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Coding and Coverage Resources

Find reimbursement resources, including coding guides, links to Medicare Coverage Determinations, on-demand webinars, and frequently asked questions pertaining to Abbott cardiovascular products.

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Contact our Healthcare Economics and Reimbursement Department for additional information or assistance. Our contact details are below.

Healthcare Economics and Reimbursement Department

Hotline +1-855-569-6430

ELECTRO-PHYSIOLOGY
CARDIAC RHYTHM MANAGEMENT
HEART FAILURE
STRUCTURAL HEART
VASCULAR

Electrophysiology

This page contains medical coding and reimbursement resources for products used to conduct electrophysiology procedures:

Coding Guides and C-Codes | Webinars | Centers for Medicare and Medicaid (CMS)

 

Coding Guides and C-Codes

Electrophysiology Coding Guide

Medicare coding and payment guide for EP services, including catheter ablation

HCPCS Device Category C-codes

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Common CPT Code Modifiers

Printable form for easy CPT coding reference

Frequently Used CPT‡ Codes for Catheter Ablation and Related Procedures

Printable form for easy CPT‡ coding reference

 

Webinars

2020 Update on Medicare Reimbursement for Electrophysiology

This one-hour webcast addresses coding and payment surrounding Electrophysiologic procedures. First, we provide an overview of an EP ablation procedure. Then we discuss 2020 coding and payment for EP ablations, EP studies, and other add on services. Finally, we review common clinical scenarios and how to appropriately report them to Medicare.

 

Centers for Medicare and Medicaid (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)

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.

Cardiac Rhythm Management

This page contains coding and reimbursement resources for Abbott cardiac rhythm management devices.

Coding Guides and Resources | Centers for Medicare and Medicaid (CMS) | Webinars

 

Coding Guides and Resources

Cardiac Rhythm Management (CRM) Coding Guide

Find Medicare coding and national payment rates for cardiac rhythm management (CRM).

Insertable Cardiac Monitors (ICM) Coding Guide

Find Medicare coding and national payment rates for Insertable/Implantable Cardiac Monitors (ICM).

Physician Non-Facility Device Monitoring Rates by Location

Find Medicare coding and payment rates, by location, for cardiac device monitoring in physician offices (non-facilities).

Cardiac Device Monitoring: CPT Codes and Common Questions

Find a summary of Medicare coding and answers to Frequently Asked Questions for device monitoring for Pacemakers, Implantable Cardioverter Defibrillators (ICD), Cardiac Resynchronization Therapy (CRT) and Insertable/Implantable Cardiac Monitors (ICM).

Insertable Cardiac Monitors (ICM) In Office Readiness Checklist

Use this printable form to assess your physician office’s readiness to begin implanting and monitoring ICMs.

HCPCS Device Category C-codes Guide

Current reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes.

 

Centers for Medicare and Medicaid (CMS)

Pacemaker NCD

Developed through an evidence-based process, this guide provides details on required medical criteria that must be met for coverage of Medicare beneficiaries.

Implantable Cardioverter Defibrillators (ICDs) NCD

Developed through an evidence-based process, this guide provides details on required medical criteria that must be met for coverage of Medicare beneficiaries.

Implantable Cardioverter Defibrillator National Coverage Determination FAQs

Coverage considerations and Frequently Asked Questions regarding ICDs.

 

Webinars

2020 ICM Insertion/Remote Monitoring Reimbursement Update

This webcast addresses coding and payment for Insertable/Implantable Cardiac Monitors (ICMs). First, we provide an overview of ICM technology and the insertion process. Then we discuss 2020 coverage, coding and payment for ICMs, including the 2020 changes to ICM remote monitoring coding. Finally, we review common patient scenarios and how to appropriately report them to Medicare.

2019/2020 Reimbursement Update: Cardiac Rhythm Management (CRM)

This one-hour webcast addresses coding, payment and national coverage indications for Pacemakers, Implantable Cardioverter Defibrillators (ICDs), and Cardiac Resynchronization Therapy (CRT-P/CRT-D). It provides an overview of payment under Medicare’s FY 2020 Inpatient Prospective Payment System (IPPS) and Medicare’s FY 2019 Physician Fee Schedule (PFS), Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment system. The program also includes common patient scenarios and how to appropriately report to Medicare.

Health Economic Summit Episode 1 - Cardiac Resynchronization Therapy (CRT)

This program is a one-hour webcast facilitated by cardiologist Dr. John Rogers. Economic and product specific topics related to CRT will be addressed including patient outcomes, Medicare reimbursement, and the economics of heart failure.

Heart Failure

This page contains coding and reimbursement resources for devices and systems used to treat heart failure:

Mechanical Circulatory Support | Acute Mechanical Circulatory Support | Pulmonary Pressure Monitoring

 

Mechanical Circulatory Support

In this section:

Coding Guides and Resources | Webinars | National Coverage Determinations | Centers for Medicare and Medicaid Services (CMS)

 

Coding Guides and Resources

Mechanical Circulatory Support (MCS) Coding Guide

Medicare coding and payment guide for for the HeartMate II™ LVAS, HeartMate 3™ LVAS and other mechanical circulatory support products

Acute Mechanical Circulatory Support (MCS) Coding Guide

Medicare coding and payment guide for the CentriMag™ System and other acute circulatory mechanical support products

Acute MCS – ECMO Coding Guide

Medicare coding and payment guide for CentriMag for utilization as Extracorporeal Membrane Oxygenation (ECMO) support

Mechanical Circulatory Support (MCS) FAQ Guide

Coverage considerations and Frequently Asked Questions surrounding MCS

HCPCS Device Category C-codes

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Common CPT Code Modifiers

Printable form for easy CPT coding reference

 

National Coverage Determinations From Medicare and Medicaid

National Coverage Determination (NCD) for Ventricular Assist Devices

Developed through an evidence-based process, this policy provides details on required medical criteria that must be met for coverage of Medicare beneficiaries.

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.

 

Centers for Medicare and Medicaid Services (CMS)

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.

 

Acute Mechanical Circulatory Support

In this section:

Coding Guides and Resources | Webinars | National Coverage Determinations | Centers for Medicare and Medicaid Services (CMS)

 

Coding Guides and Resources

Acute Mechanical Circulatory Support (MCS) Coding Guide

Medicare coding and payment guide for CentriMag and other acute mechanical circulatory support products

Acute MCS – ECMO Coding Guide

Medicare coding and payment guide for CentriMag for utilization as Extracorporeal Membrane Oxygenation (ECMO) support

HCPCS Device Category C-codes Guide

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Common CPT Code Modifiers

Printable form for easy CPT coding reference

 

National Coverage Determinations From Medicare and Medicaid

National Coverage Determination (NCD) for Ventricular Assist Devices

Developed through an evidence-based process, this policy provides details on required medical criteria that must be met for coverage of Medicare beneficiaries.

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.

 

Centers for Medicare and Medicaid Services (CMS)

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.

 

Pulmonary Pressure Monitoring

In this section:

Coding Guides and Resources | Webinars | Centers for Medicare and Medicaid Services (CMS)

If you need further assistance, connect with our Patient Therapy Access Team by phone or email: +1-800-727-7846

 

Coding Guides and Resources

CardioMEMS™ HF System Coding Guide

Medicare coding and payment guide for pulmonary artery pressure long term hemodynamic monitoring

CardioMEMS HF System FAQ Guide

Coverage considerations and Frequently Asked Questions surrounding the CardioMEMS HF System

Physician Non-Facility Remote Monitoring Rates by Location

Medicare coding and payment overview for remote monitoring by location

HCPCS Device Category C-codes

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Common CPT Code Modifiers

Printable form for easy CPT coding reference

Frequently Used CPT Codes for Cardiac Device Monitoring Services

Printable form for easy CPT‡ coding reference

 

Webinars

2020 Medicare Payment and Coding Update focused on the CardioMEMS Heart Failure System

This webcast addresses the 2020 Medicare Outpatient Prospective Payment System (OPPS), Physician Fee Schedule (PFS) payment and new CPT‡ 1 codes for the CardioMEMS 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.

Indications, Safety & Warnings

Rx Only

Brief Summary:
Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use.

HeartMate 3 LVAS Indications: The HeartMate 3 Left Ventricular Assist System is indicated for providing short- and long-term mechanical circulatory support (e.g., as bridge to transplant or myocardial recovery, or destination therapy) in patients with advanced refractory left ventricular heart failure.

HeartMate II LVAS Indications: The HeartMate II Left Ventricular Assist System is indicated for use as a “bridge to transplantation” for cardiac transplant candidates who are at risk of imminent death from non-reversible left ventricle failure. It is also indicated for use in patients with New York Heart Association (NYHA) Class IIIB or IV end-stage left ventricular failure, who have received optimal medical therapy for at least 45 of the last 60 days, and who are not candidates for cardiac transplantation. The HeartMate II Left Ventricular Assist System is intended for use both inside and outside of the hospital, or for transportation of Left Ventricular Assist Device patients via ground ambulance, airplane, or helicopter.

HeartMate 3 and HeartMate II LVAS Contraindications: The HeartMate 3 and HeartMate II Left Ventricular Assist Systems are contraindicated for patients who cannot tolerate, or who are allergic to, anticoagulation therapy.

HeartMate 3 and HeartMate II LVAS Adverse Events: Adverse events that may be associated with the use of the HeartMate 3 or HeartMate II Left Ventricular Assist System are listed below: death, bleeding, cardiac arrhythmia, localized infection, right heart failure, respiratory failure, device malfunctions, driveline infection, renal dysfunction, sepsis, stroke, other neurological event (not stroke-related), hepatic dysfunction, psychiatric episode, venous thromboembolism, hypertension, arterial non-central nervous system (CNS), thromboembolism, pericardial fluid collection, pump pocket or pseudo pocket infection, myocardial infarction, wound dehiscence, hemolysis (not associated with suspected device thrombosis) and possible pump thrombosis.

Structural Heart

This page contains coding and reimbursement resources for products used to treat structural heart conditions:

Structural Interventions and Heart Valve Replacement | MitraClip Repair

 

Structural Interventions and Heart Valve Replacement, Including PFO Closure

In this section:

Coding Guides and Resources | Centers for Medicare and Medicaid Services (CMS)

 

Coding Guides and Resources

Structural Heart and Valves Coding Guide

Medicare coding and payment guide for for the surgical heart valves

Amplatzer Piccolo™ Occluder Coding and Reimbursement Guide

Medicare coding and payment guide for Patent Ductus Arteriosus (PDA) closure procedures

PFO Letter of Medical Necessity

Template to be considered for prior authorization by physicians

PFO Letter of Appeal

Template to be considered when requesting reconsideration of a denied claim or pre-authorization

Patent Foramen Ovale Closure with the Amplatzer™ PFO Occluder for Secondary Stroke Reduction of Risk in Patients with Cryptogenic Stroke: Summary of Clinical Evidence

Clinical study results combined into one document

Clinical Documentation Checklist: Diagnosis of Cryptogenic Ischemic Stroke

Use this printable form to assist with diagnosis of this condition

 

Centers for Medicare and Medicaid Services (CMS)

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 National Coverage Determinations (NCDs)

Developed through an evidence-based process, check here for a list of CMS policies that provide coverage for all Medicare beneficiaries.

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.

 

MitraClip Repair

In this section:

Coding Guides and Resources | Centers for Medicare and Medicaid Services (CMS)

 

Coding Guides and Resources

MitraClip™ Hospital and Physician Coding and Payment Guide

Medicare coding and payment guide for TMVr procedures

MitraClip Appeal Template Letter

To be considered when appealing a denial of claim or pre-authorization

MitraClip Clinical Assessment of Prohibitive Risk for Mitral Valve Surgery

Use this guide to help facilitate a clinical determination of an individual patient’s surgical risk status

MitraClip Hospital Claim Checklist

Provides coding guidance for Medicare fee-for-service hospital claims

MitraClip Implanting Physician Checklist

Provides coding guidance for Medicare fee-for-service physician claims

MitraClip Echocardiographer Checklist

Provides coding guidance for Medicare fee-for-service echocardiographer claims

 

Centers for Medicare and Medicaid Services (CMS)

TMVr National Coverage Determination

Developed through an evidence-based process, this policy provides details on required medical criteria that must be met for coverage of Medicare beneficiaries.

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 National Coverage Determinations (NCDs)

Developed through an evidence-based process, check here for a list of CMS policies that provide coverage for all Medicare beneficiaries.

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.

Vascular

This page contains coding and reimbursement resources for products used to treat vascular conditions:

Reimbursement Resources for All Vascular Interventions | Carotid Artery Stenting | Coronary | Peripheral

 

Reimbursement Resources for all Vascular Interventions

In this section:

Medicare Reimbursement Guides | Additional coding resources

 

Medicare Reimbursement Guides

Inpatient Prospective Payment System (IPPS)

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.

Outpatient Prospective Payment System (OPPS)

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.

Ambulatory Surgical Center and Office Based Lab Reimbursement Guide

Medicare coding and payment guide for procedures performed in ASC and OBL settings

Physician Fee Reimbursement Guide

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.

 

Additional Coding Resources

Common CPT Code Modifiers

Printable form for easy CPT coding reference

HCPCS Device Category C-Codes

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

 

Carotid Artery Stenting

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

In this section:

Medicare and commercial payer coverage | CMS-approved facilities | Carotid stenting prior authorization toolkit

 

Medicare and commercial payer coverage

Medicare (CMS) Coverage

CMS coverage of carotid artery stenting (CAS) began in July 2001 when coverage of CAS was limited to patients enrolled in an IDE trial. Since that time, CMS has published multiple related coverage policies for carotid artery stenting. Policies cover CAS in an IDE investigational trial setting, in a post-approval trial setting, in a post-approval extension trial setting, and for a subset of FDA-approved indications, there is coverage outside of trials. Please view the CMS national coverage determination for additional information.

Please note: Effective December 9, 2009 Medicare clarified coverage for carotid artery stenting requiring the use of an FDA-approved or cleared embolic protection device. Medicare clarified if deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by Medicare.1

In September 2014, CMS granted approval for Percutaneous Transluminal Angioplasty (PTA) to cover carotid artery stenting through the CREST-2 trial and the CREST-2 Registry. Please view the CMS national coverage determination for additional information.

 

CREST-2

(Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial)

CREST-2, sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH), is intended to evaluate the best approach for managing asymptomatic patients with high-grade carotid atherosclerotic stenosis. This prospective multi-center randomized controlled trial started enrollment in 2014 and is expected to complete final data collection for primary outcome measure in 2020. CREST-2 site selection and credentialing is managed by a multi-disciplinary committee. Please visit the NIH StrokeNet web site or the CREST-2 Trial web site for additional information.

 

CREST-2 Registry (C2R)

The objective of CREST-2 Registry is to promote the rapid initiation and completion of patient enrollment in the CREST-2 trial. Accreditation for Cardiovascular Excellence (ACE) was selected by CMS to accredit C2R clinical sites.

National Cardiovascular Data Registry (NCDR) Peripheral Vascular Intervention (PVI) Registry and Society for Vascular Surgery’s Vascular Quality Initiative (VQI) are the selected registries to administer C2R data collection. Each C2R participating operator/site is required to have membership for either the NCDR-PVI Registry or the SVS-VQI Registry.

 

Commercial Coverage Policies / Other Third-Party Payers

Because commercial coverage varies regionally, Abbott recommends that providers verify insurance coverage prior to performing procedures.

1 Center for Medicare and Medicaid Services (CMS), Pub 100-3 Medicare National Coverage Determinations, Transmittal 115, March 5, 2010. https://www.cms.gov

References:
Centers for Medicare and Medicaid Services at www.cms.gov

 

CMS-approved facilities

Effective March 2005, the Centers for Medicare and Medicaid Services (CMS) expanded coverage of carotid artery stenting (CAS) to patients who were not enrolled in medical device trials (IDE or FDA-required post-approval). With the coverage decision, CMS stated that all facilities who planned to develop a carotid stenting program and treat patients outside of studies would have to meet additional requirements. For detailed information about CMS' coverage policy of carotid stenting procedures, please visit:

https://www.cms.gov

These requirements are summarized below:

  • All facilities shall submit an affidavit attesting to meeting specific minimum standards or attesting that they have participated in an FDA-approved carotid stenting trial (IDE or FDA required post-approval study)
  • Facilities will collect data on all carotid stenting procedures
  • Facilities will have a clear credentialing program for interventionalists performing carotid stenting

View the list of CMS Approved Carotid Stenting Facilities at the CMS website.

 

Carotid stenting prior authorization toolkit

Abbott offers this Carotid Stenting Prior Authorization Tool Kit for use by physicians and their offices when seeking prior authorization or submitting claims to plans requiring such pre-procedure approvals. This comprehensive tool kit includes information to assist your office in submitting prior authorization requests to private payers to confirm coverage for patients who may benefit from a carotid artery stent (CAS) procedure. Download the guide and the accompanying forms using the links below.

Abbott recommends seeking prior authorization for all cases except those covered by traditional (fee for service) Medicare. Please note, prior authorization is not required for fee for service Medicare patients.

Tool Kit Instructions

Download this guide for submitting prior authorization requests for your patients to private payers. It includes instructions on how to use this tool kit and the associated forms and provides a checklist of the key steps necessary to request authorization.

FDA CAS Approval Letter

Download a copy of the FDA approval letter for the RX Acculink Carotid Stent System. This letter may be required as part of the submission for CAS authorization.

Sample Standard Risk Letter of Medical Necessity

Download a sample letter template that provides suggestions to assist in writing a Letter of Medical Necessity or prior authorization request for the Acculink Carotid Artery Stent System with Accunet Embolic Protection for patients with carotid artery disease at standard surgical risk. Physicians should customize the letter based on the patient’s actual medical history and diagnosis, and to be consistent with any specific payer requirements.

Sample High Risk Letter of Medical Necessity

Download a sample letter template that provides suggestions to assist in writing a Letter of Medical Necessity or prior authorization request for the Acculink Carotid Artery Stent System with Accunet Embolic Protection for patients with carotid artery disease at high surgical risk. Physicians should customize the letter based on the patient’s actual medical history and diagnosis, and to be consistent with any specific payer requirements.

 

Coronary

Local Medicare Administrative Contractors (MACs) as well as other third party payers have their own coverage policies for coronary interventions and devices. You should contact your local Medicare Contractor and third party payers for information on their specific coverage policies for interventional cardiology. There is currently no national Medicare coverage decision for coronary interventions. Most local Medicare Contractors, Fiscal Intermediaries and/or Carriers have posted their Local Coverage Determinations (LCD) on interventional cardiology on their websites. You can find a list of Medicare Administrative Contractors, Fiscal Intermediaries and Carriers at the CMS webpage.

In this section:

Coding guides and resources | Medicare Local and National Coverage Determinations | Vessel closure details

 

Coding guides and resources

Coronary Interventions Coding Guide

Medicare coding and payment guide for coronary procedures, including Fractional Flow Reserve (FFR) and Optical Coherence Tomography (OCT) procedures

Chronic Total Occlusions (CTO) Guide

Medicare coding and payment guide for coronary artery chronic occlusion procedures

ACC-SCAI Coding Recommendation for RFR

Society provided coding recommendations

Common CPT Code Modifiers

Printable form for easy CPT coding reference

C-Code List by Product

Printable form for easy CPT coding reference

HCPCS Device Category C-Code

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

 

Medicare local and national coverage determinations

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 National Coverage Determinations (NCDs)

Developed through an evidence-based process, check here for a list of CMS policies that provide coverage for all Medicare beneficiaries.

 

Vessel closure details

The following code has been assigned to occlusive devices by CMS: G0269

G0269 is defined as: placement of an occlusive device in either a venous or arterial access site, post-surgical or interventional procedure.

Code G0269 should be used on Medicare claims to record the placement of the vasoseal and for other payers as directed.

 

Peripheral

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

In this section:

Coding guides and resources | Medicare local and national coverage determinations | Commercial coverage information

 

Coding guides and resources

Ambulatory Surgical Center and Office Based Lab Reimbursement Guide

Medicare coding and payment guide for procedures performed in ASC and OBL settings

Common CPT Code Modifiers

Printable form for easy CPT coding reference

C-Code List by Product

Printable form for easy CPT coding reference

HCPCS Device Category C-Codes Guide

Current list of reimbursement Healthcare Procedural Coding System (HCPCS) Device Category C-codes

Physician Fee Schedule

Medicare coding and payment guide for physicians performing vascular procedures

 

Medicare local and national coverage determinations

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 National Coverage Determinations (NCDs)

Developed through an evidence-based process, check here for a list of CMS policies that provide coverage for all Medicare beneficiaries.

 

Commercial coverage information

Commercial Coverage of peripheral interventions may vary. For reimbursement purposes, Abbott Vascular recommends that providers verify insurance coverage prior to performing a procedure.

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 update reproduces information for reference purposes only. It is not provided or authorized for marketing use.

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The following pages are intended for medical professionals and provide information on the proper use of products (medical devices, etc.) of Abbott Medical Japan GK.

The information provided here is not intended to provide information to patients and the general public.



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