Reimbursement

2017 TCAR Hospital Coding and Payment

Hospitals are reimbursed for TCAR procedures based on MS-DRG classifications derived from ICD-10-CM diagnosis and ICD-10-PCS codes that describe the patient’s diagnoses and procedure(s) performed during the hospital stay.

2017 National Unadjusted Payment Amounts for MS-DRGs 034, 035, and 036 “Carotid Artery Stent Procedure” (inclusive of TCAR) are: 6

  • xxx
    034 with major complication or comorbidity (MCC)
    035 with complication or comorbidity (CC)
    036 without CC/MCC

     

  • 2017
    $22,740
    $13,800
    $10,328

Appropriate ICD-10-CM diagnosis codes for the TCAR procedure include:

  • I65.(21,22,23,29)
    xxx
    I65.(8,9)
    I63.(131,132,139)
    I63.(031,032,039)
    I63.(231,232,239)

  • Occlusion and stenosis of (right, left, bilateral, unspecified) carotid artery, not resulting in cerebral infarction
    Occlusion and stenosis of (other, unspecified) precerebral artery(ies)
    Cerebral infarction due to embolism of (right, left, unspecified) carotid artery
    Cerebral infarction due to thrombus of (right, left, unspecified) carotid artery
    Cerebral infarction due to unspecified occlusion or stenosis of (right, left, unspecified) carotid arteries)

The appropriate ICD-10-PCS procedure code for the TCAR procedure 037K3DZ

The fourth character (body part) will vary depending on where the procedure takes place

  • H-common carotid artery, right;
    J-common carotid artery, left;

  • K-internal carotid artery, right; or
    L-internal carotid artery, left

C-Codes for the TCAR Procedure

C-Codes are generally used only for the outpatient setting.  TCAR and transfemoral carotid artery stenting procedures only receive CMS coverage when performed on an in-patient basis.  The following C-codes are therefore used primarily for internal tracking purposes only.

  • C1884: Embolization Protection System
    ENROUTE Transcarotid Neuroprotection System
  • C1876: Stent Non-Coated/Non-Covered with Delivery System
    ENROUTE Transcarotid Stent System
  • C1894: Introducer/Sheath, Non-Laser
    Silk Road Medical Micro-Introducer Kit

Notes:

  • For billing instructions related to clinical studies, e.g. the TCAR Surveillance Project or ROADSTER 2, see TCAR Coverage
  • ICD-10 defines “Percutaneous” as entry, by puncture or major incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure. TCAR is considered “percutaneous” by this definition.

Further information:

Medicare reimburses hospital inpatient procedures according to Medicare Severity Diagnosis Related Group (MS‐DRG) that are determined by reported ICD-10-CM and/or ICD-10-PCS codes.

Medicare Severity Diagnosis Related Group (MS‐DRG)

The MS‐DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS‐DRGs closely calibrate payment for groups of services based on the severity of a patient’s illness. One single MS‐DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of “professional” (e.g., physician) charges associated with performing medical procedures.  In some instances, commercial payers also use the MS‐DRG system or other payer‐specific system to pay hospitals for providing inpatient services.

The MS-DRGs are assigned using the principal ICD-10-CM diagnosis and additional or secondary ICD-10-CM diagnoses, the principal ICD-10-PCS procedure and additional ICD-10-PCS procedures, sex, and discharge status.

Clearly documenting procedures has become increasingly more important for both physicians and hospitals, especially with the much greater specificity of ICD-10 when compared to ICD-9.  A thorough description of a patient’s primary and all secondary diagnoses in that patient’s history and physical (H&P) along with detailed procedure dictation is the only way to ensure that a hospital will receive the appropriate MS-DRG assignment for that patient discharge as well as to ensure that the physician is reimbursed properly.  Documentation is also critical for any post-procedure audit by a payer such as CMS with the Recovery Audit Contractors (RACs).  A sample dictation for a TCAR case can be found here.

Complications or Comorbidities

In the MS-DRG system, many DRGs are split into one, two or three MS-DRGs based on whether any one of the secondary diagnoses has been categorized as a major complication or comorbidity (MCC), a complication or comorbidity (CC), or no complication or comorbidity (no CC).

An example of an MS-DRG with a three way split is “Carotid Artery Stent Procedure”:

  • 034, Carotid Artery Stent Procedure with major complication/comorbidity (MCC)
  • 035, Carotid Artery Stent Procedure with complication/comorbidity (CC)
  • 036, Carotid Artery Stent Procedure without CC or MCC

Under MS-DRGs, CMS identified those diagnoses whose presence as a secondary diagnosis leads to substantially increased hospital resource use. They then categorized this list into two different levels of severity.

MCCs reflect the highest level of severity. Examples:

  • N18.6, End Stage Renal Disease
  • I63.50, Cerebral artery occlusion, unspecified with cerebral infarction.

CCs represent the next level of severity. Examples:

  • J96.10, Chronic Respiratory Failure
  • N17.9 Acute Kidney Failure unspecified

A full list of MCCs and CCs can be found in Final Rule Tables 6I and 6J on CMS.gov.

Some MCCs and CCs are excluded because they are too closely related to the principal diagnoses. This is called the CC Exclusion List and identifies conditions that will not be considered a CC or MCC for a given principal diagnosis. For example, other restrictive cardiomyopathy (I42.5) is not a CC for congestive heart failure unspecified (I50.9).

ICD‐10‐CM (Clinical Modification)

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). The code set allows more than 14,400 different codes and permits the tracking of many new diagnoses.

ICD-10 is an updated version of the ICD-9 code sets. Several countries have taken the ICD-10 code set and modified it for use in their medical systems. The United States, through the National Center for Health Statistics, has developed the ICD-10-CM (or Clinical Modification) version of the code set for use in the US.

ICD-10-PCS (Procedure Code Set)

For detailed information, please refer to CMS’s Development of the ICD-10 Procedure Coding System.

The development of ICD-10-PCS was funded by the U.S. Centers for Medicare and Medicaid Services (CMS). ICD-10-PCS has a multiaxial seven character alphanumeric code structure that provides a unique code for all substantially different procedures, and allows new procedures to be easily incorporated as new codes.

ICD-10-PCS has a seven character alphanumeric code structure. Each character contains up to 34 possible values. Each value represents a specific option for the general character definition (e.g., stomach is one of the values for the body part character). The ten digits 0-9 and the 24 letters A-H, J-N and P-Z may be used in each character. The letters O and I are not used in order to avoid confusion with the digits 0 and 1. Procedures are divided into sections that identify the general type of procedure (e.g., medical and surgical, obstetrics, imaging).

The Tables in ICD-10-PCS are organized differently from ICD-9-CM. Each page in the table is composed of rows that specify the valid combinations of code values. In the system, the upper portion of each table specifies the values for the first three characters of the codes in that table. In the medical and surgical section, the first three characters are the section, the body system and the root operation.

The lower portion of the table specifies all the valid combinations of the remaining characters four through seven. The four columns in the table specify the last four characters. In the medical and surgical section they are labeled Body Part, Approach, Device and Qualifier, respectively. Each row in the table specifies the valid combination of values for characters four through seven. The Tables contain only those combinations of values that result in a valid procedure code.

Character Meanings

The first character of the procedure code always specifies the section. TCAR is captured with Section 0 Medical and Surgical. The sections are:

0 Medical and Surgical
1 Obstetrics
2 Placement
3 Administration
4 Measurement and Monitoring
5 Extracorporeal Assistance and Performance
6 Extracorporeal Therapies
7 Osteopathic
8 Other Procedures
9 Chiropractic
B Imaging
C Nuclear Medicine
D Radiation Oncology
F Physical Rehabilitation and Diagnostic Audiology
G Mental Health
H Substance Abuse Treatment

The second through seventh characters mean the same thing within each section, but may mean different things in other sections. In all sections, the third character specifies the general type of procedure performed. The other characters give additional information such as the body part and approach. In ICD-10-PCS, the term “procedure” refers to the complete specification of the seven characters.

Medical and Surgical Section

The seven characters for medical and surgical procedures have the following meaning:

Character 1 = Section
Character 2 = Body System
Character 3 = Root Operation
Character 4 = Body Part
Character 5 = Approach
Character 6 = Device
Character 7 = Qualifier

The medical and surgical section codes represent the vast majority of procedures reported in an inpatient setting. Medical and surgical procedure codes including those for TCAR have a first character value of “0”.

The first through fifth characters are always assigned a specific value, but the device (sixth character) and the qualifier (seventh character) are not applicable to all procedures.

Medical and Surgical Section – Character 2 – Body System

The body systems for medical and surgical section codes are specified in the second character. In order to provide necessary detail, some body systems are subdivided. For the vascular system, the section codes are 2 through 6. Section code 3 Upper Arteries applies to TCAR.

2 Heart and Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins

Medical and Surgical Section – Character 3 – Root Operation

The third character is the root operation which identifies the objective of the procedure. For TCAR, the root operation character is: 7 Dilation – Expanding an orifice or the lumen of a tubular body part.

Medical and Surgical Section – Character 4 – Body Part

The body part is specified in the fourth character. The body part indicates the specific part of the body system on which the procedure was performed (e.g., K – Internal Carotid Artery, Right or L – Internal Carotid Artery, Left). Tubular body parts are defined in ICD-10-PCS as those hollow body parts that provide a route of passage for solids, liquids, or gases. They include the cardiovascular system, and body parts such as those contained in the gastrointestinal tract, genitourinary tract, biliary tract, and respiratory tract.

Medical and Surgical Section – Character 5 – Approach

The technique used to reach the site of the procedure is specified in the fifth character. There are three different approaches: 0) open, 3) percutaneous, 4) percutaneous endoscopic. The approach is comprised of three components: the access location, method, and type of instrumentation.

For procedures performed on an internal body part, the access location specifies the external site through which the site of the procedure is reached. There are two general types of access locations: skin or mucous membranes, and external orifices. Every approach value except external includes one of these two access locations. The skin or mucous membrane can be cut or punctured to reach the procedure site.

An open method specifies cutting through the skin or mucous membrane and any other intervening body layers necessary to expose the site of the procedure. An instrumental method specifies the entry of instrumentation through the access location to the internal procedure site. Instrumentation can be introduced by puncture or minor incision, or through an external opening. The puncture or minor incision does not constitute an open approach, because it does not expose the site of the procedure.

Because TCAR 1) is accessed through the skin, 2) involves a minor incision at the base of the neck, and 2) uses instrumentation to reach an internal procedure site, it is coded as 3) Percutaneous for the Approach (Character 5). The ICD-10-PCS definition is: Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure.

Medical and Surgical Section – Character 6 – Device

The device is specified in the sixth character and is only used to specify devices that remain after the procedure is completed. D Intraluminal Device, identifies the stent left behind in TCAR. Materials incidental to a procedure such as clips, ligatures and sutures are not specified in the device character.

Medical and Surgical Section – Character 7 – Qualifier

In the case of TCAR, there is no qualifier thus the value Z No Qualifier is used. Examples of qualifiers in the Medical and Surgical Section are to identify the destination site of the root operation Bypass or to identify a sigmoidoscopy with biopsy as X Diagnostic rather than therapeutic.

  • 6 The national average 2017 Medicare rates for the hospital outpatient setting are calculated from the Inpatient Prospective Payment System (IPPS), October 2016. Any payment rates listed are Medicare national averages that may be subject to change without notice. Actual payment to a hospital will vary based on geographic location and may also differ based on policies and fee schedules outlined as terms in your health plan and/or payer contracts.
    Silk Road Medical provides this content for informational purposes only. The information contained herein is gathered from various sources and is subject to change without notice. Silk Road Medical cannot guarantee success in obtaining coverage or payment. Reimbursement for medical products and services is affected by numerous factors. It is always the provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are rendered. Actual codes and/or modifiers used are at the sole discretion of the treating physician and/or facility. Providers should contact their third-party payers for specific information on their coding, coverage, and payment policies. This guide is in no way intended to promote the off‐label use of any medical device. Information last reviewed February 17, 2017.
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