Billing for Transcatheter Aortic Valve Replacement (TAVR)

 

Open Aortic Valve Replacement

Background

Transcatheter Aortic Valve Replacement (TAVR) is a new technology for use in treating certain patients with aortic stenosis.  As an alternative to open heart surgery, a bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.  Potential benefits of this procedure are that it’s less invasive than the open technique, and it usually takes less time to perform.

One such device received FDA approval in November 2011.  Approval was granted for patients with severe aortic stenosis who are not eligible for open-heart procedures and have a calcified aortic annulus.  A heart surgeon must be involved in the decision to perform this procedure.  Patients who are candidates for an open procedure are not candidates for TAVR.

Medicare Coverage

As of May 1, 2012, the Centers for Medicare and Medicaid Services (CMS) provided Medicare coverage for TAVR.  Change Release 7879 outlines the National Coverage Determination and the specific requirements for coverage of this procedure.  The procedure must be performed for an FDA-approved indication, and the following conditions must be met.

  1. It is furnished with a complete aortic valve and implantation system that has received FDA premarket approval.
  2. Two cardiac surgeons have independently examined the patient face-to-face to determine the patient’s suitability for the procedure
  3. The patient is under the care of a heart team
  4. It is furnished in a hospital with appropriate infrastructure for this procedure
  5. The heart team and hospital must be participating in a prospective, national, audited registry.

The complete list of requirements and conditions can be found in the CMS National Coverage Determination.

For indications not FDA-approved, CMS covers TAVR under Coverage with Evidence Development (CED) for patients who are enrolled in qualifying clinical studies.

Medicare Coding Requirements for Professional Claims

For TAVR services furnished on or after May 1, 2012, you should bill with the appropriate temporary level III CPT Code:

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

Beginning January 1, 2013, CPT level 1 codes will replace the above four codes for processing TAVR claims, and CMS will issue instructions for the permanent CPT level 1 codes in a future Change Release.  Those codes will be 33361-33369, and 0318T.  These codes differentiate the approach, whether it’s open or percutaneous, and whether or not cardiopulmonary bypass support is provided and by what means.  Full descriptions of these codes are provided in the 2013 CPT book.  A link to the CMS Change Release will be provided once it is available.

Per CMS instructions, these procedure codes will only be paid by Medicare for the inpatient place of service (21) and when billed with the cosurgery modifier (62).

Medicare will only pay claim lines for these codes in a clinical trial when billed with modifier Q0 (zero). For TAVR services, use of modifier Q0 signifies CED participation (qualified registry or qualified clinical study).  In addition, the claim must reference ICD-9 code V70.7 as a secondary diagnosis which signifies CED participation.

Other private payers may very well cover this procedure using the same Level III codes listed above, but you are encouraged to contact those payers for specific coverage rules and payment policies.