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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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Hotline +1-855-569-6430

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

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).

Confirm Rx™ Insertable Cardiac Monitor Coding Guide
This quick reference guide covers coding for Confirm Rx™ ICM procedures and follow up.

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.

Clinical Experiences with Remote Monitoring: Guidance for Patient-Centric Care and Clinic Reimbursement
Remote monitoring is critical to ensure appropriate follow-up care for patients implanted with an Abbott cardiac device. This one-hour webcast provides an educational review of remote monitoring for patients with implanted pacemakers, cardiac resynchronization therapy devices, implantable cardioverter defibrillators and implantable cardiac monitors.

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

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.

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

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 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.

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
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

Common CPT Code Modifiers
This printable form offers an easy CPT coding reference.

Frequently Used CPT Codes for Cardiac Device Monitoring Services
This printable form offers an 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

HeartMate 3 and HeartMate II LVAS

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.

CardioMEMS HF System

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.

Indications and Usage: The CardioMEMS™ HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart failure hospitalizations.

Contraindications: The CardioMEMS HF System is contraindicated for patients with an inability to take dual antiplatelet or anticoagulants for one month post implant.

Potential Adverse Events: Potential adverse events associated with the implantation procedure include, but are not limited to, the following: Infection, Arrhythmias, Bleeding, Hematoma, Thrombus, Myocardial infarction, Transient ischemic attack, Stroke, Death, and Device embolization.

CentriMag Circulatory Support System and PediMag Blood Pump

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.

CentriMag Circulatory Support System Indications [PMA Approval; 30-day use]: Temporary circulatory support for up to 30 days for one or both sides of the heart to treat post-cardiotomy patients who fail to wean from cardiopulmonary bypass, providing a bridge to decision when it is unclear whether the patient's heart will recover or whether the patient will need alternative, longer-term therapy.

CentriMag Circulatory Support System Contraindications [PMA Approval; 30-day use]: The CentriMag Circulatory Support System is contraindicated for use as a cardiotomy suction device. The system is also contraindicated for patients who are unable or unwilling to be treated with an appropriate anticoagulant such as Heparin or a comparable alternative.

Humanitarian Device Statement: The CentriMag Circulatory Support System is authorized by Federal Law for temporary circulatory support for up to 30 days for patients in cardiogenic shock due to right ventricular failure. The effectiveness of this device for this use has not been demonstrated.

CentriMag RVAS Indications [Humanitarian Exemption Device (HDE) Approval; 30-day use]: The CentriMag Circulatory Support System is intended to provide temporary circulatory support for up to 30 days for patients in cardiogenic shock due to acute right ventricular failure.

CentriMag RVAS Contraindications [Humanitarian Exemption Device (HDE) Approval; 30-day use]: The CentriMag Circulatory Support System is contraindicated for use as a cardiotomy suction device. The system is also contraindicated for patients who are unable or unwilling to be treated with an appropriate anticoagulant such as Heparin or a comparable alternative.

CentriMag Blood Pump Indications [510(k) Clearance; 6-hour use]: The CentriMag Circulatory Support System is indicated to pump blood through the extracorporeal bypass circuit for extracorporeal circulatory support for periods appropriate to cardiopulmonary bypass (up to six hours). It is also indicated for use in extracorporeal support systems (for periods up to six hours) not requiring complete cardiopulmonary bypass (e.g. valvuloplasty, circulatory support during mitral valve reoperation, surgery of the vena cava or aorta, liver transplants etc.).

CentriMag Blood Pump Contraindications [510(k) Clearance; 6-hour use]: The CentriMag Circulatory Support System is contraindicated for use as a cardiotomy suction device. The system is also contraindicated for patients who are unable or unwilling to be treated with an appropriate anticoagulant such as Heparin or a comparable alternative.

PediMag™ Blood Pump Indications for Use [510(k) Clearance; 6-hour use]: The PediMag Blood Pump is indicated for use with the CentriMag Circulatory Support System console and motor to pump blood through the extracorporeal bypass circuit for extracorporeal circulatory support for periods appropriate to cardiopulmonary bypass (up to six hours) for surgical procedures such as mitral valve reoperation. It is also indicated for use in extracorporeal support systems (for periods up to six hours) not requiring complete cardiopulmonary bypass (e.g. valvuloplasty, circulatory support during mitral valve reoperation, surgery of the vena cava or aorta, liver transplants etc.).

PediMag Blood Pump Contraindications [510(k) Clearance; 6-hour use]: The PediMag Blood Pump is contraindicated for use as a cardiotomy suction device. The CentriMag Circulatory Support System is contraindicated for use as a cardiotomy suction device. The system is also contraindicated for patients who are unable or unwilling to be treated with an appropriate anticoagulant such as Heparin

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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