Post on 02-Aug-2020
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Thoratec VAD Reimbursement
Roundtable
April 1, 2015
Thoratec Reimbursement and Healthcare
Init iatives Team
Robin Roberts Bost ic
Tina Ivovic
Dennis Rivard
Stephanie Toney
Ida Jaworski
Janna Barnes
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This reimbursement information is intended to provide the health care professional
with information related to billing, coding and reimbursement requirements that
may apply to Thoratec products. It is being provided for general informational and
educational purposes only, and is not intended, and does not constitute,
reimbursement or legal advice. Use of codes identified here does not guarantee
coverage or payment at any specific level and is not intended to increase or
maximize payment by any payer. Laws, regulations and coverage policies are
complex and updated frequently. In addition, reimbursement policies vary widely
from insurer to insurer and will reflect different patient conditions. You should check
the current law and regulations and insurer’s policies to confirm the most current
coverage, coding or billing requirements. Any questions should be directed to your
attorneys or reimbursement specialist. The health care professional is responsible
for all aspects of reimbursement, including using codes that accurately reflect the
patient’s condition, procedures performed, and products used and ensuring the
veracity of all claims submitted to third party payers.
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Agenda
1. Upcoming Medicare Inpatient PPS Proposed Rule
(expected 4.10.15)
2. Update on the LVAD DT Certification Process
3. Update on driveline management Q0507-509
HCPCS codes and our meeting with CMS
4. NEW TOPIC – Medicare Physician Fee Schedule
Sustainable Growth Rate “fix” ends today
5. Save the Date - the 2015 Thoratec Economic
Summit
6. Question and Answers – ask us, or your peers!
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Medicare Inpatient PPS Proposed
Rule (expected 4.10.15)
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Medicare Inpatient Rule
• Each year, Medicare publishes their proposed rule
for inpatient hospital payments in mid-May, final rule
in mid-August
• This year, CMS has indicated that it will be released
in early April
– Expected to finalize implementation of ICD-10
– Opens a 60 day comment period
• We don’t expect any big changes in payment or
policy for Mechanical Circulatory Support therapy
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2015 HOSPITAL Medicare Inpatient ReimbursementIndication, ICD-9-CM Coding, MS-DRG Assignment & Payment
2015 Medicare MS-DRG base payment *
FY 2015 MS-DRG assignment *
37.66
Insertion of implantable
heart assist system
ICD-9-CM
procedure code
HeartMate II ®
Implantable electric
$145,933 unadjusted base
MS-DRG 1
Heart Transplant or
Implant of Heart Assist System with MCC
* Source: Congressional Federal Register, Medicare Hospital Inpatient Prospective Payment System Final Rule, August 1, 2014.
FY 2015 MS-DRG assignment, MS-DRG relative weights, and payment is for dates of service on or after October 1, 2014. When
provider-specific adjustments are applied, actual payment will usually be higher than base payment amount.
IndicationBridge to Transplant
Destination Therapy
MS-DRG 2
Heart Transplant or
Implant of Heart Assist System without MCC
$90,128 unadjusted base
or
ICD-9-CM Code
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2016 HOSPITAL Medicare Inpatient ReimbursementIndication, ICD-9-CM Coding, MS-DRG Assignment & Payment
2016 Medicare MS-DRG base payment *
FY 2016 MS-DRG assignment *
02HA0QZInsertion of Implantable
Heart Assist System, open approach
ICD-10
procedure code
HeartMate II ®
Implantable electric
tbd
MS-DRG 1
Heart Transplant or
Implant of Heart Assist System with MCC
* Source: Congressional Federal Register, Medicare Hospital Inpatient Prospective Payment System Final Rule, August 1, 2014.
FY 2015 MS-DRG assignment, MS-DRG relative weights, and payment is for dates of service on or after October 1, 2014. When
provider-specific adjustments are applied, actual payment will usually be higher than base payment amount.
IndicationBridge to Transplant
Destination Therapy
MS-DRG 2
Heart Transplant or
Implant of Heart Assist System without MCC
tbd
or
ICD-10 Code
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ICD-10 Diagnoses Associated with MCCs
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Update on the LVAD DT
Certification Process
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New Organization Approved to Certify
Hospitals for Medicare DT Implants
• Det Norske Veritas Healthcare, Inc. (DNV LG) has
been approved by CMS to be a deeming agency for
MCS DT certification as of November 5, 2014
• The Joint Commission (TJC) remains a certifying
agency
• MCS Centers now have a choice as to what agency
they will use to help them qualify for Medicare DT
reimbursement
• Thoratec supports both TJC and DNV GL
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Comparison of JC and DNV Standards for Destination Therapy Certification
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Continued
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Update on driveline
management, Q0507-509 HCPCS
codes and our meeting with CMS
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Q0508 for Driveline Stabilization Supplies,
Patient to Power Module Cable
Background:
• HCPCS codes Q0507-09 were created via Medicare Program Transmittal for use starting April 1, 2013
• Any VAD accessory or supply for an internally placed VAD not identified by a permanent HCPCS code must use Q0508; driveline stabilization systems were specifically identified
• Q0507 and Q0509 were also created for external VAD accessories and for patients not covered by Medicare at the time of VAD implantation, respectively
Source: CMS Program Transmittal 1159, December 21, 2012
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Descriptors for Q0507-Q0509
Like all replacement VAD Accessories and Supplies, these items
were paid when provided in the physician office, hospital
outpatient clinic, or by a third-party supplier licensed to provide
prosthetic devices
• Q0507 - Miscellaneous Supply Or Accessory For Use With An
External Ventricular Assist Device
• Q0508 - Miscellaneous Supply or Accessory For Use With An Implanted Ventricular Assist Device
• Q0509 - Miscellaneous Supply Or Accessory For Use With Any
Implanted Ventricular Assist Device For Which Payment Was
Not Made Under Medicare Part A
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Q0507-09 Packaged into the Hospital
Outpatient Visit Payment During 2014
• In the 2014 Medicare Hospital outpatient prospective payment system Proposed Rule, HCPCS codes Q0507-08 were given the same payment identifier as all of the other HCPCS codes, meaning it was payable via the DMEPOS fee schedule when provided in the hospital outpatient setting
• However, in the HOPPS final rule, the Q0508 code was bundled (Status Indicator N) into the payment for the visit/service provided because of new “Packaging” rules
• During 2014, these items have not been paid by Medicare in the Hospital Outpatient setting:
– driveline stabilization systems (dressings),
– patient to power module cables, or
– Power Module accessory kit (lanyard)
– Any accessories or supplies replaced for patients that were not covered by Medicare at the time of their VAD implant procedure
Sources: Federal Register, Vol 78, No. 139, July 19, 2013 and Federal Register Vol. 78, No. 237, December 10, 2013
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Despite Comment, Medicare Continues
to Package Q0507- 09 in 2015
• During the 2015 Rulemaking process, Thoratec requested that
CMS unpackage and maintain separate payment for HCPCS
codes Q0507-Q0509 under the Durable Medical Equipment,
Prosthetics, and Orthotics (DMEPOS) fee schedule for items
provided in the hospital outpatient setting
• CMS did not address our comment and continued to package
Q0507-09 into the visit or VAD interrogation in this setting
• Since1/1/2014 Medicare has not separately reimbursed for
HCPCS codes Q0507, Q0508 (driveline supplies), and Q0509 in
the hospital outpatient setting.
• January 6, 2015, we met with CMS to discuss this, and they
appeared to understand the issue – awaiting a response
Sources: Federal Register, Vol 79, No. 134, July 14, 2014 and Federal Register Vol. 79, No. , November 10, 2014
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Action Items
1. Explore whether you can see patients and supply
driveline stabilization supplies in a physician office
setting
2. Explore whether Shared Care sites currently seeing
patients in the physician office setting could supply
driveline stabilization supplies
3. Explore using a third party supplier to provide these
items to patients
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Getting Started with Continuum for
your Driveline Patients
You can use Continuum to refer patients for LVAD accessories
and/or driveline supplies.
Call (877) 217-1485 to speak with our customer service team or fax
patient information to (877) 217-1486 and we will begin the
authorization process. Please include your driveline protocol for us
to add to the patient prescription.
Please contact Dale Clark (dale.clark@continuuminc.com) or Ida
Jaworski (ida.jaworski@continuuminc.com) if you have any
questions.
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Medicare Physician Fee Schedule
SGR “Fix” Expires Today
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Medicare Physician Fee Schedule SGR
“Fix” Postponed
• The 2015 MPFS Final Rule Conversion Factor (CF) has been $35.8013
from January 1, 2015 through March 31, 2015.
• The CF for April 1, 2015 through December 31, 2015 is set at $28.2239.
• Based on historical precedence of 17 repeals in 10 years, Congress
usually passes legislation in Q1 affecting the reduction in the CF used
to convert RVUs into payment rates.
• During Washington’s “Vote-o-Rama” in late March, the House of
Representatives voted to scrap the current formula for paying
physicians – which is tied to the Sustainable Growth Rate – and
replace it with a payment system tied to quality, not quantity
• The Senate decided to wait until after recess to decide on this Bill, and
the Obama administration will delay payments for 2 weeks until they
return
• It is expected that the payment system will no longer be tied to the
SGR
Sources: Federal Register, Medicare Physician Fee Schedule Final Rule, November 10, 2014.and http://kaiserhealthnews.org
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HeartMate II®
Implantable electric
Thoratec®
CentriMag®
External
Thoratec®
PVAD™
External/pneumatic
33975, $1,350
Insertion of ventricular assist device; extracorporeal, single ventricle
(no global period)
33979, $2,013
Insertion of ventricular assist device; implantable intracorporeal, single ventricle
(no global period)
33976, $1,644
Insertion of ventricular assist device; extracorporeal, biventricular
(no global period)
33980, $1,836
Removal of ventricular assist device; implantable intracorporeal, single ventricle
(no global period)
33977, $1,164
Removal of ventricular assist device; extracorporeal, single ventricle
(no global period)
33982, $2,025
Replace VAD Pump, Intracorporeal no Bypass
(no global period)
33983, $2,392
Replace VAD Pump, Intracorporeal with Bypass
(no global period)
** Use 33999 to describe the insertion or removal of an implantable VAD for biventricular support.
For any VAD follow up, V43.21, Organ or Tissue Replaced By Other
Means, Heart Assist Device could be an appropriate ICD-9-CM
diagnosis code in addition to the underlying condition.
33978, $1,381
Removal of ventricular assist device; extracorporeal, biventricular
(no global period)
33981, $861
Replace VAD Pump, External
(no global period)
Surgeon CPT Coding & Medicare Payment for 2015*
* CPT Copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Source: Congressional Federal Register, Medicare Physician Fee Schedule Updates, November, 2014. Rates effective January 1, 2015- March 31, 2015.
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Patient has an HeartMate II® implanted internally. Surgeon bills 33979, Insertion of ventricular assist device; implantable intracorporeal, single ventricle. Patient is in the hospital for 18 days (source: The Advisory Board Company). The surgeon rounds 17 of those days, the referring cardiologist rounds 17 of those days. Patient returns to surgeon's office weekly for the first month, and then back to the referring cardiologist for monthly visits.
Example: SURGEON Example: CARDIOLOGIST
Inpatient Visits
HM II implant procedure (33979) $2,013
Rounds - 10 days acute (99233) $1,049 Rounds - 10 days acute (99233) $1,049
Rounds - 7 days lower acuity (99232) $511 Rounds - 7 days lower acuity (99232) $657
VAD Interrogation – 17 days (93750) $797 VAD Interrogation – 10 days (93750) $469
Rounds - discharge day (99239) $108 Rounds - discharge day (99239) $108
Inpatient Total: $4,478 Inpatient Total: $2,283
Outpatient Visits (either specialty may bill)
Office - 4 visits high complexity (99215) $581 Office - 4 visits high complexity (99215) $581
Office - 4 VAD Interrogation (93750) $225 Office - 4 VAD Interrogation (93750) $225
Approximate Total Surgeon payment: $5,284 Approximate Total Cardiologist payment: $3,089
Case Example: 0-Day Global Billing
* CPT Copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Source: Congressional Federal Register, Medicare Physician Fee Schedule Updates, November, 2014. Rates effective January 1, 2015- March 31, 2015.
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Economic Summit 2015
Registration emails will start in the
summer, but save the date!
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2015 Economic Summit
September 30 - October 2, 2015
Estancia Hotel, La Jolla CA
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2014 Economic SummitAll presentations available on our reimbursement
website
– Thoratec.com/Medical-Professionals/Reimbursement
– If you don’t already have access, please register and we’ll
provide access.
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Let’s open it up for any other
questions or topics!