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 patient’s discharge is assigned to the appropriate MS-DRG and to ensure appropriate reimbursement. Documentation is also critical for any post-procedure audit by a payer such as CMS with the Recovery Audit Contractors (RACs).
Request for Prior Authorization
While both carotid artery stenting and the TCAR procedure are covered under Medicare’s NCD Manual Section 20.7 if the appropriate coverage criteria are met, some non-Medicare commercial payers may have additional coverage requirements. Such payers may also require prior authorization before carotid artery revascularization can be performed. Sample letters requesting prior authorization for the TCAR procedure can be found here:
- Prior Authorization Letter for High Surgical Risk Patients
- Prior Authorization Letter for Standard Surgical Risk Patients
Denials from Payers
Some non-Medicare commercial payers will deny coverage for either carotid artery stenting or the TCAR procedure. A request for reconsideration should always be sent. Such requests should always include a detailed explanation of the medical necessity for the individual patient and any other supporting material such as information about the TCAR procedure itself.
Links to Reimbursement Related Resources
CMS Carotid Artery Stenting Facility Certification Process
CMS Carotid Artery Stenting Certified Facilities
CMS Approved Carotid Artery Stenting Studies
Percutaneous Transluminal Angioplasty (including Carotid Artery Stenting) National Coverage Determination Manual Section 20.7
National Correct Coding Initiative
Physician Fee Schedule
Physician Fee Schedule Search
General Reimbursement Resources
International Classification of Diseases (ICD)
American Medical Association (AMA) Current Procedural Terminology (CPT)
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 September 9, 2016.