fee schedule amounts are calculated according to the Resource-Based Relative Value Scale (RBRVS), which determines payment according to the relative resource costs needed to provide each service, quantified as relative value units (RVUs). The relative value for each code is divided into three components: physician work, practice expense [in either a facility (eg, inpatient or outpatient hospital) or non-facility (eg, office) setting], and professional liability insurance. Each of these components is modified by a geographic adjustment (GPCI) to reflect the variances in costs for differing localities. Payments are calculated by multiplying the geographically adjusted total relative values (resource costs) of a service by a conversion factor (CF) which is defined each year in the Final Rule. [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF = Payment On November 27, 2013, CMS issued its final policy changes for CY 2014 in the MPFS which included a 2014 Medicare physician payment update reducing the CF by 20.1% -- from $34.0230 to $27.2006 representing accumulated reductions of six years 32. On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013, which provides for a 0.5% update for claims with dates of services between January 1, 2014, through March 31, 2014 the new conversion factor is $35.8228. This law also extends the existing 1.0 floor on the physician work GPCI. On October 30, 2013, the House Ways and Means and Senate Finance Committees released a draft legislative proposal to permanently repeal the Medicare Sustainable Growth Rate (SGR) formula, which was under review and discussion at the time of this publication. Final provisions of this or other future legislation which may be passed are unknown, but may affect physician reimbursement rates beginning second quarter of 2014, possibly causing variances from the examples following. 32 Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014. CMS-1600-FC, published in the Federal Register on December 10, 2013; as amended by the Pathway for SGR Reform Act of 2013, enacted December 26, 2013.

23 Bundling NCCI and OCE Issues On October 1, 2007, CMS altered the Chapter notes for the National Correct Coding Initiative (NCCI) manual regarding multiple interventions within the same non-coronary vessel. This paragraph in Version 13.3 (Chapter 5, Item 16) stated: If an atherectomy fails to adequately improve blood flow and is followed by an angioplasty at the same site/vessel during the same patient encounter, only the successful angioplasty may be reported. Similarly if an angioplasty fails to adequately improve blood flow and is followed by an atherectomy at the same site/vessel at the same patient encounter, only the successful atherectomy may be reported. If atherectomy and/or angioplasty fail to adequately improve blood flow and are followed by a stenting procedure at the same site/vessel during the same patient encounter, only the successful stenting procedure may be reported. These principles apply to percutaneous or open procedures. Although no CCI computer edits were developed for the code pairs, this note revision indicated new CMS payment policy. After a number of entities requested this policy change be reconsidered, CMS indicated it would temporarily rescind this change, returning to the language initially published in 1996: When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the column one atherectomy procedure that was performed (generally the open procedure) is reported. This policy revision was made retroactive to October 1, 2007. The above paragraph appeared in Version 14.3 of the Manual, published in early October 2008 33. This language was revised again for Version 16.3, effective January 1, 2011: When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the more comprehensive atherectomy that was performed (generally the open procedure) should be reported (see sequential procedure policy, Chapter I, Section M). Effective January 1, 2011 there are new lower extremity endovascular revascularization procedure CPT codes which include in single codes various combinations of angioplasty, atherectomy, and/or placement of stent(s). In addition, effective January 1, 2011, Category I CPT codes for atherectomy of vessels in other anatomic sites are deleted and replaced by Category III CPT codes. Bundling issues may also affect reporting for other vascular cases for example, diagnostic imaging services in conjunction with vascular interventions: Open and percutaneous interventional vascular procedures include operative angiograms and/or venograms which should not be separately reported as diagnostic angiograms/venograms. The CPT Manual describes the circumstances under which a provider may separately report a diagnostic angiogram/venogram at the time of an interventional vascular procedure. A separately reportable diagnostic angiogram/venogram may be reported with modifier 59. If the code descriptor for a vascular procedure specifically includes diagnostic angiography, the provider should not separately report a diagnostic angiography code. 33 Letter from Correct Coding Solutions, LLC to AdvaMed, August 6, 2008, (Cordis Corporation on file). Complete current NCCI edits and 2014 Policy Manual narrative at http://www.cms.gov/nationalcorrectcodinited/.

24 If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the open or percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the open or percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 in addition to modifier 59 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the open or percutaneous intravascular interventional procedure. NCCI guidelines also provide the following instructions regarding catheter placements in conjunction with percutaneous interventions (note that the CPT includes additional bundling with regard to certain specific procedures): When a non-coronary percutaneous intravascular interventional procedure is performed on the same vessel at the same patient encounter as diagnostic angiography (arteriogram/venogram), only one selective catheter placement code for the vessel may be reported. If the angiogram and the percutaneous intravascular interventional procedure are not performed in immediate sequence and the catheter(s) are left in place during the interim, a second selective catheter placement or access code should not be reported. Additionally, dye injections to position the catheter should not be reported as a second angiography procedure. The NCCI edits are incorporated into the Outpatient Code Editor (OCE), and are therefore relevant for both outpatient hospital claims and physician professional claims. Bundling considerations may also apply to other combinations of procedures, and occasionally a code is defined in the Medicare Physician Fee Schedule as always bundled (status B ). For example, G0269 Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure. Reimbursement rates for diagnostic or interventional procedures are inclusive of access and closure, and so there is no additional reimbursement for this procedure. However, it is appropriate to report for statistical and tracking purposes.

25 CPT Coding Updates in Recent Years Significant restructuring of endovascular interventional procedure codes was undertaken by CPT in 2011, with additional revisions to cardiology and vascular procedures for 2012-2014. Endovascular Revascularization (37220 37235) Effective January 1, 2011, new lower extremity endovascular revascularization procedure CPT codes were introduced, which include in single codes various combinations of angioplasty, atherectomy, and/or placement of stent(s). 34 These new lower extremity codes no longer distinguish between open surgical exposure and percutaneous access. ALL codes in this series include angioplasty, either stand-alone or in conjunction with another type of intervention; angioplasty may not be separately reported. ALL codes in this series include selective catheter placement. Selective catheterization codes for the preceding diagnostic angiography may ONLY be reported if through a separate puncture site (distinct endpoint is now irrelevant). ALL codes in this section include imaging guidance to perform the intervention and for post-intervention documentation; embolic protection if used; and closure of the arteriotomy site by any method. Imaging codes for diagnostic angiography (eg, 75630, 75710, 75716, 75774) may be reported additionally; modifier -59 is required if on the same date/session. It is recommended modifier -59 be reported with ALL diagnostic angiography imaging codes immediately preceding intervention, regardless of anatomic site. These procedures all have APC status indicators of Q2 (T-packaged procedure), so the facility would not be paid separately with the interventional procedure. All codes are defined as unilateral report opposite leg with modifier -59, or use LT and -RT. Definitions are cumulative, and only one code will be reported per vessel, although multiple vessels may potentially be reported per case and receive separate APC payment (status indicator is T). Three anatomic territories are defined, each of which differ in coding options. Iliac Territory Includes common iliac, external iliac, and internal iliac each vessel treated may be reported separately (up to 3 per leg). Four new codes are found in this section defined by the criteria of: First vessel vs. subsequent vessel (in the same leg); and For each vessel, angioplasty only vs. stenting (with or without angioplasty). Femoral/Popliteal Vascular Territory ALL vessels from the common femoral through the popliteal are treated as a single vessel; only ONE intervention per leg is reported. Four code choices are available, based on all intervention(s) performed in the entire territory, which may be a combination of therapies on a combination of vessels/lesions: Angioplasty only; Atherectomy (with or without angioplasty); Stenting (with or without angioplasty); and Atherectomy plus stenting (with or without angioplasty). Tibial/Peroneal Territory Includes anterior tibial, posterior tibial, peroneal. Each vessel treated may be reported separately (up to 3 per leg); the tibioperoneal trunk is bundled into any intervention in either posterior tibial or peroneal; however, if interventions occur in tibioperoneal trunk and anterior tibial, the trunk may be reported separately. This territory contains eight code choices, defined by the criteria of: First vessel vs. subsequent vessel (in the same leg), each of which has 4 codes: Angioplasty only; Atherectomy (with or without angioplasty); Stenting (with or without angioplasty); and Atherectomy plus stenting (with or without angioplasty). 34 Current Procedural Terminology (CPT ) 2014, Professional Edition, American Medical Association, 2013. CPT is a registered trademark of the American Medical Association.

26 Category III Codes for Atherectomy (0234T 0238T) Effective January 1, 2011, atherectomy for all supra-inguinal vessels (including the iliac territory noted above) were deleted and replaced by Category III CPT codes, which may limit coverage by many payors. The Category III codes also do not differentiate between open vs. percutaneous access. These new codes include all radiological guidance, supervision and interpretation to perform the intervention. However it is appropriate to separately report access and selective catheterization; embolic protection, if used; and other intervention used to treat the same or other vessels (including iliac angioplasty or stenting with the new endovascular revascularization codes). Interventions in Other Vessels Codes for angioplasty (35450 35460 and 35471 35476) or stenting (37205 37208) in the aorta, brachiocephalic/subclavian artery and branches, renal or other visceral artery, or vein remain unchanged: o o o o o Open versus percutaneous access for angioplasty or stenting are different codes; Report selective catheterization separately; Report code for radiological guidance to perform the intervention; If angioplasty is performed for a distinct therapeutic intent, it may be reported in combination with stenting in the same vessel; CPT notes do not specifically prohibit reporting angioplasty with atherectomy; however, Medicare guidelines bundle report only atherectomy. Percutaneous carotid stenting with embolic protection (37215) also remains unchanged, and includes all ipsilateral selective catheterization and all diagnostic and guidance imaging. Diagnostic Cardiac Catheterization Diagnostic cardiac catheterization and angiography procedure codes were also significantly revised for 2011, deleting the majority of previous codes. Most of the new cardiac catheterization codes represent combination or packaged procedures, and in most instances, only ONE code will be reported which describes all elements of the procedure. The new diagnostic catheterization codes include injection of contrast and radiological imaging and supervision these are not longer reported as separate components. The code descriptors are cumulative, and the facility should select the code that describes all services performed. Procedures performed for patients with congenital heart disease continue to be reported with component codes for catheterization (93530-93533), with contrast injection and imaging reported separately with one or more of new codes in the range 93563-93568, and separate reimbursement is expected on physician claims. However, for outpatient hospital service reimbursement, these injection codes and certain other add-on procedures are designated as status N, and receive no additional APC payment Diagnostic cardiac catheterization procedures may be reported in conjunction with coronary intervention. Intravascular Vena Cava Filters For CPT 2012, three new codes were added relating to intravascular vena cava filters, identifying these percutaneous procedures as distinct from an open ligation of the inferior vena cava. The new procedure codes are also comprehensive packaged services, including vascular access, catheter placement, and radiological supervision and interpretation. Head and Neck Angiography Head and neck diagnostic catheterization and angiography procedures were restructured in 2013: Codes are all-inclusive, describing both catheter placement and imaging in a single code. Codes are cumulative all less selective catheter placement and imaging is bundled into more selective. The code descriptors stair step, and specific catheter location and extent of imaging (including distal runoff) are both identified. All codes include angiography of the cervicocerebral arch, when performed. All codes are unilateral report bilateral with modifier -50. If left and right sides not to same level of selectivity, report lesser code with modifier -59. Add-on codes exist for selective catheterizations of external carotid or additional intracranial branches of the internal carotid or vertebral circulatory systems.

Code Catheter Location Vessel(s) imaged 36221 Non-selective, thoracic aorta Extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral 36222 Common carotid or innominate Ipsilateral extracranial carotid 36223 Common carotid or innominate Ipsilateral intracranial carotid, includes extracranial carotid, when performed 36224 Internal carotid Ipsilateral intracranial carotid, includes extracranial carotid, when performed 36225 Subclavian or innominate Ipsilateral vertebral circulation 36226 Vertebral artery Ipsilateral vertebral circulation +36227 External carotid Ipsilateral external carotid circulation +36228 Each intracranial branch of the internal Selected vessel circulation carotid or vertebral arteries (eg, middle cerebral artery, posterior inferior cerebellar artery) Note: Codes 33221-33226 include angiography of the cervicocerebral arch, when performed; add-on codes 36227 and 36228 do not, as it would have been captured in a base code. Coronary Interventions CPT 2013 introduced significant revisions to coronary interventional procedures: Codes are cumulative. The PCI base code that includes the most intensive service(s) performed should be reported. New codes recognize the concepts of five major coronary arteries, with add-on codes for branch vessels. o Up to two coronary artery branches of the LAD, left circumflex, and right coronary arteries are recognized. The left main and ramus intermedius coronary arteries do not have recognized branches for reporting purposes. o A single graft with multiple sequential anastomoses is one vessel; a branching bypass graft (eg, Y graft) would be an additional branch. Distinct codes for interventions in or through a bypass graft, as well as PCI during an acute MI, or of a chronic total occlusion. Only one base code per major coronary artery or bypass graft is reported per vessel; others are reported as branch interventions. PCI of an additional major coronary or bypass graft should be reported using the applicable additional base code(s). However, Medicare valuation of these new procedures in the 2013 and 2014 Medicare Physician Fee Schedules identify additional branches as bundled procedures, which will not be reimbursed. By comparison, all of these CPT codes are valued in the Hospital Outpatient Prospective Payment System, as well as a series of mirrored C-codes (C9600 C9608), which describe the same family of procedures for any case involving drug-eluting stents. CPT Code Description 2014 Total RVUs 92920 Angioplasty, single vessel 15.67 + 92921 Angioplasty, additional branch Bundled 92924 Atherectomy, single vessel 18.64 + 92925 Atherectomy, additional branch Bundled 92928 Stent, single vessel 17.40 + 92929 Stent, additional branch Bundled 92933 Atherectomy + stent, single vessel 19.47 + 92934 Atherectomy + stent, additional branch Bundled 92937 PCI of or through bypass, any method(s) 17.39 + 92938 PCI of or through bypass, additional branch Bundled 92941 PCI of acute MI, all interventions, single vessel 19.51 92943 PCI of chronic total occlusion, any method(s) 19.51 + 92944 PCI of chronic total occlusion, additional branch Bundled Other Vascular Procedures 2013 Changes Transcatheter retrieval of intravascular foreign body. Two existing codes (surgical and radiological) were deleted and replaced with a single new code, 37197, which includes imaging guidance. 27

28 Transcatheter infusion: o o o Existing codes revised to state other than for thrombolysis. Codes for catheter exchange deleted. Four new codes added, all of which include imaging: 37211 Arterial infusion for thrombolysis, initial treatment day 37212 Venous infusion for thrombolysis, initial treatment day 37213 Arterial or venous, subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; 37214 cessation of thrombolysis including removal of catheter and vessel closure by any method Percutaneous Ventricular Assist Devices. Category III codes 0048T and 0050T have been deleted and replaced with four new codes for percutaneous ventricular assist devices. These codes include radiological supervision and interpretation. 33990 Insertion - arterial access only 33991 Insertion - both arterial and venous access, with transseptal puncture 33992 Removal at separate and distinct session from insertion 33993 Repositioning at separate and distinct session from insertion Percutaneous Aortic Valve Replacement. Category III codes 0256T - 0259T were deleted, and a family of five new codes were added for transcatheter placement of prosthetic aortic valves, which are differentiated by approach, as well as one new Category III code for an open thoracic approach other than transaortic. Transcatheter Stent Placement CPT 2014 revised coding for intravascular stent(s) for sites not otherwise classified, deleting existing codes for percutaneous or open stent placement (37205 37208), as well as radiological supervision and interpretation (75960), adding new codes which package the imaging and any angioplasty of the same vessel, and also distinguish arterial vs. venous placement and additional vessels at the same operative session. 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery + 37237 each additional artery (List separately in addition to code for primary procedure) 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial vein + 37239 each additional vein (List separately in addition to code for primary procedure) Vascular Embolization and Occlusion Codes 37204 and 37210 have been deleted in CPT 2014, and replaced with 4 new codes: 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) 37242 arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) 37243 for tumors, organ ischemia, or infarction 37244 for arterial or venous hemorrhage or lymphatic extravasation Other Vascular Procedures 2014 Changes Fenestrated Endovascular Repair of the Visceral and Infrarenal Aorta. Category III codes 0078T 0081T were deleted, and eight new codes introduced for multi-branching fenestrated prostheses. Carotid Artery Stent. One new code (37217) for open cervical carotid retrograde approach to place an intrathoracic carotid artery stent. New codes 93582 for transcatheter closure of patent ductus arteriosus, and 93583 for transcatheter septal reduction therapy.

29 Modifiers When submitting a particular service on a claim, it is sometimes necessary to report a modifier with the CPT code. A modifier allows a way to indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities. Some modifiers apply to either physician or hospital outpatient claims; some may only be relevant for one or the other. A complete list of modifiers is included in the HCPCS 35 and CPT 36 coding books; the concept of modifiers does not apply to ICD-9-CM procedure codes. In the table below is a list of some of the modifiers which may be common to procedures associated with Cordis products. Sample CPT / HCPCS Modifiers Modifier Description 22 Increased Procedural Service: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (eg, increased intensity, time, technical difficulty of procedure, severity of patient s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. 26 Professional Component: Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5 digit code. 51 Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated add-on codes (see Appendix D). 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. This provides a means of reporting reduced services without disturbing the identification of the basic service. 53 Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M care. 58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. 35 Healthcare Common Procedural Coding System (HCPCS) codes are developed by CMS and available in book form from several different publishers. 36 2014 Current Procedural Terminology (CPT ) Appendix A, 2013 American Medical Association. CPT is a registered trademark of the American Medical Association.

30 Modifier Description 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 25. 73 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. 74 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. 78 Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier -79. (For repeat procedures on the same day, see modifier -76.) CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device FC Partial credit received for replaced device LC Left circumflex coronary artery LD Left anterior descending coronary artery LT Left side (used to identify procedures performed on the left side of the body) LM Left main coronary artery RC Right coronary artery RI Ramus intermedius coronary artery RT Right side (used to identify procedures performed on the left side of the body) TC Technical component Note: Some of these modifiers may only be appropriate to services reported by certain types of providers (eg, physician professional services vs. facility claims).

31 CASE STUDY PAYMENT EXAMPLES The following case examples are based upon the 2014 Medicare national average or base reimbursement rates for inpatient hospital 37, outpatient hospital 38, ambulatory surgery center (ASC) 39, independent diagnostic testing facility (IDTF) 40, and physician professional services 41, without reflecting any geographic or other provider-specific payment adjustments. Please note that when a value listed under average Rate and average Payment are not identical, this indicates that a multiple procedure payment adjustment, APC status indicator, or other edit will affect reimbursement. 37 MS-DRG national average payments were calculated with a base rate of $5.799.59 using the national adjusted operating standardized amounts and the capital standard federal payment rate as issued in the Medicare Inpatient Prospective Payment System Final Rule issued by CMS on August 2, 2013 [CMS-1599-F] and published in the Federal Register on August 19, 2013; Tables 1A and 1D, Table 5, and assume that all hospitals are receiving the full 1.7% quality reporting update. Actual payment may vary based on various hospital-specific factors not reflected in the source data. 38 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum B; http://www.cms.gov/hospitaloutpatientpps, CMS-1601-FC 39 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Addendum EE -- Surgical Procedures to be Excluded from Payment in ASCs for CY 2014; http://www.cms.hhs.gov/hospitaloutpatientpps/, CMS-1601-FC, Addenda. 40 Medicare Claims Processing Manual, Chapter 35 Independent Diagnostic Testing Facility (IDTF); http://www.cms.hhs.gov/manuals/downloads/clm104c35.pdf. 41 Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014. CMS-1600-FC, published in the Federal Register on December 10, 2013, as revised by the Pathway to SGR Reform Act of 2013, signed into law on December 26, 2013.

The patient presents to the catheterization lab having suffered a non-disabling stroke two months prior and has a Rankin scale score of 3. The patient has a history of acute on chronic systolic heart failure. The right femoral artery is accessed and the physician selectively catheterizes the origin of the left common carotid artery. Contrast material is injected to perform the initial roadmap arteriogram of the common carotid artery and bifurcation. Afterward, a cervical carotid angiography is performed in anteroposterior (AP) and lateral views, which reveals a 75% stenosis in the precerebral left internal carotid artery. The embolic protection system (EPS)/delivery system is loaded and advanced into the common carotid artery. An angioplasty balloon is insufflated to pre-dilate the lesion. Following this angioplasty, a stent delivery catheter is advanced carefully across the lesion. The physician performs a final angiographic check to ensure exact positioning. He/she deploys the stent and removes the stent delivery device. Then the EPS is collapsed and removed. The completion intra-cerebral arteriogram is performed in anteroposterior (AP) and lateral views. The cerebral images are reviewed in detail for emboli, vasospasm, and cross-filling. The patient tolerates the procedure well. 32 Example 1: Carotid Artery Stenting ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 00.63 Percutaneous insertion of carotid artery stent(s) 433.11 Occlusion and stenosis of 00.61 Percutaneous transluminal angioplasty of extracranial precerebral arteries, carotid artery, with vessel(s) cerebral infarction 428.23 Acute on chronic systolic heart failure 88.41 Arteriography of cerebral arteries 00.40 Procedure on one vessel 00.45 Insertion of one stent 034 Carotid artery stent procedure with MCC 2014 Relative Wt. 2014 National Average Payment 3.4145 $ 19,803 Hospital Outpatient Rate Payment N/A Not approved; inpatient only procedure Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2013 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37215 1 Transcatheter placement of N/A Not approved; N/A Not approved; intravascular stent(s), cervical carotid artery, percutaneous, with distal embolic protection N/A C inpatient only procedure -- inpatient only procedure N/A $1,127 $1,127 Total Estimated Payment $0 $0 $0 $1,127 $0 1 Code 37215 includes all ipsilateral selective carotid catheterization, all diagnostic imaging for ipsilateral cervical and cerebral carotid angiography, and all related radiological supervision and interpretation. Diagnostic catheterization and angiography of the carotid system contralateral to the intervention may be reported with modifier -59, if performed. Although the Medicare coverage guidelines indicate that PTA is covered when considered medically necessary in conjunction with carotid artery stenting, it is not separately reported by or reimbursed to the physician.

The patient is presents for diagnostic head and neck angiography following an abnormal carotid duplex ultrasound consistent with high-grade stenosis of the left internal carotid artery. She previously had two vessel PCI for symptomatic coronary artery disease. Access is through the right femoral artery. Catheter was advanced to the ascending aorta where an arch aortogram was performed. Diagnostic catheter was advanced to the right common carotid artery where multiple images including cervical and intracranial views were obtained. Catheter was then selectively advanced to the left common carotid artery, multiple images of the carotid system were obtained. The catheter was advanced to the left subclavian where multiple images of the left subclavian and left vertebral junction were obtained. Selective catheterization and imaging of the left vertebral performed. The catheter was then advanced through right subclavian into the right vertebral artery for multiple views of the right vertebral artery throughout its cranial and cervical segments were obtained. Selective right common femoral artery angiography was performed through the sheath demonstrating the vessel to be suitable for a vascular closure device. Sheath was exchanged for a closure device, which was deployed, obtaining good hemostasis. Findings are high-grade 90% stenosis of the left internal carotid artery; moderate 50% stenosis of ostium of left vertebral artery. CPT 2013 restructured the codes for diagnostic head and neck angiography, to incorporate the full extent of a vascular family into a single code, which includes both catheter placement and radiological supervision and interpretation. The previous imaging codes 75650 and 75660-75685 have been deleted, and the upper vascular catheterization codes 36215-37618 should not be reported in conjunction with these packaged diagnostic angiography codes. Note: Although case vignette describes angiography of femoral artery, CCI notes instruct Placement of an occlusive device into an arterial or venous access site after cardiac catheterization or other diagnostic or interventional procedure should be reported as HCPCS code G0269. Provider should not report an associated imaging code such as 75710 or G0278. Since clinical intent of procedure only references finding as demonstrating the vessel to be suitable for a vascular closure device, it is not appropriate to separately report the CPT code in this example. 33 Example 2: Head and Neck Angiography ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 433.30 Occlusion and stenosis of precerebral arteries, multiple and bilateral, without mention of cerebral infarction 88.42 Aortography 414.01 Coronary atherosclerosis of native coronary artery 88.41 Angiography of cerebral arteries 793.99 Other nonspecific (abnormal) findings on radiological and other examinations of body structure V45.82 Percutaneous transluminal coronary angioplasty status 88.49 Arteriography of other specific sites 88.48 Arteriography of femoral and other lower extremity arteries 068 Nonspecific cerebrovascular accident and precerebral occlusion without infarction without MCC 2014 Relative Wt. 2014 National Average Payment 0.8582 $ 4,977

Notes: In the Hospital OPPS, all of the head and neck angiography procedures are status Q2 which are T-packaged codes, indicating that the procedure is bundled if reported for the same case as another APC which has a status of T. If there are multiple STVX and/or T packaged HCPCS codes on a specific date and no service with which the codes would be packaged on the same date, the code assigned to the APC with the highest payment rate will be paid. All other codes are packaged. For physician reimbursement, whenever any multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and then apply the appropriate multiple surgery reductions. 34 Example 2: Head and Neck Angiography Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Nat l Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 36223-50 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid Not approved in 0279 S $2,576 $0 N1 circulation and all associated radiological this setting N/A $327 $246 $1,560 $1,170 supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed 36226-50 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all Not approved in 0280 S $4,514 $9,028 N1 associated radiological supervision and this setting N/A $359 $539 $1,749 $2,624 interpretation, includes angiography of the cervicocerebral arch, when performed C1887 Catheter, guiding (may include infusion/perfusion capability) N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 G0269 Placement of occlusive device into either a venous or arterial access site, post N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 surgical or intervential procedure C1760 Closure device, vascular (implantable/insertable) N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 Total Estimated Payment $9,028 $0 $0 $785 $3,794

The patient was previously hospitalized on two occasions with pulmonary embolisms and underlying peripheral vascular disease. Upon presenting with another onset of pulmonary embolism, it was determined that a vena cava filter should be placed, in addition to anticoagulant therapy, to reduce the potential for future recurrence. A vena cavagram was achieved with access through the right femoral vein, indicating the vena cava to be patent and normal vena cava and renal vein anatomy. A vena cava filter delivery sheath was advanced over a guidewire and positioned at the orifice of the lowest renal vein. The filter was deployed through the sheath and proper placement confirmed during a follow-up vena cavagram. 2014 National Average Payment 35 Example 3A: Introduction and Placement of Vena Cava Filter w/o CC/MCC Vascular access point: Right femoral vein Catheter end point: Confluence of the iliac veins Vessels imaged: Inferior vena cava and renal vein anatomy Primary procedure: Vena cava filter placement ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 415.19 Other pulmonary embolism and 38.7 Interruption of the vena cava 168 Other Respiratory infarction 88.65 Phlebography of other intra-abdominal veins System O.R Procedures 443.9 Other peripheral vascular disease 99.19 Injection of anticoagulant without CC/MCC 2014 Relative Wt. 1.3101 $7,598

The patient was hospitalized with deep vein thrombosis and pulmonary embolism. While undergoing anticoagulation therapy, the patient experienced a retroperitoneal hemorrhage, indicating the need for termination of anticoagulation. A vena cavagram was achieved with access through the right femoral vein and provided information that the vena cava was patent and that both the vena cava and renal vein anatomy were normal. It was determined that a vena cava filter should be placed. A vena cava filter delivery sheath was advanced over a guidewire and positioned at the orifice of the lowest renal vein. The filter was deployed through the sheath and proper placement confirmed utilizing intravascular ultrasound. Note: As the patient presents with pulmonary embolus, this would be the principal diagnosis, with the retroperitoneal hemorrhage (999.2) and underlying DVT as CCs. 36 Example 3B: Introduction and Placement of Vena Cava Filter w/cc ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 415.19 Other pulmonary embolism and infarction 38.7 Interruption of the vena cava 453.40 Venous embolism and thrombosis of unspecified deep vessels of lower extremity 999.2 Other vascular complications E934.2 Adverse effects in therapeutic use of anticoagulant 88.65 Phlebography of other intra-abdominal veins 00.28 Intravascular imaging of other specified vessels 99.19 Injection of anticoagulant 167 Other Respiratory System O.R Procedures with CC 2014 Relative Wt. 2014 National Average Payment 1.9860 $11,518

The patient was hospitalized with thrombophlebitis of a deep vein of the lower extremity. While undergoing treatment with thrombolytics, the patient experienced a pulmonary embolism from a released portion of the thrombus. It was determined that a vena cava filter should be placed. A vena cavagram was achieved with access through the right femoral vein and provided information that the vena cava was patent and that both the vena cava and renal vein anatomy were normal. A vena cava filter delivery sheath was advanced over a guidewire and positioned at the orifice of the lowest renal vein. The filter was deployed through the sheath and proper placement confirmed during a follow-up vena cavagram. Note: The reason for admission (principal diagnosis) is thrombophlebitis; the pulmonary embolus is a complication which arises subsequently. Although 415.11 is included on the list of Hospital Acquired Conditions which do not support higher DRG assignment when developed after admission, this limitation only applies when it is a complication following certain specified orthopedic surgical procedures. 37 Example 3C: Introduction and Placement of Vena Cava Filter w/mcc ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 451.2 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremity 38.7 Interruption of the vena cava 415.11 Iatrogenic pulmonary embolism and infarction 88.65 Phlebography of other intra-abdominal veins 99.10 Injection or infusion of thrombolytic agent 166 Other Respiratory System O.R Procedures with MCC 2014 Relative Wt. 2014 National Average Payment 3.6741 $21,308

Example 3A - 3C: Introduction and Placement of Vena Cava Filter Outpatient Facility and Physician Examples While complications / comorbidities affect the decision of the most appropriate setting in which provide services and change inpatient payments, outpatient and physician reimbursement calculation is not affected by the secondary diagnoses and all three of these examples would be coded the same. Notes: Although a C-code exists for the vena cava filter, there is not a mandatory device edit to report C1880 in conjunction with 37191. It may be reported at the facility s discretion for inventory and other informational purposes. The 2013 CPT codes have been assigned a zero-day global period, and therefore subsequent E/M services may be reported separately -- whereas 37620 had included a 90-day postoperative period, as the definition of the code reflected either endovascular or open approaches (and so was also not approved outside the facility setting). 38 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological N/A -- Not approved 0093 T $2,847 $2,847 -- supervision and interpretation, intraprocedural in this setting N/A $250 $250 $2,683 $2,683 roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed 75945 Intravascular ultrasound (non-coronary vessel), radiological supervision and 0267 Q2 $191 $0 N1 $0 $0 $20 $20 Carrier priced interpretation; initial vessel C1880 Device -- Vena cava filter N/A N $0 N/A $0 N/A $0 N/A $0 Total Estimated Payment $2,847 $0.00 $0 $270 $2,683

CPT 2012 introduced a new code specific to retrieval of a vena cava filter; previously, the code utilized was code 37203, Retrieval of an intravascular foreign body. The procedure needs to be well documented that retrieval is not part of routine medical care. These codes have been assigned a zero-day global period, so use of postoperative modifiers such as 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period), or 58 (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period) are likely no longer applicable. The patient was previously hospitalized for a hip replacement at which time a vena cava filter was placed. It was planned that the patient would return post-operatively for a staged retrieval of the filter after the danger of a pulmonary embolus had subsided. The filter was retrieved successfully in the cath lab on a non-emergent outpatient basis. The previous cavagram was not available for review. 39 Example 4: Retrieval of a Vena Cava Filter Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Nat l Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and 0623 T $2,346 $2,346 N/A N/A -- Not approved in this $385 $385 $1,638 $1,638 interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed setting N/A C1773 Retrieval device, insertable (used to retrieve fractured medical devices) N/A N $0 $0 N/A N/A $0 N/A $0 N/A $0 Total Estimated Payment $2,346 $0 $0 $385 $1,638 Note: Although there is a C-code available for an insertable retrieval device, there is not a mandatory device edit to report C1773 in conjunction with 37193, as its use may not be required for every case (particularly if a device is being removed intact). C1773 may be reported at the facility s discretion for inventory and other informational purposes.

CPT 2012 introduced a new code specific to repositioning of a vena cava filter; previously, this would have had to be reported as an unlisted vascular surgery procedure. The patient was previously hospitalized for a hip replacement at which time a vena cava filter was placed. It was planned that the patient would return post-operatively for repositioning of the filter after [period of time]. The filter was repositioned successfully in the cath lab on a non-emergent outpatient basis. Note: During 2011 and prior years, repositioning was reported as unlisted procedures. Unlisted procedure codes are often defined as ancillary procedures, separately reimbursed. However, they were assigned to a low reimbursement APC, and so imaging code 75825 became the most significant procedure in the case. In the physician fee schedule, unlisted procedure codes are by report, and there is no predetermined allowable amount these procedure are priced by the carrier according to documentation, and so average reimbursement could not be identified prior to introduction of the specific code in 2012. 40 Example 5: Repositioning of a Vena Cava Filter Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and N/A -- Not approved radiological supervision and interpretation, 0623 T $2,346 $2,346 -- in this setting intraprocedural roadmapping, and imaging N/A $377 $377 $1,555 $1,555 guidance (ultrasound and fluoroscopy), when performed Total Estimated Payment $2,346 $0 $0 $377 $1,555

The patient was previously hospitalized for a hip replacement at which time a vena cava filter was placed. It was planned that the patient would return post-operatively for removal and replacement of the filter after [period of time], as it had been determined that the patient was still at risk of DVT and pulmonary embolus. The filter was replaced successfully in the cath lab on a non-emergent outpatient basis, and proper placement confirmed utilizing intravascular ultrasound. 41 Example 6: Replacement of a Vena Cava Filter Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Nat l Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, 0091 T $2,847 $2,847 -- N/A -- Not approved in this $250 $125 $2,683 $2,683 intraprocedural roadmapping, and imaging setting guidance (ultrasound and fluoroscopy), when performed 37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach N/A including vascular access, vessel selection, and radiological supervision and 0623 Q2 $2,346 $0 N/A -- Not approved in this $385 $385 $1,638 $819 interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed setting 75945 Intravascular ultrasound (noncoronary vessel), radiological supervision 0267 Q2 $155 $0 N1 $0 $0 $20 $20 Carrier priced and interpretation; initial vessel C1773 Retrieval device, insertable (used to retrieve fractured medical devices) N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 C1880 Device -- Vena cava filter N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 Total Estimated Payment $2,847 $0 $0 $530 $3,502 Notes: For 2014, the status indicator for 37193 was changed from T to Q2 (T-packaged code), and so there is no separate APC payment for removal when reported with insertion (replacement). It should still be reported separately to provide data for outlier calculation and future rate setting.

Example 7: PTA and Stent Placement in the Contralateral Common Iliac Artery After Successful CTO Crossing Catheter access was achieved through the right femoral artery. An original diagnostic flush aortogram with pelvic run-off revealed a chronic total occlusion of the left common iliac artery. A CTO catheter was employed which successfully crossed the occlusion, allowing a balloon angioplasty of the left common iliac to be performed, which had a suboptimal result. Two stents were implanted in the same vessel under radiological supervision. Hemostasis was achieved using a vascular closure device. 42 ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.8 Atherosclerosis of other specified arteries 440.4 Chronic total occlusion of artery of the extremities 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.40 Procedure on one vessel 00.46 Insertion of two stents 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 253 Other vascular procedures with CC 2014 Relative Wt. 2014 National Average Payment 2.5172 $ 14,599 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent 0229 T $9,120 $9,120 G2 $5,038 $5,038 $531 $531 $4,750 $4,750 placement(s), includes angioplasty within same vessel, when performed 75630-59 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 and interpretation G0269 Placement of occlusive device into N/A either a venous or arterial access site, post N/A N $0 $0 N/A $0 $0 $0 $0 $0 $0 surgical or intervential procedure C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) C1760 Closure device, vascular (implantable/insertable) N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 Total Estimated Payment $9,120 $5,038 $0 $619 $4,933

Example 8: PTA Common and External Iliac Arteries and Intravascular Stent(s) Placement from Contralateral Access The physician uses a retrograde right femoral puncture to introduce a catheter into the aorta. An aortogram together with bilateral iliofemoral angiography with distal runoff is performed, identifying high grade lesions at the left common and external iliac arteries. Catheter is advanced contralaterally, PTA performed on both vessels, with suboptimal results. An endovascular stent is then deployed in each vessel. 43 ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.8 Atherosclerosis of other specified arteries 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.41 Procedure on two vessels 00.46 Insertion of two stents 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 254 Other vascular procedures without CC/MCC 2014 Relative Wt. 2014 National Average Payment 1.7012 $ 9,866 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent 0229 T $9,120 $9,120 G2 $5,038 $5,038 $531 $531 $4,750 $4,750 placement(s), includes angioplasty within same vessel, when performed Ì 37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes 0083 T $4,410 $2,205 G2 $2,436 $1,218 $224 $224 $2,638 $2.638 angioplasty within same vessel, when performed N/A 75630-59 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 and interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $11,325 $6,256 $0 $843 $7,571

The physician uses a retrograde right femoral puncture to introduce a catheter into the aorta. An aortogram together with bilateral iliofemoral angiography with distal runoff is performed, identifying high grade lesion at the origin of the left common iliac artery. The physician uses a retrograde left femoral artery puncture to introduce a guidewire and PTA balloon catheter into the left iliac lesion site. PTA performed on left common iliac, with suboptimal result due to elastic recoil. An endovascular stent is then deployed. 44 Example 9: PTA Common Iliac Artery and Intravascular Stent(s) Placement from Separate Ipsilateral Access ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.8 Atherosclerosis of other specified arteries 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.40 Procedure on one vessel 00.45 Insertion of one stent 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 254 Other vascular procedures without CC/MCC 2014 Relative Wt. 2014 National Average Payment 1.7012 $ 9,866 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent 0229 T $9,120 $9,120 G2 $5,038 $5,038 $531 $531 $4,750 $4,750 placement(s), includes angioplasty within same vessel, when performed 36200-59-51 Placement of catheter in aorta (separate access from intervention) N/A N $0 $0 N1 $0 $0 $159 $80 $635 $318 75630-59 Aortography, abdominal plus N/A bilateral iliofemoral lower extremity, catheter, 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 by serialography, radiological supervision and interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $9,120 $5,038 $0 $699 $5,251

Patient presents to hospital with claudication and cold left leg below the knee. Dorsalis pedis pulse is barely palpable and patient consent is obtained for inpatient angiogram and angioplasty of the superficial femoral artery. A right femoral access is obtained and a catheter advanced to the aorta where an aortogram with iliofemoral imaging is performed. The catheter is then advanced to the contralateral left common iliac where an additional selective angiogram of the left lower extremity is performed. A total occlusion of the left proximal superficial femoral artery is found and after several attempts to pass a wire fail, a total occlusion crossing catheter is employed. The occlusion is then crossed successfully and angioplasty and stenting under radiological supervision was conducted. 45 Example 10: Diagnostic Angiography of Contralateral SFA and SFA Angioplasty and Stent Placement ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.21 Atherosclerosis of the extremities with intermittent claudication 440.4 Chronic total occlusion of artery of the extremities 39.90 Insertion of non-drug-eluting, peripheral (non-coronary) vessel stent(s) 00.40 Procedure on one vessel 00.45 Insertion of one stent 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 253 Other vascular procedures with CC 2014 Relative Wt. 2014 National Average Payment 2.5172 $ 14,599 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37226 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent 0229 T $9,120 $9,120 G2 $5,038 $5,038 $533 $533 $9,188 $9,188 placement(s), includes angioplasty within same vessel, when performed 75630-59 Aortography, abdominal, by serialography, radiological supervision and 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 interpretation 75710-59 Angiography, extremity, N/A unilateral, radiological supervision and 0279 Q2 $2.576 $0 N1 $0 $0 $55 $55 $177 $177 interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $9,120 $5,038 $0 $676 $9,548 Note: The presence of a chronic total occlusion (CTO), ICD-9-CM diagnosis code 440.4, is identified as a CC in the Hospital Inpatient Prospective Payment System, and therefore affects MS-DRG assignment. However, there is no procedure code for reporting the use of a chronic total occlusion crossing device for either outpatient facility or physician coding, and the use of a CTO device to facilitate guidewire placement across the lesion by any means is not separately reported.

Example 11: Diagnostic Angiography of Contralateral Extremity and Tibioperoneal Angioplasty and Stent Placement Patient presents to hospital with claudication and cold left leg below the knee. Dorsalis pedis pulse is barely palpable and patient consent is obtained for angiogram and intervention of the calf vessels. A right femoral access is obtained and a catheter advanced to the aorta where an aortogram with bilateral runoff is performed. The catheter is then advanced to the contralateral left popliteal where a second angiogram of the left lower extremity is performed. A tight subtotal occlusion of the left common tibioperoneal trunk is found. The occlusion is crossed successfully with a stiff guidewire, and angioplasty is conducted, with residual stenosis, followed by stent placement under radiological supervision. Hemostasis was achieved using a vascular closure device. 46 ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.21 Atherosclerosis of the extremities with intermittent claudication 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.40 Procedure on one vessel 00.45 Insertion of one stent 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 254 Other vascular procedures without CC/MCC 2014 Relative Wt. 2014 National Average Payment 1.7012 $ 9,866 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal 0229 T $9,120 $9,120 G2 $5,038 $5,038 $736 $736 $8,434 $8,434 stent placement(s), includes angioplasty within same vessel, when performed 75630-59 Aortography, abdominal with bilateral iliofemorals, by serialography, 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 radiological supervision and interpretation 75710-59 Angiography, extremity, N/A unilateral, radiological supervision and 0279 Q2 $2.576 $0 N1 $0 $0 $55 $55 $177 $177 interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) C1760 Closure device, vascular (implantable/insertable) N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 Total Estimated Payment $9,120 $5,038 $0 $879 $8,794

47 Example 12: Diagnostic Angiography of Extremity and Two Vessel Tibioperoneal Angioplasty and Stent Placement Patient presents to hospital with claudication and cold right leg below the knee. Dorsalis pedis pulse is barely palpable and patient consent is obtained for angiogram and possible intervention. An antegrade right femoral access is obtained and initial runoff angiography is performed through the sheath, showing the SFA with minimal disease, poor imaging in calf. The catheter is then advanced to the popliteal where a second angiogram of the right lower extremity is performed. Significant occlusive disease of the both the anterior tibial and posterior tibial arteries is found. Angioplasty is performed in each vessel, with suboptimal result, followed by stent placements under radiological supervision. ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.21 Atherosclerosis of the extremities with intermittent claudication 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.41 Procedure on two vessels 00.46 Insertion of two stents 88.48 Arteriography of femoral and other lower extremity arteries 254 Other vascular procedures without CC/MCC 2014 Relative Wt. 2014 National Average Payment 1.7012 $ 9,866 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal 0229 T $9,120 $9,120 G2 $5,038 $5,038 $736 $736 $8,434 $8,434 stent placement(s), includes angioplasty within same vessel, when performed Ì 37234 Revascularization, endovascular, open or percutaneous, tibial/ peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), 0083 T $4,410 $2,205 N/A $2,436 $1,218 $295 $295 $3,935 $3,935 includes angioplasty within same vessel, when performed 75710-59 Angiography, extremity, N/A unilateral, radiological supervision and 0279 Q2 $2.576 $0 N1 $0 $0 $55 $55 $177 $177 interpretation Ì 75774-59 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and N/A N $0 $0 N1 $0 $0 $18 $18 $99 $99 interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $11,325 $6,256 $0 $1,104 $12,645

Patient presents for assessment of extensive peripheral vascular disease and intervention. A right femoral access is obtained and a catheter advanced to the aorta where an aortogram with bilateral runoff is performed. The catheter is then advanced to the contralateral left common femoral where a second angiogram of the left lower extremity is performed. A tight stenosis of the mid left SFA is found, along with extensive disease of the calf vessels. The SFA occlusion is crossed successfully with a stiff guidewire, and angioplasty is conducted, with residual stenosis, followed by stent placement under radiological supervision. Subsequently, the catheter is further advanced to the popliteal where an additional selective angiogram of the right lower extremity is performed. Significant occlusive disease of the both the anterior tibial and tibioperoneal trunk arteries are found, including chronic total occlusion of the tibioperoneal trunk. After several attempts to pass a wire fail, a total occlusion crossing catheter is employed to cross the CTO of the tibioperoneal trunk and facilitate guidewire placement across the lesion, which is then followed by atherectomy and stent placement performed in the tibioperoneal trunk. Angioplasty alone is performed on the anterior tibial. 48 Example 13: Diagnostic Angiography and Multi-Vessel Lower Extremity Interventions ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.20 Atherosclerosis of the extremities, unspecified 440.4 Chronic total occlusion of artery of the extremities 17.56 Atherectomy of other non-coronary vessel(s) 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.42 Procedure on three vessels 00.46 Insertion of two stents 88.42 Aortography 88.48 Arteriography of femoral and other lower extremity arteries 253 Other vascular procedures with CC 2014 Relative Wt. 2014 National Average Payment 2.5172 $ 14,599

Note: The presence of a chronic total occlusion (CTO), ICD-9-CM diagnosis code 440.4, is identified as a CC in the Hospital Inpatient Prospective Payment System, and therefore affects MS-DRG assignment. However, there is no distinct code for reporting the use of a chronic total occlusion crossing device for either outpatient facility or physician coding, and the use of a CTO device to facilitate guidewire placement across the lesion by any means is not separately coded. 49 Example 13: Diagnostic Angiography and Multi-Vessel Interventions Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 37231 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, 0319 T $15,510 $15,510 J8 $12,174 $12,174 $806 $806 $13,463 $13,463 includes angioplasty within same vessel, when performed 37226-51 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent 0229 T $9,120 $4,560 G2 $5,038 $2,519 $533 $267 $9,188 $4,594 placement(s), includes angioplasty within same vessel, when performed Ì 37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with 0083 T $4,410 $2,205 G2 $2,436 $1,218 $213 $213 $1,238 $1,238 transluminal angioplasty 75630-59 Aortography, abdominal with N/A bilateral iliofemorals, by serialography, 0279 Q2 $2.576 $0 N1 $0 $0 $88 $88 $183 $183 radiological supervision and interpretation 75710-59 Angiography, extremity, unilateral, radiological supervision and 0279 Q2 $2.576 $0 N1 $0 $0 $55 $55 $177 $177 interpretation Ì 75774-59 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and N/A N $0 $0 N1 $0 $0 $18 $18 $99 $99 interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1724 Catheter, transluminal atherectomy, rotational N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $22,275 $15,911 $0 $1,447 $19,754

The interventionalist punctured the right common femoral artery and performed selective catheter placement and angiography of the right and left main renal arteries. The angiogram revealed high-grade stenoses in the mid-portion of both renal arteries. It was decided to proceed immediately to an intervention; the patient had been prepared for that possibility. Balloon angioplasty was performed on both arteries with a satisfactory result for the left renal artery. A suboptimal angioplasty result in the right renal artery was resolved with placement of an endovascular stent. Note: In 2011 and previously, when renal artery diagnostic angiography was performed, catheter placement (36245 or 36245-50) and imaging (75722 or 75724) were reported separately. Beginning with CPT 2012, new combination codes were added which capture all components of the study. These codes offer four choices: main renal artery (first order vessel) vs. superselective (second order vessel or higher branches), each of which has further options of either unilateral or bilateral study. If superselective imaging is performed on one kidney, and main renal artery catheterization on the other, report each study as unilateral identify which kidney by modifiers LT (left) and RT (right). If both kidneys are catheterized to the same level of selectivity, then report a single bilateral code for the entire study. Each of these four new codes includes any accessory renal arteries serving the same kidney, so 75774 for an additional vessel selectively imaged no longer applies in renal angiography. 50 Example 14: Bilateral Renal Artery Balloon Angioplasty and Stent Placement ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 39.50 Angioplasty of other non-coronary vessel(s) 440.1 Atherosclerosis of renal artery 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 00.41 Procedure on two vessels 00.45 Insertion of one stent 88.45 Arteriography of renal arteries 254 Other vascular procedures without CC/MCC 2014 Relative Wt. 2014 National Average Payment 1.7012 $ 9,866

Note: 2014 CPT revisions bundle angioplasty into the stent placement code, so 35471 is no longer reported on the stented vessel, although it is appropriate to report on the contralateral renal artery which was treated with angioplasty only modifiers identify laterality. New code 36236 also includes radiological guidance, so neither 75960 nor 75968 are reported additionally. 51 Example 14: Bilateral Renal Artery Balloon Angioplasty and Stent Placement Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 35471-LT Transluminal balloon angioplasty, Not approved in 0083 T $4,410 $2,205 N/A percutaneous; renal or visceral artery this setting $548 $548 $2,566 $1,283 37236-RT Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, 0229 T $9,120 $9,120 G2 $4,858 $4,858 $482 $241 $2,863 $2,863 including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery 36252-59 Selective catheter placement (first order), main renal artery and any accessory N/A renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), imaging postprocessing, 0279 Q2 $2,576 $0 N1 $0 $0 $382 $191 $1,561 $781 permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral 75966-LT Transluminal balloon angioplasty, renal or other visceral artery, radiological N/A N $0 $0 N1 $0 $0 $64 $64 $176 $176 supervision and interpretation C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $11,325 $4,858 $0 $1,044 $5,103

An end stage renal disease patient on chronic dialysis is referred for emergency restoration of flow to the access graft to prevent interruption of scheduled dialysis. This example assumes the use of two separate catheters to perform angioplasties of the arterial and the venous anastomoses of the dialysis graft under radiologic supervision, following a diagnostic angiogram of the access graft. Note: MS-DRG assignment will depend upon documented reason for admission. If for the graft occlusion (996.73), then end stage renal disease is an identified MCC; if for the end stage renal disease (585.6), then the graft complication is considered a CC. 52 Example 15: Dialysis Fistula/Graft Repair ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 996.73 Other complication due to renal dialysis device, implant, and graft 585.6 End stage renal disease V45.11 Renal dialysis status 39.50 Angioplasty of other noncoronary vessel(s) 88.67 Phlebography of other specified sites using contrast material 00.40 Procedure on one vessel 252 Other vascular procedures with MCC 253 Other vascular procedures with CC 2014 Relative Wt. 2014 National Average Payment 3.1477 $18,255 2.5172 $14,599

Note: Effective January 1, 2010, the G-codes for hemodialysis graft PTA (G0392 and G0393) have been deleted. Also, the codes for diagnostic access and angiography (36145, 75790) were deleted and merged into a single new complete procedure code (36147), with new code 36148 for additional access if needed for therapeutic intervention. For 2012, extensive notes were added in the CPT discussing diagnostic and interventional procedures on AV dialysis shunts which combines multiple vessels into anatomic territories for coding purposes. Although most AV shunt interventions are coded as venous, angioplasty of the native artery and periarterial anastomosis through to the venous outflow tract is reported as arterial. 53 Example 15: Dialysis Fistula/Graft Repair Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or 0083 T $4,410 $4,410 P3 $978 $978 $355 $355 $1,610 $1,610 branches, each vessel 36147 Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access 0668 T $827 $413 P2 $457 $228 $195 $97 $853 $426 of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through N/A entire venous outflow including the inferior or superior vena cava Ì 36148 Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (graft/fistula); additional access N/A N $0 $0 N1 $0 $0 $51 $51 $265 $265 for therapeutic intervention (List separately in addition to code for primary procedure) 75962 Transluminal balloon angioplasty, peripheral artery other than renal or other visceral artery, iliac, or lower extremity, N/A N $0 $0 N1 $0 $0 $27 $27 $147 $147 radiological supervision and interpretation Total Estimated Payment $4,823 $1,206 $0 $530 $2,448

The patient during previous hemodialysis therapies demonstrated increasing venous pressure measurements. The last therapy had three dynamic venous pressure measurements above 125mm hg that indicated a need for a graft angiogram. The patient was found to have significant graft stenosis that needed immediate attention to allow for dialysis. Thrombolytic therapy for the patient was contraindicated. Informed consent was obtained from the patient for a mechanical thrombectomy as the primary method for disruption of the thrombus of the dialysis access graft. Vascular access obtained via the brachial artery and basilic vein. Venous angioplasty was performed after thrombus removal to assist with graft patency. 54 Example 16: Thrombus Management for ESRD Patient Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 35476 Transluminal balloon angioplasty, percutaneous; venous 0083 T $4,410 $4,023 P3 $923 $462 $283 $142 $1,469 $735 36147 Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access 0668 T $827 $413 P2 $457 $228 $195 $97 $853 $426 of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava Ì 36148 Introduction of needle or intracatheter; arteriovenous shunt created N/A for dialysis (graft/fistula); additional access N/A N $0 $0 N1 $0 $0 $51 $51 $265 $265 for therapeutic intervention (List separately in addition to code for primary procedure) 36870 2 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical 0653 T $3,083 $1,541 A2 $1,703 $1,703 $313 $313 $1,866 $933 thrombus extraction and intra-graft thrombolysis 75978-26 Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and 0093 Q2 $2,847 $0 N1 $0 $0 $27 $27 $145 $145 interpretation Total Estimated Payment $5,717 $2,393 $0 $630 $2,504 2 A 90 day global period applies to this code.

Example 17: Diagnostic Left Heart Catheterization & Coronary Angiography of Native Vessels and Bypass Grafts Patient with coronary artery disease status post coronary artery bypass grafting in 2005 now presents with accelerated angina. A cardiac catheterization is being performed to evaluate coronary anatomy using radial artery access 3. Patient also has some known renal insufficiency. Left and right coronary angiography in multiple projections was performed using two catheters. The catheter was then exchanged over a guidewire with a 5-F IMA catheter which was used to cannulate the left subclavian and the left internal mammary artery and multiple projections were taken. Left ventriculography was not performed. Findings are: Due to amount of contrast used today in a patient with reduced renal function, the patient will be brought back within the next couple of days for planned intervention. 55 1. Extensive 3-vessel native coronary artery disease. 2. There is a critical 90% stenosis of the right coronary artery. 3. Patent left internal mammary artery graft to the left anterior descending artery. 4. The saphenous vein graft to the circumflex artery was patent, without significant stenosis. ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 414.01 Coronary atherosclerosis of native coronary artery 37.22 Left heart cardiac catheterization 413.9 Other and unspecified angina pectoris 585.9 Chronic kidney disease, unspecified V45.81 Aortocoronary bypass status 88.53 Angiocardiography of left heart structures 88.56 Coronary arteriography using two catheters 88.44 Arteriography of other intrathoracic vessels 287 Circulatory disorders except acute myocardial infarction, with cardiac catheterization without MCC 2014 Relative Wt. 2014 National Average Payment 1.0866 $6,302 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93455 Catheter placement in coronary artery(s) for coronary angiography, including N/A -- Invasive or intraprocedural injection(s) for coronary interventional procedure angiography, imaging supervision and codes in the Medicine interpretation; with catheter placement(s) in 0080 T $2,587 $2,587 Chapter of CPT are not bypass graft(s) (internal mammary, free recognized for ASC arterial, venous grafts) including payment. intraprocedural injection(s) for bypass graft $744 $308 $308 $1,052 $1,052 angiography Total Estimated Payment $2,587 $0 $744 $308 $1,052 3 Vascular access is included in all cardiac catheterization and interventional procedures, whether by femoral artery puncture, radial artery puncture, or cutdown.

Patient with history of surgically corrected congenital cardiac anomaly presents for catheterization to monitor function due to manifestation of pulmonary hypertension. Catheterization with hemodynamic measurements obtained in right and left heart with right and left chamber angiography and pulmonary angiography, but without imaging of coronary arteries. Pharmacological agent was administered to assess hemodynamic function, with measurements taken before, during, and after administration of agent. 56 Example 18: Diagnostic Right and Left Heart Catheterization & Angiography for Congenital Anomaly ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 416.8 Other chronic pulmonary heart disease 37.23 Combined right and left heart cardiac catheterization V13.65 Personal history of (corrected) congenital malformation of heart and 88.54 Combined right and left heart angiocardiography circulatory system V15.29 Personal history of surgery to other organs Note: List additionally original congenital anomaly(ies) if still present 88.43 Arteriography of pulmonary arteries 88.44 Arteriography of other intrathoracic vessels 00.12 Administration of inhaled nitric oxide 287 Circulatory disorders except acute myocardial infarction, with cardiac catheterization without MCC 2014 Relative Wt. 2014 National Average Payment 1.0866 $6,302

57 Example 18: Diagnostic Right and Left Heart Catheterization & Angiography for Congenital Anomaly Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93531 Combined right heart catheterization Carrier and retrograde left heart catheterization, for 0080 T $2.587 $2,587 priced congenital cardiac anomalies $463 $463 Carrier priced Ì 93565 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial N/A N $0 $0 N/A $44 $44 $44 $44 angiography (List separately in addition to code for primary procedure) Ì 93566 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial N/A N $0 $0 N/A $44 $44 $173 $173 angiography (List separately in addition to code for primary procedure) Ì 93568 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for N/A N $0 $0 N/A -- Invasive or interventional procedure codes in the Medicine Chapter of CPT are not recognized for ASC N/A $45 $45 $154 $154 pulmonary angiography (List separately in addition to code for primary procedure) payment. Ì 93463 Pharmacological agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after, and N/A N $0 $0 N/A $109 $109 $109 $109 repeat pharmacological agent administration, when performed (List separately in addition to code for primary procedure) C1887 Catheter, guiding (may include infusion/perfusion capability) N/A N $0 $0 N/A N/A $0 N/A Total Estimated Payment $2,587 $0 Carrier $705 $480+

Catheterization of the coronary arteries and percutaneous placement of a bare metal intracoronary stent after diagnostic evaluation of the right and left coronary arteries using two catheters performed at the same session. A stenotic lesion of 85% was found in the left main artery. Left heart catheterization and ventriculography were not performed. 58 Example 19: Diagnostic Left Heart Catheterization & Coronary Angiography with Stent Placement ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 36.06 Insertion of non-drug-eluting coronary artery stent(s) 414.01 Coronary atherosclerosis of native coronary artery 00.66 Percutanous transluminal coronary angioplasty [PTCA] 88.56 Coronary arteriography using two catheters 00.40 Procedure on one vessel 00.45 Insertion of one stent 249 Percutaneous cardiovascular procedure with non-drug-eluting stent without MCC 2014 Relative Wt. 2014 National Average Payment 1.8245 $10,581 Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93454-59 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary 0080 T $2,587 $1,293 $637 $267 $133 $903 $903 N/A -- Invasive or angiography, imaging supervision and interventional procedure interpretation codes in the Medicine 92928-LM 4 Percutaneous transcatheter Chapter of CPT are not placement of intracoronary stent(s), with Not Not approved in 0104 T $6,364 $6,364 recognized for ASC $623 $623 coronary angioplasty when performed; allowed this setting payment. single major coronary artery or branch C1887 Catheter, guiding (may include infusion/perfusion capability) N/A N $0 $0 N/A N/A $0 N/A $0 Total Estimated Payment $7,657 $0 N/A $756 $903 4 A new anatomic modifier LM has been added for 2013 to describe interventions of the left main coronary artery. Coding guidelines for 2012 and previous years indicated to report using either LD (left anterior descending) or LC (left circumflex), depending upon which branch of the left coronary system was dominant.

A diagnostic left heart catheterization was performed, including selective injection of the coronary arteries and a left ventriculogram. Intravascular ultrasound imaging further confirmed the presence of a long lesion in the left anterior descending (LAD) coronary artery, where a drug-eluting stent was placed. Balloon angioplasty was performed on a single lesion in the circumflex artery. Patient has a comorbid condition of acute systolic heart failure. 59 Example 20: Diagnostic Heart Catheterization with Insertion of Coronary Artery Stent and Angioplasty ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 36.06 Insertion of non-drug-eluting coronary artery stent(s) 414.01 Coronary atherosclerosis of native coronary artery 428.21 Acute systolic heart failure 00.66 Percutanous transluminal coronary angioplasty [PTCA] 37.22 Left heart cardiac catheterization 88.53 Angiocardiography of left heart structures 88.57 Other and unspecified coronary arteriography 00.24 Intravascular imaging of coronary vessels 00.41 Procedure on two vessels 00.45 Insertion of one stent 248 Percutaneous cardiovascular procedure with non-drug-eluting stent with MCC or 4+ vessels/ stents 2014 Relative Wt. 2014 National Average Payment 2.9479 $14,149

60 Example 20: Diagnostic Heart Catheterization with Insertion of Coronary Artery Stent and Angioplasty Hospital Outpatient Ambulatory Surgery Center IDTF Physician In Facility Non-Facility (Office) APC 2014 2014 Rate Payment Not approved in this setting Not approved in this setting Carrier Carrier priced priced SI 2014 Nat l 2014 SI 2014 Nat l 2014 Nat l 2014 Avg. Nat l Avg. Avg. Avg. Nat l Avg. 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93458-59 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 0080 T $2,587 $1,293 $758 $326 $163 $1,084 $1,084 interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 92928-LD Percutaneous transcatheter N/A -- Invasive or placement of intracoronary stent(s), with interventional procedure 0104 T $6,364 $6,364 $623 $623 coronary angioplasty when performed; codes in the Medicine Not single major coronary artery or branch Chapter of CPT are not allowed 92920-LC Percutaneous transluminal recognized for ASC coronary balloon angioplasty; single major 0083 T $4,410 $2,205 payment. $561 $281 coronary artery or branch Ì 92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including Carrier N/A N $0 $0 imaging supervision, interpretation and priced $91 $91 report; initial vessel (List separately in addition to code for primary procedure) C1753 Catheter, intravascular ultrasound N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 C1876 Stent, noncoated/noncovered, with delivery system N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion capability) N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 Total Estimated Payment $9,862 $0 N/A $1,158 $1,084 Note: For hospital outpatient claims for insertion of drug-eluting coronary stents, see C9600-C9608.

Example 21: Diagnostic Heart Catheterization, Stent Placement, and Angioplasty for Acute Myocardial Infarction Patient with a recent diagnosis of coronary artery disease after he sustained an anterior myocardial infarction 3 months ago. He received primary PCI of his LAD with a 3.0 x 16 mm bare metal stent, and presents today with new onset of severe chest pain. A diagnostic left heart catheterization was performed, including selective injection of the coronary arteries and a left ventriculogram. The LAD has a stent in the proximal segment which is 100% thrombosed, as are the diagonal branches. Moderate stenosis was also found in the diagonals, right coronary artery, and circumflex artery. Balloon angioplasty was used to dilate the existing stent and mid-distal LAD, followed by extensive aspiration thrombectomy throughout the LAD. Intravascular ultrasound was used to evaluate the LAD. A bare metal stent was positioned across the mid portion of the LAD overlapping the second diagonal branch and also overlapping the distal edge of the existing stent. Another bare metal stent was deployed across the proximal and mid portion of the LAD, overlapping the proximal edge of the initially deployed stent. Kissing balloon angioplasty was performed of the LAD/D2 bifurcation, which had been jailed by the stent. Finally, a left ventricular assist device was advanced arterially over the wire into the left ventricle. 2014 National Average Payment 61 ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 00.66 Percutanous transluminal coronary angioplasty [PTCA] 410.01 Acute myocardial infarction of anterolateral wall, initial episode of care 36.06 Insertion of non-drug-eluting coronary artery stent(s) 428.21 Acute systolic heart failure 785.51 Cardiogenic shock 414.01 Coronary atherosclerosis of native coronary artery 996.72 Other complication due to other cardiac device, implant, and graft 412 Old myocardial infarction V45.82 Percutaneous transluminal coronary angioplasty status 37.68 Insertion of percutaneous external heart assist device 36.09 Other removal of coronary artery obstruction 37.22 Left heart cardiac catheterization 88.53 Angiocardiography of left heart structures 88.57 Other and unspecified coronary arteriography 00.24 Intravascular ultrasound of coronary vessels 00.41 Procedure on two vessels 00.46 Insertion of two stents 00.44 Procedure on vessel bifurcation 248 Percutaneous cardiovascular procedure with non-drug-eluting stent with MCC or 4+ vessels/stents 2014 Relative Wt. 2.9479 $17,097

Example 21: Diagnostic Heart Catheterization, Stent Placement, and Angioplasty for Acute Myocardial Infarction Note: While specific codes were added in CPT 2013 to report interventions of additional branches of a major coronary artery in the same case, the Medicare Physician Fee Schedule has identified these codes as bundled, with zero RVUs. To compensate, work RVUs for the single vessel intervention codes were increased on average 10% from the RUC s recommendations to reflect the estimated frequency at which additional branches might be treated. The Hospital Outpatient Prospective Payment System has assigned APC rates to all additional branch vessel codes, as well as a series of mirrored C-codes (C9600 C9608), which describe the same family of procedures for any case involving drug-eluting stents. 62 Hospital Outpatient Ambulatory Surgery Center IDTF Physician In Facility Non-Facility (Office) APC 2014 2014 Rate Payment Not approved in this setting Not approved in this setting Not approved in this setting Carrier Carrier priced priced SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93458-59 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 0080 T $2,587 $1,293 $758 $326 $163 $1,084 $1,084 interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 92941-LD Percutaneous transluminal revascularization of acute total/subtotal occlusion during myocardial infarction, coronary artery or coronary artery bypass 0104 T $6,364 $6,364 graft, any combination of intracoronary stent, N/A -- Invasive or $699 $699 atherectomy and angioplasty, including interventional procedure aspiration thrombectomy when performed, codes in the Medicine Not single vessel Chapter of CPT are not Allowed Ì 92921-LD Percutaneous transluminal recognized for ASC coronary angioplasty; each additional branch 0083 T $4,4410 $2,205 payment. Bundled of a major coronary artery 33990 Insertion of ventricular assist device, N/A Not approved; percutaneous, including radiological N/A C inpatient only supervision and interpretation, arterial procedure access only $454 $227 Ì 92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including Carrier N/A N $0 $0 imaging supervision, interpretation and priced $91 $91 report; initial vessel (List separately in addition to code for primary procedure) C1753 Catheter, intravascular ultrasound N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion capability) N/A N $0 $0 N/A $0 $0 N/A N/A $0 N/A $0 Total Estimated Payment $10,946 $0 N/A $1,180 N/A

A diagnostic left heart catheterization with coronary angiography was performed via radial artery access that revealed a 90% stenosis in the right coronary artery (RCA). Selective bilateral renal artery angiography during the same session revealed an 85% lesion in the mid-portion of the right renal artery. Prior testing had suggested that renal artery stenosis was a likely cause of the patient s malignant hypertension. Subsequent to the diagnostic evaluation, balloon angioplasty was used to dilate the RCA. A suboptimal angioplasty result in the right renal artery was resolved with placement of an endovascular stent under radiological supervision. Both procedures were successful. Note: MS-DRG assignment will depend upon documented reason for admission. If for the coronary atherosclerosis, then neither of the patient s other diagnoses are considered to be an MCC, so MS-DRG 251 would apply. If considered for the renal artery atherosclerosis, then renovascular malignant hypertension is a CC, and will cause the MS-DRG to be assigned to 253. If the malignant hypertension is the admitting (principal) diagnosis, then it cannot be considered to be a CC of itself neither 414.01 or 440.1 are identified CCs, and MS-DRG 254 would apply. 63 Example 22: Stent Placement in the Right Coronary Artery and Balloon Angioplasty of the Right Renal Artery ICD-9-CM Diagnosis Codes and Descriptions ICD-9-CM Procedure Codes and Descriptions MS-DRG Code and Description 00.66 Percutanous transluminal coronary angioplasty [PTCA] 414.01 Coronary atherosclerosis of native coronary artery 405.01 Secondary renovascular hypertension, malignant 440.1 Atherosclerosis of renal artery 39.50 Angioplasty of other non-coronary vessel(s) 39.90 Insertion of non-drug-eluting, peripheral (noncoronary) vessel stent(s) 37.22 Left heart cardiac catheterization 88.53 Angiocardiography of left heart structures 88.57 Other and unspecified coronary arteriography 00.41 Procedure on two vessels 00.45 Insertion of one stent 251 Percutaneous cardiovascular procedure without coronary artery stent without MCC 253 Other vascular procedures with CC 254 Other vascular procedures without CC or MCC 2014 Relative Wt. 2014 National Average Payment 1.9737 $11,447 2.5172 $14,599 1.7012 $9,866

64 Example 22: Balloon Angioplasty of the Right Coronary Artery and Stent Placement in the Right Renal Artery Hospital Outpatient Rate Payment Ambulatory Surgery Center IDTF Physician APC SI 2014 Nat l 2014 Nat l SI 2014 Nat l 2014 Nat l 2014 In Facility Non-Facility (Office) Avg. Avg. Avg. Avg. Nat l Avg. 2014 2014 2014 2014 CPT and Description APC Rate Payment ASC Rate Payment Payment Rate Payment 93458-59 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 0080 T $2,587 $1,293 N/A -- Invasive or interventional procedure $758 $326 $163 $1,084 $542 interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 92920-RC Percutaneous transluminal coronary balloon angioplasty; single major 0083 T $4,410 $2,205 codes in the Medicine Chapter of CPT are not recognized for ASC payment. $561 $561 Not approved this setting in coronary artery or branch 36252 Selective catheter placement (first order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), imaging postprocessing, 0279 Q2 $2,576 $0 N1 $0 $0 $382 $191 $1,561 $781 permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral 37236-RT Transcatheter placement of an Not Allowed intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, 0229 T $9,120 $9,120 G2 $4,858 $4,858 $482 $241 $2,863 $2,863 including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery C1876 Stent, non-coated/non-covered, with delivery system N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, N/A N $0 $0 N/A $0 $0 N/A $0 N/A $0 infusion/perfusion capability) Total Estimated Payment $12,618 $4,858 N/A $1,156 $4,728

Cordis Corporation Cordis Corporation 2014 155-8319-1 23197 01/14