Inpatient Hospital Claim Requirements for Cardiac Procedures

on Tuesday, 10 September 2019. All News Items | Medicare Coverage | Billing

A Code Here, a Code There

Medicare has National Coverage Determinations (NCDs) that describe the requirements that must be performed and documented for the cardiac services of Transcatheter Aortic Valve Replacement (TAVR), Left Atrial Appendage Closure (LAAC), and Transcatheter Mitral Valve Repair (TMVR). Be sure to read the other article in this week’s Wednesday@One that discusses these requirements. Hopefully your cardiology department is familiar with the NCDs and has implemented processes to ensure the documentation in your records supports Medicare’s requirements. But isn’t it frustrating if all the requirements are met and appropriately documented, to have your Medicare claim denied, rejected, or returned due to missing claim elements? And in addition to the frustration, your facility is delaying or missing out on your Medicare DRG payments.

Claims for these services obviously must include the appropriate procedure codes and diagnosis codes. In addition, since all of these cardiac services are covered under Coverage with Evidence Development (CED), the claims must include a secondary diagnosis code, condition code, and value code related to the clinical trial/registry. All three of these procedures are inpatient-only procedures and would be billed on an inpatient claim, type of bill, 11x and paid under a Medicare DRG payment.

Specifically, for each procedure the following is required on the institutional inpatient claim:

Left Atrial Appendage Closure (LAAC) (Watchman procedure):

  • Procedure Code - 02L73DK (Occlusion of Left Atrial Appendage with Intraluminal Device, Percutaneous Approach)
  • One of the following diagnosis codes –
    • I48.0 - Paroxysmal Atrial Fibrillation
    • I48.1 - Persistent Atrial Fibrillation
    • I48.2 - Chronic Atrial Fibrillation
    • I48.91 - Unspecified Atrial Fibrillation
  • Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
  • Condition Code 30 - Qualified Clinical Trial
  • Value Code D4 and corresponding 8-digit clinical trial number (Clinical trail and/or registry numbers can be found on Medicare’s CED website.)

Transcatheter Aortic Valve Replacement (TAVR):

  • Procedure Code – One of the following procedure codes –
    • 02RF37Z (Replacement of Aortic Valve with Autologous Tissue Substitute, Percutaneous Approach),
    • 02RF38Z (Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Approach),
    • 02RF3JZ (Replacement of Aortic Valve with Synthetic Substitute, Percutaneous Approach),
    • 02RF3KZ (Replacement of Aortic Valve with Nonautologous Tissue Substitute, Percutaneous Approach),
    • 02RF37H (Replacement of Aortic Vavle with Autologous Tissue Substitute, Transapical, Percutaneous Approach),
    • 02RF38H (Replacement of Aortic Valve with Zooplastic Tissue, Transapical, Percutaneous Approach),
    • 02RF3JH (Replacement of Aortic Valve with Synthetic Substitute, Transapical, Percutaneous Approach), or
    • 02RF3KH (Replacement of Aortic Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Approach)
  • Procedure Code - X2A5312 (Cerebral Embolic Filtration, dual filter in innominate artery and left common carotid artery, percutaneous approach) when used
  • One of the following diagnosis codes –
    • I35.0 - Nonrheumatic aortic (valve) stenosis
    • T82.222A - Displacement of biological heart valve graft, initial encounter (Code for when a previously placed valve was malpositioned or became displaced)
    • T82.857A - Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter (Code for when the previously placed valve developed stenosis prematurely)
    • T82.223A - Leakage of biological heart valve graft, initial encounter (Code for when the previously placed valve developed regurgitation prematurely)
    • Z45.09 - Encounter for adjustment and management of other cardiac device (Code for when the previously placed valve developed stenosis or regurgitation as an expected occurrence as it degenerates towards end-of-life)
  • Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
  • Condition Code 30 - Qualified Clinical Trial
  • Value Code D4 and corresponding 8-digit clinical trial number

Transcatheter Mitral Valve Repair (TMVR) (MitraClip procedure):

  • One of the following Procedure Codes
    • 02UG3JZ - Supplemental Mitral Valve with Synthetic Substitute, Percutaneous approach
    • 02QG3ZE - Repair Mitral Valve created from Left Atrioventricular Valve, Percutaneous Approach
    • 02QG4ZE - Repair Mitral Valve created from Left Atrioventricular Valve, Percutaneous Endoscopic Approach
    • 02UG37E - Supplement Mitral Valve created from Left Atrioventricular Valve with Autologous Tissue Substitute, Percutaneous Approach
    • 02UG38E - Supplement Mitral Valve created from Left Atrioventricular Valve with Zooplastic Tissue, Percutaneous Approach
    • 02UG3JE - Supplement Mitral Valve created from Left Atrioventricular Valve with Synthetic Substitute, Percutaneous Approach
    • 02UG3KE - Supplement Mitral Valve created from Left Atrioventricular Valve with Nonautologous Tissue Substitute, Percutaneous Approach
    • 02UG3KZ - Supplement Mitral Valve with Nonautologous Tissue Substitute, Percutaneous Approach
    • 02UG47E - Supplement Mitral Valve created from Left Atrioventricular Valve with Autologous Tissue Substitute, Percutaneous Endoscopic Approach
    • 02UG48E - Supplement Mitral Valve created from Left Atrioventricular Valve with Zooplastic Tissue, Percutaneous Endoscopic Approach
    • 02UG4JE - Supplement Mitral Valve created from Left Atrioventricular Valve with Synthetic Substitute, Percutaneous Endoscopic Approach
    • 02UG4KE - Supplement Mitral Valve created from Left Atrioventricular Valve with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach
    • 02WG37Z - Revision of Autologous Tissue Substitute in Mitral Valve, Percutaneous Approach
    • 02WG38Z - Revision of Zooplastic Tissue in Mitral Valve, Percutaneous Approach
    • 02WG3JZ - Revision of Synthetic Substitute in Mitral Valve, Percutaneous Approach
    • 02WG3KZ - Revision of Nonautologous Tissue Substitute in Mitral Valve, Percutaneous Approach
  • One of the following diagnosis codes –
    • I34.0 - Nonrheumatic mitral (valve) insufficiency
    • I34.1 - Nonrheumatic mitral valve prolapse
  • Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
  • Condition Code 30 - Qualified Clinical Trial
  • Value Code D4 and corresponding 8-digit clinical trial number

MACs will fully reject inpatient claims for these cardiac procedures when billed without the appropriate procedure, diagnosis, or clinical trial codes. Hospitals that perform these procedures need to put processes in place for communication between the clinical department, coding, and the billing office so that the appropriate claim elements are added. Internal claim processing edits to halt claims with one of the applicable procedure codes may be an option to verify appropriate diagnosis codes and allow the addition of the clinical trial codes.

Refer to the NCDs and corresponding claims processing instructions for complete Medicare requirements.

NCD 20.32 TAVRNCD 20.33 TMVR, and NCD 20.34 LAAC.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

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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