Reimbursement

2017 TCAR Physician Coding and Payment Summary

Physicians may report TCAR procedures using CPT code 37215:

CPT 37215: Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection

  • Relative Value Unit (RVU)3
    2017 National Payment4
    Global period
    Bilateral procedure (modifier 50)
    Multiple procedure (modifier 51)
    Co-Surgeon (modifier 62)
    Team Surgery
    Assistant surgeon (modifiers 80 – 82)

  • 29.42
    $1,044
    90 days
    Yes
    Yes
    No
    No
    Yes (supporting documentation required)

ICD-10-CM diagnosis codes that may support utilization of the TCAR procedure include:

  • I65.(21,22,23,29)

    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)

Notes:

  • For billing instructions related to clinical studies, e.g. the TCAR Surveillance Project or ROADSTER 2, see TCAR Coverage
  • Some payors require that ICD-10-CM diagnosis codes accompany reported CPT codes for proper claims processing.
  • CPT 37215 describes “distal embolic protection.” This refers to protection of the brain distal to the stent placement. CMS guidance confirms that proximally placed retrograde flow embolic protection systems qualify as distal embolic protection.
  • CPT 37215 includes: Moderate (conscious) sedation (99143-99145), All ipsilateral carotid imaging including completion angiography, Ipsilateral selective carotid catheterization, Placement of embolic protection device, Pre- and post-stenting balloon angioplasty, Completion angiogram. Such services should not be separately reported.5
  • Coverage and payment for CPT code 37215 is:
    • Only available from Medicare in the Inpatient setting;
    • Subject to the terms of the National Coverage Determination Manual Section 20.7; and
    • Only available in facilities certified to have met CMS’s minimum facility standards for performing carotid artery stenting, which include local credentialing requirements. A list of certified facilities is viewable here and more information on the certification process is here.
  • CPT 37216 (Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection) is not covered by Medicare. This code does not appropriately describe the use of the ENROUTE Transcarotid NPS which is required for both transcarotid access and embolic protection.
  • CPT codes 37217 and 37218 describe carotid stenting in the intrathoracic common carotid and innominate arteries. CPT codes 37217 and 37218, therefore, do not appropriately describe TCAR procedures targeting lesions at the cervical level (at or near the carotid bifurcation).
  • CPT 36625 may be used to describe an additional surgical exposure: Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown. According to Medicare’s Correct Coding Policy Edits, when CPT code 36625 is reported with 37215, modifier -59 must also be reported. For the TCAR procedure (37215), modifier 59 would be appropriate with CPT 36625 only if the additional cutdown is performed in a different session or surgery, on a different site, or with a separate incision. If the cutdown is performed on the same artery as the TCAR incision, it would not be reported with modifier 59.

Further information:

Medicare and most payers typically identify services rendered by physicians and other healthcare practitioners according to reported CPT codes.  Payment for services, when appropriate, is generally made according to established fee schedules.  In some instances, reported CPT codes must be supported by reporting an appropriate ICD-10-CM diagnosis code.

Current Procedural Terminology (CPT)

CPT codes are published by the American Medical Association and are used to report medical services and procedures performed by or under the direction of physicians.  Physician payment for procedures may vary according to site of service.  A hospital outpatient department, inpatient department, or ambulatory surgical center (ASC) are considered to be facility settings and services rendered in those settings are payable under the Medicare Physician Fee Schedule at the facility rate.  Physician services provided in the physician office are payable under the Medicare Physician Fee Schedule at the non-facility rate.

Relative value units (RVUs)

RVUs are a measure of relative value used to identify the relative resource intensity of physician services. The Omnibus Budget Reconciliation Act of 1989 required the implementation of a Medicare fee schedule with a listing of distinct physician services. The services are classified using the Current Procedural Terminology, which is owned and maintained by the American Medical Association. Each service in the fee schedule is scored under the resource-based relative value scale (RBRVS) and assigned RVUs which ultimately determine payment for the service.

CPT Modifiers:

According to the CPT, “A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers enable health care professionals to effectively respond to payment policy requirements established by other entities.” A complete listing of modifiers is in Appendix A of the CPT coding book. Not all modifiers can be reported with all CPT codes or with other modifiers. Modifiers may be used to indicate to the recipient of a report that:

  • A service or procedure had both a professional and technical component
  • As service or procedure was performed by more than one physician or other health care professional and/or in more than one location
  • A service of procedure was increased or reduced
  • Only part of a service was performed
  • An adjunctive service was performed
  • A bilateral service was performed
  • A service or procedure was provided more than once
  • Unusual events occurred

The -62 (co-surgeon) modifier may not be appended to CPT code 37215 (Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection).

Modifiers ensure that provider services are properly reimbursed. For example, the -80 (assistant surgeon) modifier increases the payment for the CPT code by 16% to account for the additional resources of the assistant surgeon.

  • 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).

The -50 (bilateral procedure) modifier increases the payment for the CPT code amount by 50% to account for the additional resources required to furnish a bilateral service.

ICD‐10‐CM:

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-CM diagnosis codes should accompany reported CPT codes for proper claims processing in certain settings.

For example, when CPT code 37215 is reported to a payer, an appropriate ICD-10-CM diagnosis code may be required for proper claims processing and payment. A given CPT code may be supported by many different ICD-10-CM diagnoses. Providers should refer to Local and National Coverage Determinations (LCDs and NCDs) from CMS and Local Medicare Carriers as well as coverage policies from private insurance payers in order to determine which ICD-10-CM diagnosis codes support which CPT codes.

  • 3 The 2016 physician relative value units (RVUs) are from the 2016 RVU file available on the CMS website here, as of August 25, 2016.
    4 The national average 2017 Medicare rates to physicians shown are based on the 2017 conversion factor of $35.8887 and do not reflect payment cuts due to sequestration. Medicare payment for a given procedure in a given locality in 2017 should be available in the Medicare Physician Fee Schedule Look-up file accessible through the CMS website at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Any payment rates listed may be subject to change without notice. Actual payment to a physician 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.
    5 American Medical Association (AMA), 2016 Current Procedural Terminology (CPT), Professional Edition.
    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.
    • ©2017 Silk Road Medical

    • 735 North Pastoria Avenue, Sunnyvale, CA 94085

      phone: 855.410.TCAR (8227)
      local phone: 408.720.9002
      fax: 408.720.9013