Vascular Plug Procedures» 2013 Coding and Payment Reference Guide St. Jude Medical Cardiovascular Division
2 IMPORTANT: St. Jude Medical provides this reference for information purposes only. This reference guide does not serve as reimbursement or legal advice, nor is it intended to increase payment from any payer. Nothing in this reference guide guarantees that the levels of reimbursement, payment or charges are accurate or that reimbursement will be received. The health care professional (HCP) is responsible for obtaining reimbursement and for verifying the accuracy and veracity of all claims submitted to third-party payers. Laws, regulations and coverage policies are complex and updated frequently, and therefore HCPs should consult their payers directly regarding coverage policies. Please find the coding and payment information for procedures including the use of vascular plugs, below. In addition, St. Jude Medical offers a reimbursement hotline, which provides live coding and billing information from dedicated reimbursement specialists. Hotline support is available from 8:00 a.m. to 5:00 p.m. Central Time, Monday through Friday at (855) 569-6430. Hotline reimbursement assistance is provided subject to the disclaimers set forth above. Common PHYSICIAN Procedure Codes for Vascular Plug Procedures Effective January 1 December 31, 2013 CPT Code 1 37204 Description Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, noncentral nervous system, non-head or neck Medicare Average National Payment Rate 2 $900 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation $66 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion $83 Notes: The vascular plug may be used in stand-alone procedures or as an adjunct to a more comprehensive procedure Add selective catheter placement codes as applicable Common HOSPITAL INPATIENT Procedure Codes for Vascular Plug Procedures Effective October 1, 2012 September 30, 2013 ICD-9-CM Procedure Code 3 Description Common Medicare MS-DRG Assignment Medicare National Average MS-DRG Payment 4 39.79 Other endovascular procedures on other vessels 237 Major cardiovascular procedures with MCC 238 Major cardiovascular procedures without MCC $29,547 $18,398 MCC major complications and comorbidities; CC complications and comorbidities
3 Common HOSPTIAL OUTPATIENT Procedure Codes for Vascular Plug Procedures Effective January 1 December 31, 2013 CPT Code 1 Description APC 5 Description Status Indicator 5 Medicare National Average APC Payment 5 37204 Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck 0082 Coronary or Non-Coronary Atherectomy T $7,671* 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation NA N Bundled 75898 Angiography through existing catheter for followup study for transcatheter therapy, embolization or infusion NA 6 Q1 Bundled Applicable C-Codes 6 C1769 Guide wire N/A N Bundled Status Indicators: T=Significant Procedure, multiple procedure applies; N=Items and Services Packaged into APC Rates; Q1 = Paid under OPPS; Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, V, or X *NOTE: Payment for this APC may change on a quarterly basis. Please consult www.cms.gov. Common CPT Code Modifiers 1 22 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient s condition, physical and mental effort required. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by adding modifier 50 to the appropriate 5 digit code. 51 Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated add-on codes. 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure.
4 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 25. 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or qualified health care professional subsequent to the original procedure or service. 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. 80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). 81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. 82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). 99 Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
5 References: 1. Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. 2. Per CMS-1590-FC determined by multiplying the physician fee schedule conversion factor ($34.0230) by the total adjusted facility relative value units (RVUs). Payment amount represents national average with no geographic adjustment. Individual physician reimbursement will vary. 3. ICD-9-CM Code Book - v30 FY2013 (Effective October 1, 2012). 4. Per CMS-1588-F Assumes payment for a large urban hospital with wage index > 1 and full update. Medicare payment = MS-DRG relative weight x (labor standardized amount + non-labor standardized amount + capital rate). 5. Per CMS-1589-FC. 6. CPT 75898 maps to APC 0397, Vascular Imaging. The APC status indicator for CPT 75898 is Q1, and APC payment is packaged when performed on the same date of service as other CPT codes assigned status indicators S, T, V or X. 7. Per CMS List of Device Category Codes for Present or Previous Pass-Through Payment and Related Definitions, Updated January, 2012. Unless otherwise noted, indicates that the name is a trademark of, or licensed to, St. Jude Medical or one of its subsidiaries. ST. JUDE MEDICAL, the nine-squares symbol and MORE CONTROL. LESS RISK. are trademarks and services marks of St. Jude Medical, Inc. and its related companies. 2013 St. Jude Medical, Inc. All Rights Reserved. MM01017 (01) US 07/12 IPN 2400-12