2014 Medicare Hospital Coding and Reimbursement Changes. January, 2014

Transcription

1 204 Medicare Hospital Coding and Reimbursement Changes January, 204

2 Disclaimer This presentation is intended only for educational use. Any duplication is prohibited without written consent of the authors. This information does not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for their interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. CPT Information: CPT copyright 203 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. Note: CPT code descriptions may be abbreviated and not listed in their entirety in all cases in this presentation. For full descriptions, please refer to your CPT code book. 2

3 AAPC This program has prior approval of the American Academy of Professional Coders (AAPC) for one continuing education hour. Granting of this prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor. The AAPC requires attendees to listen to the entire presentation in order to qualify for the CEU certificate. 3

4 Agenda Coding and APC Changes for CY 204 Coding Scenarios for Cardiac Rhythm Devices/Catheters Coronary Procedure Payments Cardiac Device Monitoring Services Additional Information & Resources Appendix 4

5 Coding and APC Changes for CY 204 5

6 Changes in Outpatient Services Payment: 6

7 204 Packaged Services Five categories are packaged effective January st. Add-on procedures 2. Device removal procedures 3. Certain clinical Lab tests 4. Drugs, biologicals, and radiopharmaceuticals used in a diagnostic test or procedure 5. Drugs and biologicals when used as supplies in a surgical procedure Addendum P provides the list of codes associated with these packaged services. See below for one example of each category: (3D mapping) (remove pacemaker generator) (complete blood count CBC) 4. J250 (stress agent dobutamine HCL/250 mg) 5. Q406 (skin substitute dermagraft) This packaging is in addition to those procedures and items already packaged due to status N designation. December 0, 203 Federal Register publication of the CY 204 Final Rule (CMS-60-FC), pages 74832, and Addendum P 7

8 204 OPPS Device Removal Packaged Procedures CPT code Brief description Remove pacemaker generator only Remove transvenous pacemaker lead, single lead system atrial or ventricular Remove transvenous pacemaker leads, dual lead system 3324 Remove ICD generator only Remove single or dual ICD lead(s), by transvenous extraction Remove implantable loop recorder OPPS Final Rule Home Page for CY 204, CY 204 Addendum P 8

9 Packaged Removal Codes Payment Comparisons Service provided Remove PM generator and insert ICD system 204 National Payment 203 National Payment % Change $32,45 $3, % Remove lead from single chamber pacemaker and insert new lead $4,602 $4,608 (0.%) Remove ICD generator, all of the ICD leads and insert ICD system $32,45 $32,363 (0.7%) OPPS Final Rule Home Page for CY 204 and 203, Addendum B 9

10 Coming Next: Comprehensive APCs Implementation date for Comprehensive Ambulatory Payment Classifications (APCs) is To improve accuracy and increase transparency for Medicare payment, 29 Comprehensive APCs will be created for device dependent procedures. Many of these are in the cardiovascular service line. All services on the claim that represent the provision of the primary service and all adjunctive services that are integral to or support the delivery of the service will be bundled as a component of the Comprehensive APC payment. Therefore, one single payment will be made by Medicare. December 0, 203 Federal Register publication of the CY 204 Final Rule (CMS-60-FC), page

11 Hospital Outpatient Visits Medicare has created a single level II HCPCS code (G0634) for the technical component of the Outpatient (OP) visit: G0634 falls under the new APC 0634 [Hospital Clinic Visits]. The CY 204 national payment is $ The 5 levels of OP visit CPT codes will not be accepted by Medicare for services provided on and after January st, 204. These visit codes are: and Medicare did not finalize replacing the 5 level ED (Emergency Department, Type A and B) CPT visit codes with a single HCPCS level II code. CPT codes continue to be valid for reporting ED visits. December 0, 203 Federal Register publication of the CY 204 Final Rule (CMS-60-FC), pages 74832,

12 More 204 Changes 2

13 204 OPPS: APC Reassignments CPT Code Brief Description Reposition pacer/icd lead Reposition LV lead Relocate pocket for pacer Relocate pocket for ICD 204 APC and National Payment APC 003 $,524 APC 0328 $, Remove ILR APC 002 $, In person device evaluation of implantable CV monitor Electronic of antitachycardia pacemaker system Initial set-up of wearable cardioverter-defibrillator $36.5 APC 069 $276 APC 069 $ APC and National Payment APC 005 $,683 APC 036 $,2 APC 0020 $584 APC 0035 $23.43 $33.95 $33.95 The OPPS Final Rule Home Page for CY 204 and 203, Addendum B 3

14 Pocket Revision CPT Description Changes 33222: Relocation of skin pocket for pacemaker 33223: Relocation of skin pocket for cardioverter-defibrillator Revision of a skin pocket is included in , Relocating of a skin pocket for a pacemaker (33222) or cardioverter-defibrillator (33223) is necessary for various clinical situations, such as infection or erosion. Relocation of an existing pulse generator may be performed as a stand-alone procedure or at the time of a pulse generator or electrode insertion, replacement, or repositioning. When skin pocket relocation is performed as part of an explant of an existing generator followed by replacement with a new generator, the pocket relocation is reported separately, Skin pocket relocation includes all work associated with the initial pocket (eg, opening the pocket, incision and drainage of hematoma or abscess if performed, and any closure performed) in addition to the creation of a new pocket for the new generator to be placed. American Medical Association 204 CPT code book 4

15 Clarification: Supervision of Observation Services Medicare considers Observation services Extended Duration Services and requires that the practitioner provide ongoing supervision of the patient s care to determine if and when the patient s status should be changed. CMS has clarified that there is no Medicare requirement for multiple evaluations of the beneficiary (by the Provider) during the provision of Observation services. OPPS 204 rule clarifies that once the practitioner determines that the patient is stable, the patient may be transitioned to general supervision. Medicare states: Once the supervising physician or appropriate non-physician practitioner transitions the beneficiary to general supervision and documents the transition in the medical record, Medicare requires further assessment of the beneficiary either per hour or at some other point during provision of the service. Medicare does not require an additional initiation period of direct supervision during the service. The observation services are billed hourly. December 0, 203 Federal Register publication of the CY 204 Final Rule (CMS-60-FC), page

16 IP Admission Crossing at least 2 Midnights Effective for dates of Admission on or after October, 203 Purpose:. Clarify appropriateness of inpatient hospital admissions and provide medical review guidelines 2. Decrease financial burden to beneficiaries due to increasing use of Observation. CMS Presumptions:. Inpatient admissions are reasonable and necessary for Medicare beneficiaries whose length of stay spans 2 midnights. Exceptions are stated in the final rule and include inpatient-only procedures, discharges, and transfers. 2. Hospital services spanning less than 2 midnights will be presumptively paid as outpatient services. CMS will not audit claims for adherence to the 2 Midnight Rule for dates of service prior to March, 204 to allow hospitals time to get necessary processes in place. CMS has provided several Open Door forums to provide further clarification for hospital providers. The most recent posting to the CMS website is dated December 23, 203. August 9, 203 Federal Register publication of the IPPS FY 204 Rule, pages and Inpatient Hospital Reviews 6

17 204 IP PPS: Part B Inpatient Billing Expands Benefit Category for Re-billing When, post discharge, the Inpatient admission is determined not reasonable and necessary then determine if: Part B services were delivered that would have reasonable and necessary if the patient had been treated as an outpatient Patient has Part B benefits The admission date is on or after October, 203 The DOS falls within the timely filing requirement (within one year) Type of Bill would be 2X (hospital inpatient billed as outpatient) Applicable when: Part A claim is denied by Medicare contractor A hospital may not submit a Part B claim and also pursue an appeal to a denied Part A claim. Hospital self-audit determines these services do not qualify for Part A billing. CMS has issued guidance about submitting a rebilled Part B claim make sure to check for your Medicare contractor s instruction. August 9, 203 Federal Register publication of the IPPS FY 204 Rule, pages

18 Part B Inpatient Billing Caveats Services defined as only outpatient cannot be reported on a Part B inpatient Medicare claim (e.g., Observation, Emergency department visits) Clarification: those services provided under the 3-day Window Rule may have 2 bills resubmitted for the Part B payment: When a Part A claim is rebilled under the CMS IPPS 204 final rule, hospitals are instructed to bill the services, provided prior to the date of admission under the 3-Day Window, on an outpatient claim, 3x bill type (Part B outpatient services). Qualifying observation service, ED visits, etc. will be included on this claim When a Part A claim is rebilled, hospitals are instructed to bill services provided after the date of admission as inpatient Part B on a 2x bill type. Condition code 44: Still valid when it is determined that a patient does not meet inpatient criteria prior to discharge. The physician documents that he/she agrees with change in status to Outpatient. Condition code 44 on claim allows this service to be billed as Outpatient bill type 3x. August 9, 203 Federal Register publication of the IPPS FY 204 Rule, pages and the National Uniform Billing Committee Manual for Condition Code 44 8

19 Part B Rebilling Example Inpatient receives ICD for Primary prevention, and hospital Utilization Review determines post-discharge that the patient did not meet CMS 204 inpatient admission criteria, and in fact, did not stay past 2 midnights. The hospital may elect to rebill services that could have been performed as an outpatient such as ancillary services, the implant, and supplies, as an inpatient Part B service using bill type 2x. The hospital cannot bill the room charge, as this is an inpatient only service. The hospital resubmits the appropriate inpatient Part B claim, bill type 2x, following Contractor instructions. Let s take a closer look August 9, 203 Federal Register publication of the IPPS FY 204 Rule, pages

20 Example: Inpatient Claim Inpatient claim Bill type x: (for illustrative purposes only) Revenue Code Description HCPCS Units Charge 0 Med/Surg PVT $xx,xxx 0258 IV fluids 7 $xxx 0272 Sterile supplies 8 $xxx 0275 Supply Pacemaker $x,xxx 0278 Supply implant 2 $xx,xxx 030 Lab Chemistry $xxx 0305 Lab Hematology $xxx 0324 Chest XRay $xxx 048 Cardiac cath lab 2 $x,xxx 0730 EKG $xxx 20

21 Example: Outpatient Claim Outpatient claim Bill type 2x (for illustrative purposes only) Revenue Code Description HCPCS Units Charge 0258 IV fluids 7 $xxx 0272 Sterile supplies 8 $xxx 0275 Lead, pacing C898 $x,xxx 0278 Cardio defibrillator C72 $xx,xxx 0278 Lead, defibrillator C895 $x,xxx 030 Comp Metabolic Profile * $xxx 0305 Complt CBC w auto diff * $xxx 0324 Chest Xray sngl view 700 $xxx 048 ICD implant DC Q0 $xx,xxx 048 DFT testing 9364 $x,xxx 0730 EKG $xxx * Packaged payment for CY 204 per Addendum P 2

22 Occurrence Code 72 The National Uniform Billing Committee has redefined a code in its billing data set (Occurrence Code 72) to allow hospitals to denote inpatient claims meeting the CMS two-midnight benchmark through a combination of outpatient and inpatient services. Effective December, 203, hospitals may use Occurrence Code 72 on inpatient bills to denote the date span of contiguous outpatient hospital services that preceded the inpatient admission. The revised code aims to prevent the claim from being audited. CMS is developing a Change Request (CR 8586) and a MedLearn Matters document, which should be published within the next few weeks and will include examples. CMS December 23, 203 FAQ on 2 Midnight Inpatient Admission Guidance & Patient Status Reviews for Admissions on or after October,

23 204 Medicare Device Credits for OP Services Comparison Example Assumption: Device credit of $5,000 received by hospital CPT code, APC assignment (Remove and replace pacemaker pulse generator; dual lead system) (APC Level II Insert/Replace Permanent Pacemaker) CY 204 FD Value Code CY 204 APC national payment = $8,388 $8,388 less warranty credit amount of $5,000 $3, Hospital Payment CY 203 FB (No cost/full credit Modifier) CY 203 APC national payment = $7,75 $7,75 * Offset % of 74% = $5,709 $7,75 minus $5,709 = $2,006 Hospital Payment FD: Credit received from the manufacturer for a replaced medical device. CY 204 Federal Register dated , pages CY 203 Table 29 identifies applicable APCs and the offset percentages per Federal Register dated , pages

24 Definition Change: Condition Codes 49 and 50 Condition Code 49: Product Replacement within Product Lifecycle Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly. Condition Code 50: Product Replacement for Known Recall of a Product Manufacturer or FDA has identified the product for recall and therefore replacement. Effective Condition Code 49 definition will change to: Replacement of a product earlier than the anticipated lifecycle Source: National Uniform Billing Committee (NUBC) August 2, 203 conference call minutes CMS Manual Pub Medicare Claims Processing, Transmittal 74 dated November 4, 2005 is available at: 24

25 Medicare Revises Pacemaker National Coverage Determination (NCD) Effective for DOS on and after August 3, 203 Covered indications for implanted permanent single or dual chamber cardiac pacemakers:. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction (SND) 2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block (AVB). This NCD states: Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion). Cardiac Resynchronization Therapy (CRT) pacemakers are not included in this NCD, so coverage will be determined by Medicare contractors. 25

26 Coding Scenarios for Cardiac Rhythm Devices/Catheters 26

27 Outpatient hospital APC payments National Medicare Hospital Outpatient Payment Rates for Significant Medtronic Therapies Therapy/CPT Code CY CY CY CY CY CY APC~ 200^ ICDs (33249) APC 008 $27,728 $26,830 $29,767 composite $30,680 composite $32,45 composite 5.9% CRT-Ds (33249 and ) APC 008 & 048/0655 $34, APC 048 $32, APC 048 $29, APC 048 $30,680 composite $32,45 composite (7.%) Pacemakers (33208) APC 0655 $9,559 $9,485 $9,693 $0,87 $0, % Final Hospital payment rules for CY 200 through 204 are available at: Payment/HospitalOutpatientPPS/index.html ~APC: Ambulatory Payment Classification; CPT copyright 203 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. ^ APC payment rates reflect changes based on the Affordable Care Act. 27

28 Volumes Released by Medicare Medicare releases frequencies by HCPCS and APCs in the proposed and final rules. The information below includes frequencies for selected CRDM procedures based on the final rules for CY 20 through CY 204. Code ,624 8,436 8,683 8, ,926 33,797 35,925 38, ,666 0,424,647, ,256 2,553 2,532 22, ,459 4,093 5,55 5, ,79 2,96 2,650 3,380 Cost Stats file by HCPCS available at Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html 28

29 Volumes and National Payment Rates Volumes per Medicare Stats File National Medicare Payment Rates Codes * $7,82 $7,833 $8,230 $8, ,624 8,436 8,683 8,979 $7,82 $7,833 $8,230 $8, ,926 33,797 35,925 38,380 $9,485 $9,693 $0,87 $0, $9,485 $9,693 $0,87 $0, ,666 0,424,647,262 $0,630 $9,693 $0,87 $0, ,256 2,553 2,532 22,52 $26,830 $29,767 $30,680 $32, ,459 4,093 5,55 5,909 $5,399 $5,633 $5,893 $6, ,79 2,96 2,650 3,380 $585 $579 $584 $,46 * Payments effective April, 20. Cost Stats file by HCPCS available at Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html 29

30 Comparison OP to IP Volumes & Rates ICD/CRT-D System Implant 45,000 40,000 35,000 30,000 25,000 20,000 5,000 0,000 5,000 CPT Volume Payment Medicare National Outpatient Rates ICD implant CPT MS-DRG 227 Volume Payment Medicare National Inpatient Rates ICD implant MS-DRG IPPS final rules and OPPS final rules and tables for are available at: 30

31 Comparison OP to IP Volumes & Rates Dual Chamber (DC) Pacemaker Implant 45,000 40,000 35,000 30,000 25,000 20,000 5,000 0,000 5,000 CPT Volume Payment Medicare National Outpatient Rates DC PM Implant CPT MS-DRG 244 Volume Payment Medicare National Inpatient Rates DC PM Implant MS-DRG 244 IPPS final rules and OPPS final rules and tables for are available at: 3

32 AV Node ablation with Pacemaker Implant During diagnostic EPS, physician determines patient does not have an ablatable focus so an AV node/his ablation is performed instead. A pacemaker is implanted following the ablation. Description CPT Adjustments APC National Payment Diagnostic EPS composite 8000 $3,5 AV node ablation composite 3D mapping packaged $0 Insert SC ventricular pacer % reduction 0089 $4,395 Total Estimated Payment $7,50 SC: Single Chamber HRS 203: Coding Guide for Heart Rhythm Procedures and Services, page 48 32

33 Dual Chamber Pacemaker upgrade to ICD A patient with previously placed DC pacemaker has VT and requires an ICD. The physician removes the previous pacemaker, caps the RV lead and inserts a new DC ICD, RV endocardial lead and uses the existing RA lead. Defibrillator threshold testing (DFT) is performed. Description CPT Adjustments APC National Remove pacer generator packaged $0 Payment Insert DC ICD $32,45 DFT 9364 status N $0 Total Estimated Payment $32,45 DC: VT: status N: Dual Chamber Ventricular Tachycardia Items and services packaged into APC rates HRS 203: Coding Guide for Heart Rhythm Procedures and Services, page 67 33

34 Upgrade Single Chamber Pacemaker to CRT-P Physician upgrades a previously placed SC ventricular pacemaker to a system capable of Bi-V pacing to achieve cardiac resynchronization therapy. The old ventricular pacemaker is removed, the RV pacing lead is attached to the new generator, an atrial pacing lead is placed, and a third lead is placed transvenously in the coronary sinus (CS) and advanced into the coronary venous system to pace the left ventricle. Contrast injection with CS imaging is performed to assess the coronary venous anatomy and assist with LV lead placement. Description CPT Adjustments APC National Payment Upgrade SC to DC pacer $0,588 Insert LV lead % reduction 0655 $5,294 Total Estimated Payment $5,882 SC: DC: Single Chamber Dual Chamber HRS 203: Coding Guide for Heart Rhythm Procedures and Services, page 62 34

35 Coronary Procedure Payments 35

36 Coronary Procedure Payments Selected Code Brief Description APC and Status Indicator 204 Medicare National APC Payment 203 Medicare National APC Payment % Change (decrease) 9345 through through Cardiac catheterizations Cardiac catheterizations, congenital 0080 (T) $2,587 $2,650 (2.4%) The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 36

37 Coronary Procedure Payments Selected Code Brief Description PTCA, atherectomy, single branch Each additional branch PTCA, single branch 9292 Each additional branch Placement of intracoronary stent(s), single branch Each additional branch Atherectomy and stent(s) APC and Status Indicator 204 Medicare National APC Payment 203 Medicare National APC Payment % Change (decrease) 0082 (T) $8,843 $7,67 5.3% 0083 (T) $4,40 $4, % 004 (T) $6,364 $6,0 4.% Each additional branch C9600 C960 C9602 C9603 DES, single vessel Each additional branch Atherectomy and DES, single vessel Each additional branch 0656 (T) $7,74 $7,763 (0.6%) The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 37

38 Cardiac Device Monitoring Services 38

39 Diagnostic Tests and the Global Surgical Period Services not included in the Global Surgery Package that may be paid separately: Initial consultation or evaluation by the surgeon to determine the need for surgery (major surgical procedures). Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complication of the surgery. Diagnostic tests and procedures, including diagnostic radiological procedures. Device monitoring procedures are diagnostic procedures. Publication Medicare Claims Processing Manual, Chapter 2 Physician/NonPhysician Practitioners is available at: 39

40 Cardiac Pacemaker Evaluation Services NCD and of CMS Pub The decision as to how often any patient s pacemaker should be monitored is the responsibility of the patient s physician who is best able to take into account the condition and circumstances of the individual patient. Transtelephonic monitoring (TTM) Guidelines I and II for both single and dual chamber pacemakers are included in this NCD. Pacemaker clinic service frequency guidelines for routine monitoring are: Single chamber: Twice in the first 6 months following implant, then once every 2 months Dual chamber: Twice in the first 6 months following implant, then once every 6 months Increased frequency of monitoring must be supported by documented medical necessity. 40

41 Additional Information & Resources 4

42 Medtronic economic resources include webcasts for hospitals & physicians on key topics

43 CRDM Information CRDM healthcare economics Visit our website: us: Call our Coding Hotline: (866) To ensure you receive advance notification of webcast events, it is very easy to register at Join our List Subscribe to receive news and updates. 43

44 Medtronic Cardiovascular Contact Information Vascular Contact Information: Coding Hotline number: (877)

45 Appendix 45

46 Data Sources CMS November 27, 203 Fact Sheet: CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 204 : Sheets/203-Fact-Sheets-Items/ html The OPPS Final Rule Home Page for CY 204 and CY 203: Payment/HospitalOutpatientPPS/index.html December 0, 203 Federal Register publication of the CY 204 Final Rule (CMS-60-FC): 46

47 Data Sources Medicare Inpatient rule for FY 204 dated August 9, 203 is at: Inpatient Hospital Reviews updated information is located at: Programs/Medical-Review/InpatientHospitalReviews.html CMS Frequently Asked Questions dated December 23, Midnight Inpatient Guidance & Patient Status Reviews for Admissions on or after October, 203 includes a link for the Occurrence Span Code 72 at: Programs/Medicare-FFS-Compliance-Programs/Medical- Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews _223203_508Clean.pdf 47

48 Data Sources CY 204 OPPS Addenda (includes Addendum A, B, C, D-, D-2, E, L, M, N, and P) can be found at: Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and- Notices-Items/CMS-60-FC-.html?DLPage=&DLSort=2&DLSortDir=descending Pub Medicare Claims Processing, Transmittal 2845 Change Request 8572 dated December 27, 203 is at: Guidance/Guidance/Transmittals/Downloads/R2845CP.pdf 48

49 Status Indicators Status Indicator C M N S Item/Code/Service Inpatient Procedures. Not paid under OPPS. Admit patient. Bill as Inpatient. (e.g., 33203: Insertion of epicardial electrode(s); endoscopic approach) Items and Services Not Billable to the Fiscal Intermediary/MAC. Not paid under OPPS. (e.g., 93294, 93295, 93297, 93298) Items and Services Packaged into APC Rates. Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment. (e.g., 9363, 9362, 93622, 93623, 93640, 9364, 93662) Significant Procedure, Not Discounted when Multiple. Paid under OPPS; separate APC payment. (e.g., 33282: Insert patient activated cardiac event recorder) T Q2 Q3 X Significant Procedure, Multiple Reduction Applies. Paid under OPPS; separate APC payment. (e.g., 3326: Insert single transvenous lead) T-Packaged codes. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. () Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In other circumstances, payment is made through a separate APC payment. Codes that may be paid through a Composite APC. () Composite APC payment based on OPPS composite-specific payment criteria. (2) Separate APC payment or packaged into payment for other services. (e.g., 93656) Ancillary Services. Paid under OPPS; separate APC payment. (e.g., 9304: Rhythm ECG tracing) Addendum D is available at: 49

50 APC Payment Comparisons CPT Brief Description APC 204 and SI Insert pacer system; atrial Insert pacer system; ventricle Insert pacer system; A and V 3320 Insert temporary lead, single 332 Insert temporary leads, dual 3322 Insert pacer gen. only; w/ single lead 3323 Insert pacer gen. only; w/ dual leads APC 0089 $8,790 (T) APC 0089 $8,790 (T) APC 0655 $0,588 (T) APC 006 $4,602 (T) APC 006 $4,602 (T) APC 0090 $7,353 (T) APC 0654 $8,388 (T) APC 203 and SI APC 0089 $8,230 (T) APC 0089 $8,230 (T) APC 0655 $0,87 (T) APC 006 $3,766 (T) APC 006 $3,766 (T) APC 0090 $6,62 (T) APC 0654 $7,75 (T) % Change 6.8% 6.% 3.9 % 22.2% 22.2%.2% 8.7% The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 50

51 APC Payment Comparisons CPT Brief Description APC 204 and SI 3324 Upgrade single pacer to dual pacer 3325 Reposition previously placed RA or RV lead 3326 Insert single lead, pacer/icd 3327 Insert 2 leads, pacer/icd 3328 Repair single lead, pacer/icd Repair 2 leads, pacer/icd 3322 Insert pacer gen. only; w/ multiple leads APC 0655 $0,588 (T) APC 003 $,524 (T) APC 006 $4,602 (T) APC 006 $4,602 (T) APC 005 $2,38 (T) APC 005 $2,38 (T) APC 0654 $8,388 (T) APC 203 and SI APC 0655 $0,87 (T) APC 005 $,683 (T) APC 006 $3,766 (T) APC 006 $3,766 (T) APC 005 $,683 (T) APC 005 $,683 (T) APC 0654 $7,75 (T) % Change 3.9 % (9.4%) 22.2% 22.2% 37.7% 37.7% 8.7% The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 5

52 APC Payment Comparisons CPT Brief Description APC 204 and SI Relocate skin pocket for pacemaker Relocate skin pocket for cardioverterdefibrillator Insert LV lead, attach to existing pacer/icd Insert LV lead at time of pacer/icd generator implant Reposition previously placed LV lead Remove pacer gen. and replace pacer gen.; single lead system APC 0328 $,37 (T) APC 0328 $,37 (T) APC 0655 $0,588 (T) APC 0655** $0,588 (T) APC 003 $,524 (T) APC 0090 $7,353 (T) APC 203 and SI APC 036 $,2 (T) APC 036 $,2 (T) APC 0655 $0,87 (T) APC 0655** $0,87 (T) APC 005 $,683 (T) APC 0090 $6,62 (T) % Change 23.3% 23.3% 3.9% 3.9% (9.4%).2% ** Single Composite APC 008 is applicable when ICD/CRT-D generator and leads are implanted on same date of service. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 52

53 APC Payment Comparisons CPT Brief Description APC 204 and SI Remove pacer and replace pacer gen.; dual lead system Remove pacer and replace pacer gen.; multiple lead system Insert ICD gen. only; w/ existing dual leads 3323 Insert ICD gen. only; w/ multiple leads Remove pacer lead; single Remove pacer leads; dual APC 0654 $8,388 (T) APC 0654 $8,388 (T) APC 007 $25,08 (T) APC 007 $25,08 (T) APC 005 $2,38 (Q2) APC 005 $2,38 (Q2) APC 203 and SI APC 0654 $7,75 (T) APC 0654 $7,75 (T) APC 007 $22,52 (T) APC 007 $22,52 (T) APC 005 $,683 (T) APC 005 $,683 (T) % Change 8.7% 8.7%.%.% 37.7% 37.7% Q2: Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 53

54 APC Payment Comparisons CPT Brief Description APC 204 and SI Insert ICD gen. only; w/ single lead APC 007 $25,08 (T) 3324 Remove ICD gen. only APC 005 $2,38 (Q2) Remove ICD leads; by transvenous extraction Insert or replace ICD system w/ transvenous leads, single or dual chamber Remove ICD and replace ICD gen.; single lead system APC 005 $2,38 (Q2) APC 008** $32,45 (Q3) APC 007 $25,08 (T) APC 203 and SI APC 007 $22,52 (T) APC 005 $,683 (T) APC 005 $,683 (T) APC 008** $30,680 (Q3) APC 007 $22,52 (T) % Change.% 37.7% 37.7% 4.8%.% Q2: Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. Q3: Codes that may be paid through a Composite APC. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 54

55 APC Payment Comparisons CPT Brief Description APC 204 and SI Remove ICD and replace ICD gen.; dual lead system Remove ICD and replace ICD gen.; multiple lead system Insert patient-activated cardiac event recorder (ILR) APC 007 $25,08 (T) APC 007 $25,08 (T) APC 0680 $6,223 (S) Remove ILR APC 002 $,46 (Q2) APC 203 and SI APC 007 $22,52 (T) APC 007 $22,52 (T) APC 0680 $5,893 (S) APC 0020 $584 (T) % Change.%.% 5.6% 96.2% Q2: Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 55

56 APC Payment Comparisons CPT Brief Description APC 204 and SI Cardioversion, external APC 0679 $44 (S) 9296 Cardioversion, internal APC 0679 $44 (S) Program device evaluation; single lead pacemaker system Program device evaluation; dual lead pacemaker system 9328 Program device evaluation; multiple lead pacemaker system Program device evaluation; single lead ICD system $36.5 (S) $36.5 (S) $36.5 (S) $36.5 (S) APC 203 and SI APC 0679 $400 (S) APC 0679 $400 (S) $33.95 (S) $33.95 (S) $33.95 (S) $33.95 (S) The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B % Change 0.2% 0.2% 6.5% 6.5% 6.5% 6.5% 56

57 APC Payment Comparisons CPT Brief Description APC 204 and SI Program device evaluation; dual lead ICD system Program device evaluation; multiple lead ICD system $36.5 (S) $36.5 (S) Program device evaluation; ILR $36.5 (S) APC 203 and SI $33.95 (S) $33.95 (S) $33.95 (S) % Change Peri-procedural device evaluation, pacer Status N Status N NA Peri-procedural device evaluation, ICD Status N Status N NA Interrogation device evaluation; all pacemaker systems Interrogation device evaluation; all ICD systems Interrogation device evaluation; implantable CV monitor (ICM) $36.5 (S) $36.5 (S) $36.5 (S) $33.95 (S) $33.95 (S) APC 0035 $23.43 (X) 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% Status N: Items and Services Packaged into APC Rates The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 57

58 APC Payment Comparisons CPT Brief Description APC 204 and SI 9329 Interrogation device evaluation, ILR Interrogation; wearable ICD system Transtelephonic pacemaker evaluation(s), up to 90 days Interrogation device evaluation(s), up to 90 days; pacemaker system or ICD system Interrogation device evaluation(s), (remote), up to 30 days; ILR or ICM Echo, transthoracic, 2D, complete, with spectral and color flow Doppler $36.5 (S) $36.5 (S) $36.5 (S) $36.5 (S) $36.5 (S) APC 0269 $427 (S) APC 203 and SI $33.95 (S) $33.95 (S) $33.95 (S) $33.95 (S) $33.95 (S) APC 0269 $390 (S) The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B % Change 6.5% 6.5% 6.5% 6.5% 6.5% 9.5% 58

59 APC Payment Comparisons CPT Brief Description APC 204 and SI Echo, transthoracic, 2D, complete, w/o spectral and color flow Echo, transthoracic, 2D, follow-up or limited study APC 0269 $427 (S) APC 0697 $25 (S) Stress TTE APC 0269 $427 (S) 9335 Stress TTE complete APC 0270 $594 (S) APC 203 and SI APC 0269 $390 (S) APC 0697 $23 (S) APC 0269 $390 (S) APC 0270 $559 (S) Transseptal puncture Status N APC 0080 $2,650 (T) Bundle of His recording APC 0084 $754 (S) APC 0084 $705 (S) % Change 9.5% 7.8% 9.5% 6.3% NA 6.9% Status N: Items and Services Packaged into APC Rates The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 59

60 APC Payment Comparisons CPT Brief Description APC 204 and SI Intra-atrial recording APC 0084 $754 (S) Right ventricular recording APC 0084 $754 (S) 9360 Intra-atrial pacing APC 0084 $754 (S) 9362 Intraventricular pacing APC 0084 $754 (S) 9365 Esophageal pacing of atrial electrogram 9366 Esophageal pacing of atrial electrogram; w/recording APC 0084 $754 (S) APC 0084 $754 (S) APC 203 and SI APC 0084 $705 (S) APC 0084 $705 (S) APC 0084 $705 (S) APC 0084 $705 (S) APC 0084 $705 (S) APC 0084 $705 (S) % Change 6.9% 6.9% 6.9% 6.9% 6.9% 6.9% The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 60

61 APC Payment Comparisons CPT Brief Description APC 204 and SI 9368 Induction of arrhythmia by electrical pacing 9369 Comprehensive EP study; without induction of arrhythmia Comprehensive EP study; with induction of arrhythmia EP follow-up study with pacing and recording to test effectiveness EP evaluation of single or dual chamber ICD Catheter ablation of AV node function Composite AV node ablation (93650) and either 9369 or APC 0084 $754 (S) APC 0085 $4,233 (Q3/T) APC 0085 $4,233 (Q3/T) APC 0085 $4,233 (T) APC 0084 $754 (S) APC 0085 $4,233 (Q3/T) APC 8000 $3,5 (Q3) APC 203 and SI APC 0084 $705 (S) APC 0085 $3,922 (Q3/T) APC 0085 $3,922 (Q3/T) APC 0085 $3,922 (T) APC 0084 $705 (S) APC 0085 $3,922 (Q3/T) APC 8000 $,46 (Q3) Q3: Codes that may be paid through a Composite APC. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B % Change 6.9% 7.9% 7.9% 7.9% 6.9% 7.9% 7.7% 6

62 APC Payment Comparisons CPT Brief Description APC 204 and SI Composite Composite Composite EPS, catheter ablation of SVT EPS, catheter ablation of VT EPS, catheter ablation of AF by PVI APC 8000 $3,5 (Q3) Tilt table evaluation APC 00 $325 (S) Electronic analysis of antitachycardia pacemaker system APC 069 $276 (S) Set up wearable ICD APC 069 $276 (S) APC 203 and SI % Change APC 8000 $,46 (Q3) 7.7% APC 00 $304 (S) $33.95 (S) $33.95 (S) 6.9% 72.6% 72.6% Q3: Codes that may be paid through a Composite APC. The OPPS Final Rule Home Page for CY 204 and CY 203, Addendum B 62