Approved Add-On Payments for FY 2015
UPDATED OCTOBER 6, 2014
The Centers for Medicare and Medicaid Services (CMS) just recently released the Final Rule for FY 2015. As many of you know, each DRG represents the average resources needed to treat patients grouped to that DRG relative to the national average of resources used to treat all Medicare patients. When the estimated costs for new medical services and technologies cannot be adequately reimbursed under the current DRG rate for similar-type resources, CMS allows for additional payments for hospitals in certain circumstances. This article will focus on the approved add-on payments for new services and new technologies, for FY 2015.
There are three criteria that new medical services or technologies have to meet in order to receive the additional payment:
- The medical service or technology must be new;
- The medical service or technology must be costly such that the DRG rate otherwise applicable to discharges involving the medical service or technology is determined to be inadequate; and
- The service or technology must demonstrate a substantial clinical improvement over existing services or technologies.
Eight technologies have been approved for additional payments in FY 2015:
- Glucarpidase (Trade Brand Voraxaze®)
- Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft
- Argus® II Retinal Prosthesis System
- Zilver® PTX® Drug Eluting Peripheral Stent
- CardioMEMS™ JF (Heart Failure) Monitoring System
- MitraClip® System
- Responsive Neurostimulator (RNS®) System
Glucarpidase (Trade Brand Voraxaze®)
Glucarpidase is a treatment for toxic plasma Methotrexate concentrations in patients with delayed Methotrexate clearance due to impaired renal function.
- Procedure code: (00.95) (Injection or infusion of Glucarpidase) must be listed on the claim
- Maximum add-on payment: $45,000
Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft
The Zenith Fenestrated Graft treats patients with an AAA who are not anatomically suitable for current treatment.
- Procedure code: (39.78) (Endovascular implantation of branching or fenestrated grafts(s) in aorta) must be listed on the claim
- Maximum add-on payment is $8,171.50
Kcentra™ is a replacement therapy for fresh frozen plasma (FFP) for patients with an acquired coagulation factor deficiency due to Warfarin and who are experiencing a severe bleed.
- Procedure code: (00.96) (Infusion of 4-Factor Prothrombin Complex Concentrate) must be listed on the claim
- Maximum add-on payment: $1,587.50
Argus® II Retinal Prosthesis System
The Argus® II is for patients with Retinitis Pigmentosa (RP) providing electrical stimulation of the retina to induce visual perception.
- Procedure code: (14.81) (Implantation of epiretinal visual prosthesis) must be listed on the claim
- Maximum add-on payment: $72,028.75
Zilver® PTX® Drug Eluting Peripheral Stent
The Zilver® PTX® is the first drug-eluting stent for placement into the superficial femoral artery (SFA).
- Procedure code: (00.60) (Insertion of drug-eluting stent(s) of superficial femoral artery) (above-the-knee femoropopliteal) must be listed on the claim
- Maximum add-on payment: $1,705.25
CardioMEMS™ HF (Heart Failure) Monitoring System
An implantable hemodynamic monitoring system comprised of an implantable sensor/monitor placed in the distal pulmonary artery. This system measures multiple pulmonary artery pressure parameters for an ambulatory patient to measure and transmit data via a wireless sensor to a secure website.
- Procedure code: (38.26) (Insertion of implantable wireless pressure sensor for intracardiac or great vessel hemodynamic monitoring) must be listed on the claim
- Maximum add-on payment: $8,875
MitraClip®System is a transcatheter mitral valve repair system that includes a MitraClip® device implant, a Steerable Guide Catheter, and a Clip Deliver System. It is designed to perform reconstruction of the insufficient mitral valve for high-risk patients who are not candidates for conventional open mitral valve repair surgery.
- Procedure code: (35.97) (Percutaneous mitral valve repair with implant) must be listed on the claim
- Maximum add-on payment: $15,000
Responsive Neurostimulator (RNS®) System
The Responsive Neurostimulator (RNS®) System treats people who have been diagnosed with epilepsy whose partial-onset seizures have not been adequately controlled with antiepileptic medications.
- Procedure code: 01.20 (Cranial implantation or replacement of neurostimulator pulse generator)
- Procedure code: (02.93) (Implantation or replacement of intracranial neurostimulator leads(s)).
- Both of these procedure codes must be listed on the claim
- Maximum add-on payment: $18,475
The Council on Technology and Innovation (CTI) at CMS oversees the priority on coordinating coverage, coding, and payment processes for Medicare with respect to new technologies and procedures, and new drug therapies. They also promote the exchange of this information between CMS and other entities. The CTI is composed of senior CMS staff and clinicians and is co-chaired by the Director of the Center for Clinical Standards and Quality (CCSQ), and the Director of the Center for Medicare (CM) which is also designated as the CTI’s Executive Coordinator.
Article by Susie James
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.
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