CardioMEMS HF System Reimbursement and Coding | Abbott
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CARDIOMEMS HF SYSTEM

Reimbursement & Coding

Our reimbursement resources provide information about coverage, coding and payment, denied claims and supporting documentation for the CardioMEMS™ HF System.

Important Medicare Local Coverage Determination (LCD) Update

As of July 1st, 2020, Novitas Solutions, Inc. (NOVITAS) and First Coast Service Options, Inc. (FCSO) retired their local non-coverage policies (LCD L36419 and LCD L33777) for the CardioMEMS HF System. Novitas is the Medicare Administrative Contractor (MAC) that administers the Medicare claims for DE, MD, NJ, PA, DC, AR, CO, LA, MS, NM, OK and TX. FCSO is the MAC for FL, Puerto Rico, and the Virgin Islands.

For dates of service on and after July 1st, 2020, providers can provide pulmonary artery pressure sensor implant (CPT 33289) and remote monitoring services (CPT 93264) for appropriately indicated Medicare patients based on reasonable and medically necessary guidelines similar to the other Medicare contractors. This means that Novitas and FCSO will implicitly cover wireless pulmonary artery sensor implants and remote monitoring based on medical appropriateness and the FDA approved indication, and the claims processing edits for denying the aforementioned procedure codes will be removed. Providers should continue to document medical necessity of the CardioMEMS HF System for their patients.

Coding and Coverage

As a breakthrough, first in-kind technology, the Centers for Medicare and Medicaid Services (CMS) granted the CardioMEMS HF System new technology payments for the inpatient and outpatient hospital settings. These payments recognized the CardioMEMS HF System as a substantial clinical improvement over previous standard of care.

Since these new technology payments have expired, CMS has established both inpatient and outpatient reimbursement mechanisms for the CardioMEMS HF System implant procedure. CMS also established hospital outpatient and office-based reimbursement of ongoing remote monitoring.

At a high level, it is important to note the following:

  • Physician and hospital coding is in place for reporting the CardioMEMS™ Pulmonary Artery (PA) Sensor implant procedure and remote monitoring.
  • Coverage continues to be based on medical necessity. All local Medicare Administrative Contractors (MACs) implicitly cover CardioMEMS implant and remote monitoring procedures based on “reasonable and necessary” guidelines.
    • As of July 1st, 2020, Novitas Solutions, Inc. (NOVITAS) and First Coast Service Options, Inc. (FCSO) retired their local non-coverage policies (LCD L36419 and LCD L33777) for CardioMEMS.
    • Novitas is the Medicare Administrative Contractor (MAC) that administers the Medicare claims for DE, MD, NJ, PA, DC, AR, CO, LA, MS, NM, OK and TX. FCSO is the MAC for FL, Puerto Rico, and the Virgin Islands.
    • For dates of service on and after July 1st, 2020, providers can provide pulmonary artery pressure sensor implant (CPT 33289) and remote monitoring services (CPT 93264) for appropriately indicated Medicare patients based on reasonable and medically necessary guidelines similar to the other Medicare contractors.
    • This means that Novitas and FCSO will implicitly cover wireless pulmonary artery sensor implants and remote monitoring based on medical appropriateness and the FDA approved indication, and the claims processing edits for denying the aforementioned procedure codes will be removed.
    • Providers should continue to document medical necessity of CardioMEMS for their patients.
  • Commercial payers and Medicare Advantage plans may cover depending on the ability to successfully obtain prior authorization.
  • Several commercial payers now have positive coverage policies supporting the CardioMEMS HF System. These policies include Highmark, BCBS of NE and Priority Health. It is always important to check with the payers’ coverage policy and prior authorize for services.
  • Hospital payment is established for the CardioMEMS PA Sensor implant procedure. The CY2020 Medicare national average payment rate for comprehensive ambulatory payment classification (C-APC) 5200 is $28,518 when performed in the outpatient hospital setting. In the inpatient hospital setting, the CardioMEMS HF System implant procedure maps to MS-DRG 264 with a FY2020 Medicare base payment rate of $20,266.

Reimbursement Resources

Please review the following reimbursement resources that provide physician and hospital coding and payment rates for the CardioMEMS HF System and the remote monitoring services provided after the implant. Additional resources and information available on the reimbursement page.

Coding Guides and Resources

CardioMEMS HF System Coding Guide

This Medicare coding and payment guide offers information about reimbursement for pulmonary artery pressure long-term hemodynamic monitoring.

CardioMEMS HF System FAQ Guide

Physician Non-Facility Remote Monitoring Rates by Location

This document provides a Medicare coding and payment overview for remote monitoring by location.

HCPCS Device Category C-codes

This document delivers a current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Frequently Used CPT Codes for Cardiac Device Monitoring Services

This printable form offers an easy CPT coding reference.

Prior Authorization and Appeals

Abbott offers the Prior Authorization and Appeals templates for use by providers when seeking prior authorization or appealing denials of coverage. The objective of these resources is to provide assistance in submitting individual coverage consideration for appropriately indicated patients who may benefit from implantation of a pulmonary sensor device for remote hemodynamic monitoring of heart failure. Download the templates using the links below to customize and provide medical justification for consideration of this procedure.

Letter of Prior Authorization and Medical Necessity

Download a sample letter template that provides suggestions to assist in writing a Letter of Medical Necessity or prior authorization request for CardioMEMS implant. Physicians should customize the letter based on the patient's medical history and diagnosis and to be consistent with any specific prior authorization requirements from the health plan.

Letter of Appeal

Download a sample letter template that provides suggestions to assist in writing a Letter of Appeal of a denial of coverage for CardioMEMS implant procedures. Physicians should customize the letter based on the patient's medical history and diagnosis, and to be consistent with any specific appeal requirements from the health plan.

Webinars

2022 Medicare Payment and Coding Update Focused on the CardioMEMS HF System

This webcast addresses the 2022 Medicare Payment Updates for the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), the Physician Fee Schedule (PFS), and coding and coverage for procedures supporting the CardioMEMS HF System implant and remote monitoring.

Centers for Medicare and Medicaid Services (CMS)

Cardiac Catheterization Performed in Other Than a Hospital Setting

Provides Medicare guidance on coverage when the procedure is performed in a location other than a hospital.

CMS Physician Fee Schedule Prospectus

This guide includes Medicare Physician Payment Rates for cardiovascular procedures. For more detailed information, please refer to the CY Physician Fee Schedule Final Rule on the CMS website.

CMS Inpatient Reimbursement Prospectus

This guide provides a summary of the Medicare Hospital Inpatient Prospective Payment System (IPPS). It includes information on the Readmission Reductions Program, Value Based Purchasing, and Hospital Inpatient Reimbursement Rates for select cardiovascular DRGs. For more detailed information, please refer to the FY IPPS Final Rule on the CMS website.

CMS Outpatient Reimbursement Prospectus

This guide provides a summary of the Medicare Hospital Outpatient Prospective Payment System (OPPS) Update. It includes updates to the Comprehensive APC Policy, Site Neutral Payments, Device Intensive Procedures, the Transitional Pass-Through Payment Policy, and Hospital Outpatient Reimbursement Rates for select cardiovascular APCs. For more detailed information, please refer to the CY OPPS Final Rule on the CMS website.

Medicare Local Coverage Determinations (LCDs)

In the absence of a national coverage policy, an item or service may be covered at a local basis. Check here for a list of CMS policies that provide Medicare beneficiaries coverage in certain locations across the country.

Medicare Learning Network (MLN) Matters Articles

Focusing on coverage, billing, and payment rules for specific provider types, these articles explain national Medicare policy in an easy-to-understand format.

National Correct Coding Initiatives Edits

Developed by CMS, the initiative promotes correct coding methodologies to control improper coding leading to inappropriate payment.

HE&R Disclaimer

This document and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal, reimbursement, business, clinical, or other advice. Furthermore, it is not intended to and does not constitute a representation or guarantee of reimbursement, payment, or charge, or that reimbursement or other payment will be received. It is not intended to increase or maximize payment by any payer. Similarly, nothing in this document should be viewed as instructions for selecting any particular code, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently, and, therefore, the customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding, or reimbursement specialist for any questions related to coding, billing, reimbursement or any related issues. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.

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Coding Challenges

Our regional, field-based Health Economics & Reimbursement (HE&R) team is available to assist with reimbursement education and coding, coverage and payment questions specific to the CardioMEMS HF System and other Abbott therapies and products.

To contact the HE&R team, please email or call the Reimbursement Hotline at (855) 569-6430

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