TCAR Reimbursement

TCAR Reimbursement

This page provides resources to assist with the coding, coverage, and reimbursement for TCAR procedures.

Reimbursement Support

Contact our Health Economics & Reimbursement Team for assistance with coding, billing, payer coverage, and denied claims.

• Email: reimbursement@silkroadmed.com
• Voicemail: (855) 410-8227 Option #5

Reimbursement Guides

Comprehensive reimbursement guides to help healthcare providers with coding, coverage, and payment for TCAR procedures.

Medicare (CMS) Coverage

Medicare covers TCAR under the National Coverage Determination (NCD) 20.7 for Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting, which was last updated on October 11, 2023. A high-level summary of the expanded NCD is available here. This NCD covers carotid stenting procedures for traditional Medicare and Medicare Advantage beneficiaries under the following sections:

• B3. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approval Studies (e.g., Vascular Quality Initiative TCAR Surveillance Project or VQI TSP)
• B4. Concurrent with Carotid Stent Placement

Traditional Medicare (also known as fee for service Medicare) does not require prior authorization for procedures.

Medicare Advantage plans are managed by private insurers and must cover TCAR according to the NCD. They cannot have more restrictive coverage criteria than the NCD, but they may require prior authorization or precertification.

Non-Medicare Coverage

Non-Medicare payers, such as private insurers, Medicaid, and the Veteran’s Administration, have different coverage plans and policies. Contact the payer before the TCAR procedure to verify coverage and billing requirements for carotid artery stenting.

VQI TCAR Surveillance Project

The Vascular Quality Initiative (VQI) TCAR Surveillance Project (TSP) is an FDA-approved post-approval surveillance registry sponsored by the Society for Vascular Surgery Patient Safety Organization to monitor the safety and effectiveness of transcarotid stents in patients with symptomatic and asymptomatic carotid artery disease at standard or high risk. Medicare provides reimbursement to hospitals and physicians who participate in the registry and adhere to the study protocol. To submit claims for VQI TSP, facilities and providers should include National Clinical Trial (NCT) identifier NCT02850588 and follow the appropriate billing instructions.

ROADSTER 3 Study

Silk Road Medical is conducting an FDA post-approval study of TCAR in standard-risk patients with significant carotid artery disease to evaluate real-world usage of the ENROUTE Transcarotid Stent System and ENROUTE Transcarotid Neuroprotection System in patients at standard risk for adverse events from carotid endarterectomy (CEA).  Medicare reimburses hospitals and physicians for participating in the study. To submit claims for ROADSTER 3, facilities and providers should use National Clinical Trial (NCT) identifier NCT05365490 along with the appropriate codes and modifiers.

Prior Authorization Tool Kit

Some Medicare Advantage and private insurance plans require prior authorization or precertification for TCAR. Use these resources to request coverage and review payer guidelines to avoid denials, payment losses, and penalties.

For questions about a specific health plan policy, please contact our Health Economics & Reimbursement Team for assistance.

Documentation Resources

Accurate and complete patient medical records and detailed procedure dictation are essential for proper MS-DRG assignment and physician reimbursement.

Additional Resources

Below are additional resources for customers that address select components of NCD 20.7 section B4 that expands coverage for carotid stenting to a broader patient population.

Disclaimer

Silk Road Medical has compiled this information for your convenience. Silk Road Medical cannot guarantee success in obtaining coverage or payment. Silk Road Medical cannot guarantee the accuracy or appropriateness of any patient or procedure characterizations provided using this information. It is always the provider’s responsibility to determine the appropriateness of any treatment and accurately describe patient characteristics and services furnished. Providers should consult with their payers regarding appropriate documentation, medical necessity, and coding information consistent with individual payer requirements and policies. This information is in no way intended to promote the off‐label use of any medical device.

References

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