Billing for Intracoronary Stent Placement
Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug-eluting or drug-eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Intracoronary Drug-Eluting Stents), respectively). In order to effectuate this policy, we created HCPCS G-codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug-eluting intracoronary stent placement procedures that parallel existing Procedure codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug-eluting intracoronary stent placement procedures. For CY 2012 and years prior, Procedure codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.
Effective January 1, 2013, the AMA’s Procedure Editorial Panel is deleting Procedure codes 92980 and 92981 and replacing them with the following new Procedure codes:
• Procedure code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)
• Procedure code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• Procedure code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);
• Procedure code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• Procedure code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);
• Procedure code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));
• Procedure code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
• Procedure code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel); and
• Procedure code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C-codes to parallel the new Procedure codes:
• HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);
• HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);
• HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));
• HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
• HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel); and
• HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
Procedure codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug-eluting intracoronary stent placement procedures and are assigned to APC 0104. HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.
Transitional Corridor Payments
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit provider’s losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.
Section 405 of BIPA provides that children’s hospitals described in §1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000. Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below. Contractors determine TOPs eligibility and calculate interim TOPs.
Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC. The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data. TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.
Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC. They are:
• The provider number;
• Fiscal year begin date;
• The provider type;
• Actual geographic location - CBSA (from the IPSF);
• Wage index location - CBSA (from the IPSF); and
• Bed size (from the IPSF)
Pursuant to §403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost report for the cost reporting period ending in calendar year 1996. The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment-to-cost ratio used in calculating a TOP will be based on the hospital’s first cost report for a period ending after calendar year 1996 and before calendar year 2001. This provision is effective retroactively to August 1, 2000.
Future updates will be issued in a Recurring Update Notification.
ICD-10 Codes that may support medical necessity (for dates of service on or after October 1, 2015): Drug-eluting Stents for Ischemic Heart Disease
I20.0 - I20.9 Angina pectoris
I21.01 – I21.4 ST elevation (STEMI) and non-ST elevation (NSTEMI)
myocardial infarction
I22.0 – I22.9 Subsequent ST elevation (STEMI) and non-ST elevation
(NSTEMI) myocardial infarction
I24.0 - I24.9 Other acute ischemic heart diseases
I25.10 – I25.119 Atherosclerotic heart disease of native coronary artery with or
without angina pectoris
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 – I25.799 Atherosclerosis of coronary artery bypass graft(s) and coronary
artery of transplanted heart with angina pectoris
I25.810 – I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
T82.817A - T82.817S Embolism of cardiac prosthetic devices, implants and grafts
T82.827A - T82.827S Fibrosis of cardiac prosthetic devices, implants and grafts
T82.837A - T82.837S Hemorrhage of cardiac prosthetic devices, implants and grafts
T82.847A - T82.847S Pain from cardiac prosthetic devices, implants and grafts
T82.857A - T82.857S Stenosis of cardiac prosthetic devices, implants and grafts
T82.867A - T82.867S Thrombosis of cardiac prosthetic devices, implants and grafts
T82.897A - T82.897S Other specified complication of cardiac prosthetic devices,
implants and grafts
T82.9xxA - T82.9xxS Unspecified complication of cardiac and vascular prosthetic
device, implant and graft
36.07:
Insertion of drug-eluting coronary
artery stent(s)
00.66:
Percutaneous transluminal
coronary angioplasty
17.55
Transluminal coronary
atherectomy
Code Also
00.40:
Procedure on single vessel
00.41:
Procedure on two vessels
00.42:
Procedure on three vessels
00.43:
Procedure on four or more
vessels
00.44:
Procedure on vessel/bifurcation
00.45:
Insertion of one vascular stent
00.46:
Insertion of two vascular stents
00.47:
Insertion of three vascular stents
00.48:
Insertion of four or more vascular stent
00.24:
Intravascular imaging of coronary
vessels
00.28:
Intravascular imaging, other
specified vessel(s)
00.29:
Intravascular imaging unspecified
vessel(s)
Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug-eluting or drug-eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Intracoronary Drug-Eluting Stents), respectively). In order to effectuate this policy, we created HCPCS G-codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug-eluting intracoronary stent placement procedures that parallel existing Procedure codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug-eluting intracoronary stent placement procedures. For CY 2012 and years prior, Procedure codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.
Effective January 1, 2013, the AMA’s Procedure Editorial Panel is deleting Procedure codes 92980 and 92981 and replacing them with the following new Procedure codes:
• Procedure code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)
• Procedure code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• Procedure code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);
• Procedure code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• Procedure code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);
• Procedure code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));
• Procedure code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
• Procedure code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel); and
• Procedure code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C-codes to parallel the new Procedure codes:
• HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);
• HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
• HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);
• HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));
• HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
• HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel); and
• HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
Procedure codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug-eluting intracoronary stent placement procedures and are assigned to APC 0104. HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.
Transitional Corridor Payments
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit provider’s losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.
Section 405 of BIPA provides that children’s hospitals described in §1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000. Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below. Contractors determine TOPs eligibility and calculate interim TOPs.
Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC. The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data. TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.
Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC. They are:
• The provider number;
• Fiscal year begin date;
• The provider type;
• Actual geographic location - CBSA (from the IPSF);
• Wage index location - CBSA (from the IPSF); and
• Bed size (from the IPSF)
Pursuant to §403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost report for the cost reporting period ending in calendar year 1996. The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment-to-cost ratio used in calculating a TOP will be based on the hospital’s first cost report for a period ending after calendar year 1996 and before calendar year 2001. This provision is effective retroactively to August 1, 2000.
Future updates will be issued in a Recurring Update Notification.
ICD-10 Codes that may support medical necessity (for dates of service on or after October 1, 2015): Drug-eluting Stents for Ischemic Heart Disease
I20.0 - I20.9 Angina pectoris
I21.01 – I21.4 ST elevation (STEMI) and non-ST elevation (NSTEMI)
myocardial infarction
I22.0 – I22.9 Subsequent ST elevation (STEMI) and non-ST elevation
(NSTEMI) myocardial infarction
I24.0 - I24.9 Other acute ischemic heart diseases
I25.10 – I25.119 Atherosclerotic heart disease of native coronary artery with or
without angina pectoris
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 – I25.799 Atherosclerosis of coronary artery bypass graft(s) and coronary
artery of transplanted heart with angina pectoris
I25.810 – I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
T82.817A - T82.817S Embolism of cardiac prosthetic devices, implants and grafts
T82.827A - T82.827S Fibrosis of cardiac prosthetic devices, implants and grafts
T82.837A - T82.837S Hemorrhage of cardiac prosthetic devices, implants and grafts
T82.847A - T82.847S Pain from cardiac prosthetic devices, implants and grafts
T82.857A - T82.857S Stenosis of cardiac prosthetic devices, implants and grafts
T82.867A - T82.867S Thrombosis of cardiac prosthetic devices, implants and grafts
T82.897A - T82.897S Other specified complication of cardiac prosthetic devices,
implants and grafts
T82.9xxA - T82.9xxS Unspecified complication of cardiac and vascular prosthetic
device, implant and graft
36.07:
Insertion of drug-eluting coronary
artery stent(s)
00.66:
Percutaneous transluminal
coronary angioplasty
17.55
Transluminal coronary
atherectomy
Code Also
00.40:
Procedure on single vessel
00.41:
Procedure on two vessels
00.42:
Procedure on three vessels
00.43:
Procedure on four or more
vessels
00.44:
Procedure on vessel/bifurcation
00.45:
Insertion of one vascular stent
00.46:
Insertion of two vascular stents
00.47:
Insertion of three vascular stents
00.48:
Insertion of four or more vascular stent
00.24:
Intravascular imaging of coronary
vessels
00.28:
Intravascular imaging, other
specified vessel(s)
00.29:
Intravascular imaging unspecified
vessel(s)