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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!