Cardiology Coding Alert

These services may get their own set of Category I codes in 2013.

Practices performing transthoracic aortic valve replacement (TAVR) have some work to do to see if they meet Medicare's strict requirements for coverage with evidence development (CED).

If you code for an interventional cardiologist who will be involved in TAVR procedures, sometimes called transcatheter aortic valve implantation (TAVI), you should review the decision memo at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=257.

The memo goes into detail on requirements such as:

• The treatment must be aimed at "symptomatic aortic valve stenosis when furnished according to an FDA approved indication"
• Two cardiac surgeons must independently examine the patient
• The patient must be under the care of a heart team (meeting specific experience requirements) in a hospital (meeting specific infrastructure and program requirements)
• An interventional cardiologist and cardiac surgeon must work together intra-operatively
• The heart team and hospital must participate in a national registry.

Plus, the decision memo provides alternative requirements for TAVR in clinical studies. You can see approved registries and trials at http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=257 .

Don't miss: CMS states, "TAVR is not covered for patients in whom existing co-morbidities would preclude the expected benefit from correction of the aortic stenosis."

Commenters Focus on Experience Requirements

If you feel the decision memo is restrictive with onerous requirements, your thoughts are in line with many of the commenters who wrote CMS about the proposed national coverage determination (NCD). For instance, many sent comments about the experience requirements for interventional cardiologists and facilities. As an example, in comments on the proposed NCD, Louis A. Cannon, MD, FACA, FCCP, FACC, FACP, president of Cardiac and Vascular Research Center of Northern Michigan, stated that the guidelines were biased toward larger centers. "Communities and hospitals such as ours should not face a lack of access because we have not performed 15 (arbitrary) left sided procedures over the course of the last year(s)."

Christopher White, MD, FSCAI, president of the Society for Cardiovascular Angiography and Interventions, commented that a requirement for the interventional cardiologist to be board certified or board eligible in interventional cardiology could present a problem for pediatric interventional cardiologists who enter the field through pediatric medicine rather than through internal medicine. (In fact, the Society opposed the creation of an NCD at present because it may "be slow to evolve in a field of medicine that is rapidly changing." The Society felt local policies would be more appropriate for now.)

Capture the Service With Cat. III Codes

In 2012, the codes that apply to TAVR are Category III codes:

• 0256T, Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach
• 0257T, ... open thoracic approach (e.g., transapical, transventricular)
• 0258T, Transthoracic cardiac exposure (e.g., sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; without cardiopulmonary bypass
• 0259T, ... with cardiopulmonary bypass.

For your interventional cardiologist, look in particular at implant codes 0256T and 0257T. Instructions with these codes specify that the codes don't include "cardiac catheterization [93451-93572] when performed at the time of the procedure for diagnostic purposes prior to aortic valve placement." So if there is a diagnostic cardiac cath at the same encounter, you may report it in addition to the TAVR codes.

However, 0256T and 0257T include "all other catheterization[s], temporary pacing, intraprocedural contrast injection[s], fluoroscopic radiological supervision and interpretation, and imaging guidance," the instructions state. So you should not report these related services in conjunction with the TAVR code.

Difference: Codes 0256T and 0257T differ based on approach. Code 0256T is endovascular, such as via a femoral or iliac approach. Code 0257T applies to open thoracic approaches. These include transapical (through the apex of the left ventricle) and transventricular (through the ventricle) approaches. CPT® Assistant (August 2011) includes a clinical example for 0257T in which the physician chooses a transapical approach because "significant aortoiliac disease precludes transfemoral or transiliac vascular access."

Keep in mind: The physician performing the transthoracic cardiac exposure may report 0258T (without cardiopulmonary bypass) or 0259T (with cardiopulmonary bypass) separately.

Be on Alert for New Instructions

Now that CMS has announced TAVR coverage, keep your eyes open for updated payer policies. Watch for rules regarding which modifiers apply, as well as covered diagnoses. You may see a code such as 424.1 (Aortic valve disorders).

Coverage from private payers is less certain. America's Health Insurance Plans (AHIP), through executive vice president of clinical affairs and strategic planning Carmella Bocchino, RN, MBA, commented to CMS that coverage should be limited to patients in appropriate clinical trials.

Also stay tuned to see if TAVR gets new Category I codes for 2013. According to the CPT® Editorial Panel meeting action summary, the panel accepted conversion of TAVR codes 0256T-0259T to Cat. I 334xx codes. If the codes are finalized, you also can expect to see "new guidelines and instructions in the Surgery/Cardiovascular and Cardiac Valves/Aortic Valve section to instruct the appropriate use of these codes" (Feb. 2012 document, www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-summary-panel-actions.page).