Billing for Intracoronary Stent Placement

Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug-eluting or drug-eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Intracoronary Drug-Eluting Stents), respectively). In order to effectuate this policy, we created HCPCS G-codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug-eluting intracoronary stent placement procedures that parallel existing Procedure  codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug-eluting intracoronary stent placement procedures. For CY 2012 and years prior, Procedure  codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.

Effective January 1, 2013, the AMA’s Procedure  Editorial Panel is deleting Procedure  codes 92980 and 92981 and replacing them with the following new Procedure  codes:

Procedure  code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)

• Procedure  code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• Procedure  code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);

• Procedure  code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• Procedure  code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);

• Procedure  code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));

• Procedure  code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);

• Procedure  code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel); and

• Procedure  code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).

In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C-codes to parallel the new Procedure  codes:

• HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);

• HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);

• HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));

• HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);

• HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel); and

• HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).

Procedure  codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug-eluting intracoronary stent placement procedures and are assigned to APC 0104. HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.

Transitional Corridor Payments

The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit provider’s losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.

Section 405 of BIPA provides that children’s hospitals described in §1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000. Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below. Contractors determine TOPs eligibility and calculate interim TOPs.

Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC. The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data. TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.

Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC. They are:

• The provider number;

• Fiscal year begin date;

• The provider type;

• Actual geographic location – CBSA (from the IPSF);

• Wage index location – CBSA (from the IPSF); and

• Bed size (from the IPSF)

Pursuant to §403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost report for the cost reporting period ending in calendar year 1996. The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment-to-cost ratio used in calculating a TOP will be based on the hospital’s first cost report for a period ending after calendar year 1996 and before calendar year 2001. This provision is effective retroactively to August 1, 2000.

Future updates will be issued in a Recurring Update Notification.

Coverage Indications, Limitations, and/or Medical Necessity

Overview

Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty or simply angioplasty, is a non-surgical procedure used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease. These stenotic segments are due to the buildup of the cholesterol-laden plaques that form due to atherosclerosis. During PCI, a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. A stent is often placed at the site of blockage to permanently open the artery.

Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.

Indications:

Percutaneous coronary intervention (PCI) may be indicated in the management of patients with:
acute coronary syndrome (e.g. acute myocardial infarction, unstable angina)

a history of significant obstructive atherosclerotic disease

restenosis of a coronary artery previously treated with intracoronary stent or other revascularization procedure

chronic angina

silent ischemia

Intracoronary ultrasound (IVUS) may be separately covered when needed to assess the extent of coronary stenosis if equivocal on angiography, or when needed to assess the patency and integrity of a coronary artery during percutaneous coronary intervention. Alternatively, intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement may be performed to assess the degree of stenosis within a vessel. Intracoronary ultrasound or fractional flow reserve measurement should be performed on an individual artery as clinically indicated. Both procedures are not considered medically necessary unless written documentation is submitted to support medical necessity. Intracoronary ultrasound and Doppler fractional flow reserve studies can be required in multivessel coronary artery disease (CAD).

A diagnostic cardiac catheterization to assess the nature of the lesion(s) prior to the intervention is a covered service. The diagnostic cardiac catheterization may be performed at any time prior to the PCI, including the same day as the PCI. Performance of a diagnostic cardiac catheterization and interventional procedure on the same day is increasingly the standard of practice. If the diagnostic catheterization is done within 30 days of the PCI, it is usually not necessary to repeat the catheterization unless there is a documented change in the patient’s condition. While there may be reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center, excessive dye load, further treatment planning or evaluation of angiography, etc.), it is recommended that both procedures be performed during the same encounter when medically appropriate, with detailed discussion of benefits and risks of PCI. Separation of these procedures for the purpose of circumventing the multiple surgery pricing, or for the convenience of physician or hospital scheduling, is considered an inappropriate practice and may subject the services to review and denial for medical necessity. The decision to stage these procedures is deferred to the judgment of the interventional cardiologist, and individualized only to the clinical needs of the patient. (e.g., dye load already received; need to correlate findings with other test results, etc.). Reasons for delaying an indicated percutaneous coronary intervention should be documented in the medical record. Unless there is a new clinical event, a change in symptomatology, abnormal examination or other test results, a repeat diagnostic catheterization within three months of the last diagnostic catheterization and prior to the percutaneous coronary intervention is generally not reimbursable and is considered not reasonable and necessary.

Limitations: 

Generally PCI is not indicated for:
Patients that can be managed medically.

Right heart catheterization and insertion of a Swan – Ganz catheter are not generally medically necessary for a PCI and will be denied, unless medically necessary when performed incident to a diagnostic catheterization prior to the intervention.

Standby services of a surgeon or anesthesiologist are not covered services.

Patient with stable CAD.



ICD-10 Codes that may support medical necessity (for dates of service on or after October 1, 2015): Drug-eluting Stents for Ischemic Heart Disease

I20.0 – I20.9 Angina pectoris
I21.01 – I21.4 ST elevation (STEMI) and non-ST elevation (NSTEMI)
myocardial infarction
I22.0 – I22.9 Subsequent ST elevation (STEMI) and non-ST elevation
(NSTEMI) myocardial infarction
I24.0 – I24.9 Other acute ischemic heart diseases
I25.10 – I25.119 Atherosclerotic heart disease of native coronary artery with or
without angina pectoris
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 – I25.799 Atherosclerosis of coronary artery bypass graft(s) and coronary
artery of transplanted heart with angina pectoris
I25.810 – I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
T82.817A – T82.817S Embolism of cardiac prosthetic devices, implants and grafts
T82.827A – T82.827S Fibrosis of cardiac prosthetic devices, implants and grafts
T82.837A – T82.837S Hemorrhage of cardiac prosthetic devices, implants and grafts
T82.847A – T82.847S Pain from cardiac prosthetic devices, implants and grafts
T82.857A – T82.857S Stenosis of cardiac prosthetic devices, implants and grafts
T82.867A – T82.867S Thrombosis of cardiac prosthetic devices, implants and grafts
T82.897A – T82.897S Other specified complication of cardiac prosthetic devices,
implants and grafts
T82.9xxA – T82.9xxS Unspecified complication of cardiac and vascular prosthetic
device, implant and graft
36.07:
Insertion of drug-eluting coronary
artery stent(s)
00.66:
Percutaneous transluminal
coronary angioplasty
17.55
Transluminal coronary
atherectomy
Code Also
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 one vascular stent
00.46:
Insertion of two vascular stents
00.47:
Insertion of three vascular stents
00.48:
Insertion of four or more vascular stent

00.24:
Intravascular imaging of coronary
vessels
00.28:
Intravascular imaging, other
specified vessel(s)
00.29:
Intravascular imaging unspecified
vessel(s)