2019 reimbursement changes for subcutaneous cardiac rhythm … · (specific to subcutaneous cardiac...

2019 REIMBURSEMENT CHANGES FOR SUBCUTANEOUS CARDIAC RHYTHM MONITORS

PRESENTED BYKATIE SHEPARD, SR. RBT & HEALTH POL ANALYSTMEDTRONIC CARDIAC RHYTHM & HEART FAILURE

Recorded December 6, 2018

DISCLAIMER

Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (e.g., instructions for use, operator’s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service.

CPT® copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use.

2 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors

2019 REIMBURSEMENT CHANGESSUBCUTANEOUS CARDIAC RHYTHM MONITORS

New! CPT Codes for Insertion/Removal Procedures

New Code Numbers

New Code Descriptors

Payment Changes

New! Office Place of Service

Non-physician Practitioners (NPPs)

Device Monitoring Editorial Changes, Clarifications

Frequently Asked Reimbursement Questions

Contact Information


NEW NOMENCLATURE/CODE DESCRIPTOR LANGUAGE

Implantable Cardiac Monitor (ICM)

Measures physiologic parameters

(e.g. Optivol)

Implantable Loop Recorder (ILR)

Existing Reveal LINQ™ device descriptor

(no physiologic parameters)

Subcutaneous Cardiac Rhythm Monitor

New Reveal LINQ™ device descriptor

(no physiologic parameters)

CURRENT STARTING 1/1/2019

Implantable Cardiac Physiologic Monitor (ICPM)

Measures physiologic parameters

(e.g. Optivol)


2019 CPT® CODE CHANGES

CPT®

Code Descriptor

33282 Implantation of patient-activated cardiac event recorder

33284 Removal of an implantable, patient-activated cardiac event recorder

CPT®

Code Descriptor

33285 Insertion, subcutaneous cardiac rhythm monitor, including programming

33286 Removal, subcutaneous cardiac rhythm monitor

Procedures Performed on or Before

12/31/2018

Procedures Performed on or After

1/1/2019

5

Source: AMA 2018 & 2019 Codebooks.

2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors

2019 CPT® CODE CHANGES

CPT®

Code Descriptor

33282 Implantation of patient-activated cardiac event recorder

33284 Removal of an implantable, patient-activated cardiac event recorder

CPT®

Code Descriptor

33285 Insertion, subcutaneous cardiac rhythm monitor, including programming

33286 Removal, subcutaneous cardiac rhythm monitor

Procedures Performed on or Before

12/31/2018

Procedures Performed on or After

1/1/2019

6

Source: AMA 2018 & 2019 Codebooks.


2019 RELATIVE VALUE UNITS

CPT®

Code Description wRVUPE RVU

(Facility)

PE RVU

(Non-fac)

MP RVU

Total Facility

RVU

Total Non-Facility

RVUINSERTION

33285

Insertion, subcutaneous cardiac rhythm monitor, including programming

1.53 0.70 144.18* 0.36 2.59 146.07

REMOVAL

33286Removal, subcutaneous cardiac rhythm monitor 1.50 0.69 1.95 0.35 2.54 3.80

*Non-facility PE RVU includes the device.

Source: 2019 Final Medicare Physician Fee Schedule (MPFS) Released November 1, 2018.


8

SPOTLIGHT RVU & RATE CHANGES: PHYSICIANCMS NATIONAL RATES

RVUs Professional Rates Rate Change

% ChangeCPT Short

Descriptor2018 2019 2018 2019

Implant/Insertion

3.25 1.53 $236 $93 -$143 -61%

Removal 2.75 1.50 $207 $92 -$115 -56%

Valued by physician specialty societies using surveys of physicians who are familiar with the service: Time Technical skill required Mental and physical effort (intensity)

Changes reflect several factors including a decrease in time associated with the evolution (e.g. miniaturization) of the devices

Medicare Physician Fee Schedule Files available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

2019 MEDICARE NATIONAL PAYMENTS OFFICE & OUTPATIENT PLACE OF SERVICE

CPT®

Code Description

2019 National

Rate (Non-

facility)

2019 Professional

National Rate

(Facility)

2019 OPPS

National Rate

2019 ASC

National Rate

Insertion

33285Insertion, subcutaneous cardiac rhythm monitor, including programming

$5,264 $93 $7,404 $6,375

Removal

33286Removal, subcutaneous cardiac rhythm monitor $137 $92 $579 $298

2019 MPFS Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html2019 OPPS Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html

NEW! OFFICE PLACE OF SERVICEHOW DO WE KNOW?

How do we know that LINQ procedures will now be paid by CMS in the office setting starting 1/1/2019?

From the Medicare Physician Fee Schedule:

“For procedures that can be furnished in a physician’s office, as well as in a facility setting, where Medicare makes a separate payment to the facility for its costs in furnishing a service, we establish two PE RVUs: facility and nonfacility.”

Previous codes for these procedures did not have non-facility PE RVUs assigned.

New codes for these procedures have non-facility PE RVU assignments.

10

Source: 2019 MPFS Files Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

11

GLOBAL SURGICAL PACKAGE CHANGES

2018 2019

CPT Short Descriptor

Global Period Assignment

Procedure Classification

Global Period Assignment

Procedure Classification

Implant /Insertion

090Major

Procedures000

Endoscopies and Some

Minor Procedures

Removal 090Major

Procedures000

Endoscopies and Some

Minor Procedures

CMS assigns a global surgical package to all CPT codes.

Global surgical packages impact physician coding and payment only for procedures performed within the specified number of days after a surgical procedure.

The reclassification of these procedures to 000-day globals opens the door for non-physician practitioners (NPPs) to perform these services when additional specified criteria are met.

MPFS Files Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html

NON-PHYSICIAN PRACTITIONERS (NPP)

What is an NPP? Examples of non-physician practitioners are nurse practitioners and physician assistants

What has changed for NPP performing LINQ insert/removal procedures? The global period change opens the door for non-physician practitioners (NPPs) to perform these procedures for Medicare benefeciaries

Does this all mean that an NPPs can start performing these procedures on 01/01/2019? No. There are several considerations to be investigated and addressed individually by location before an NPP performs these procedures

How are NPPs paid for their work?

• NPPs are paid at 85% of the physician rate

• Under specific criteria, NPP procedures can be billed “incident to” a physician (i.e. under the physician NPI) to receive the full 100% physician payment rate

• The requirements for “incident to” billing are complex and vary by payer, both Medicare MACs and private payers

New codes classified as “minor surgical procedures”

CPT Coding Changes

Varying licensure requirements by NPP (e.g. NP, PA)

State Licensure

Credentialing Malpractice Insurance

Individual Payer Policy (MAC, Private Payer)

? ? ? ?

12

Medicare Benefit Policy Manual Chapter 15 (190)—Physician Assistant (PA) Services; (200)—Nurse Practitioner (NP) ServicesMedicare Benefit Policy Manual Chapter 15 (60.2)—Services of Nonphysician Personnel Furnished Incident To Physician’s Services


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf


DEVICE MONITORING—DESCRIPTOR CHANGES

2018 2019

CPT®

Code Descriptor DescriptorIn Person Interrogation or Programming Evaluation

93285ILR system programming device evaluation

Subcutaneous cardiac rhythm monitor systemprogramming device evaluation

93291Interrogation device evaluation; ILR system, including heart rhythm derived data analysis

Interrogation device evaluation; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis

Remote Interrogation Evaluation

93298Interrogation device evaluation(s), (remote) up to 30 days; ILR system [professional service]

Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system [professional service]

93299Interrogation device evaluation(s), up to 30 days; ICM/ILR system [technical service]

Interrogation device evaluation(s), up to 30 days; ICPM/ILR system [technical service]


Parameters that must be Checked During Interrogation Evaluation

All programmed parameters

The heart rate and rhythm during recorded episodes from both patient-initiated and device algorithm detected events, when present

Differentiating Programming Evaluation from Interrogation Evaluation

Iterative adjustments of the programmable parameters are conducted

Iterative adjustments provide information that permits the operator to assess and select the most appropriate final program parameters to:

Provide for consistent delivery of the appropriate therapy; and

Verify function of the device

Final program parameters may or may not change after evaluation

(Specific to subcutaneous cardiac rhythm monitors) Often, but not always, the tachycardia and bradycardia detection criteria will be adjusted

DEVICE MONITORING—INTRODUCTORY TEXT CHANGES

Source: AMA CPT Codebook 2019.


15

FREQUENTLY ASKED REIMBURSEMENT QUESTIONS

1. What CPT code should be reported when the Reveal LINQ requires repositioning?

2. How does payment to the physician vary by site of service?

3. Is there a separate code I need to report for the device when the insertion is performed in the office?

4. What is the minimum number of days that the patient needs to be in the remote monitoring program for the services (PC/TC) to be billable?

5. Can an NPP serve as a supervisor for in person monitoring?


16

CUSTOMER-FACING RESOURCESAVAILABLE ON CRHF REIMBURSEMENT WEBSITE

Resources available at: http://Medtronic.com/crhfreimbursement


http://medtronic.com/crhfreimbursement

FOR MORE INFORMATIONCONTACT CRHF REIMBURSEMENT SERVICES


APPENDIX

REFERENCES/RESOURCES

AMA CPT 2019 Codebook. CPT codes and descriptions only are copyright ©2018 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein.

2019 Medicare Final Inpatient Prospective Payment System. Released Aug 2, 2018.

2019 Medicare Final Outpatient Prospective Payment System. Released Nov 2, 2018.

2019 Medicare Final Physician Fee Schedule. Released Nov 1, 2018.

Medicare Benefit Policy Manual Chapter 15 (60.2)—Services of Nonphysician Personnel Furnished Incident To Physician’s Services

Medicare Benefit Policy Manual Chapter 15 (190)—Physician Assistant (PA) Services; (200)—Nurse Practitioner (NP) Services; (210)—Clinical Nurse Specialist (CNS) Services


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html



INPATIENT RATE CHANGES FY 2018 - FY 2019For Cardiac Diagnoses

MS-DRG MS-DRG Description

FY 2018 National

Rate

FY 2019 National

Rate % Change

260CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC

$21,620 $22,112 2.3%

261CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC

$11,680 $12,168 4.2%

262CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC

$9,950 $9,964 0.1%

WEIGHTED AVERAGE--------------------------------------- $14,336 $15,071 5.1%

For Cryptogenic Stroke

MS-DRG MS-DRG Description

FY 2018 National

Rate

FY 2019 National

Rate % Change

040PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC

$22,948 $23,998 4.6%

041PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM

$14,048 $14,408 2.6%

042PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC

$11,514 $11,433 -0.7%

WEIGHTED AVERAGE--------------------------------------- $16,908 $17,132 1.3%


21

OUTPATIENT RATE CHANGES CY 2018 - CY2019IMPLANT/INSERTION & REMOVAL

CPT Code

Short Descriptor

Ambulatory Surgical Center

Hospital Outpatient

2018 2019 % Change

2018 2019 % ChangeAPC Rate APC Rate

33285 Insertion $6,403 $3,701 -42% 5222* $7,371 5222 $7,404 0%

33286 Removal $298 $298 0% 5071* $573 5071 $579 0%*Previous codes 33282 (implant) and 33284 (removal) were assigned to the same APCs as the new 2019 codes.


DEVICE EVALUATION RATE CHANGES CY 2018 – CY 2019 2018 2019

CPT®

Code Short Descriptor

Medicare National

Physician Rate (non-facility)

Medicare National

Physician Rate (non-facility)

Medicare National OPPS

Rate

Medicare National OPPS

Rate

In Person Interrogation & Programing Evaluation

93285

Device programming $44 $49

$38 $37$27 (26) $27 (26)

$17 (TC) $22

93291

Device interrogation $33 $39

$17 $17$19 (26) $19 (26)

$15 (TC) $20 (TC)

Remote Interrogation Evaluation

93298

Device interrogation—professional service

$27 $27Physician

OnlyPhysician

Only

93299

Device interrogation—technical service Contractor

PricedContractor

Priced$38 $37



BRIEF STATEMENT

BRIEF STATEMENT

Indications: Reveal LINQTM LNQ11 Insertable Cardiac Monitor and Patient Assistant

The Reveal LINQTM Insertable Cardiac Monitor is an implantable patient-activated and automatically-activated monitoring system that records subcutaneous ECG and is indicated in the following cases:

Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias

Patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia

This device has not specifically been tested for pediatric use.

Patient Assistant: The Patient Assistant is intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates the data management feature in the Reveal LINQTM Insertable Cardiac Monitor to initiate recording of cardiac event data in the implanted device memory.

Contraindications: There are no known contraindications for the implant of the Reveal LINQTM Insertable Cardiac Monitor. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated.

Warnings/Precautions: Reveal LINQTM LNQ11 Insertable Cardiac Monitor

Patients with the Reveal LINQTM Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external de brillation, lithotripsy, therapeutic ultrasound, and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing as described in the Medical procedure and EMI precautions manual. MRI scans should be performed only in a specified MR environment under specified conditions as described in the Reveal LINQTM MRI Technical Manual.

Patient Assistant: Operation of the Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device.

Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin.

See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events.

For further information, please call Medtronic at 1 (800) 328-2518 or consult Medtronic’s website at www.medtronic.com.

Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.

http://www.medtronic.com/

2019 reimbursement changes for subcutaneous cardiac rhythm … · (specific to subcutaneous cardiac...

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