Abbott Atherectomy for Lower Extremity Revascularization User Guide

Abbott Atherectomy for Lower Extremity Revascularization

Specifications:

• Product Name: Atherectomy for Lower Extremity Revascularization
• Usage: Removal of plaque from blood vessels in the peripheral area
• Procedure Settings: Hospital inpatient, hospital outpatient, ambulatory surgical center (ASC)

Product Usage Instructions

Hospital Inpatient:
For hospital inpatient procedures, refer to the relevant ICD-10 PCS procedure codes provided in the manual. Ensure proper documentation of patient conditions and services rendered during admission to determine MS-DRG for reimbursement.

Hospital Outpatient:
Use the specified CPT codes for hospital outpatient procedures. Assign the appropriate APC based on the type of atherectomy procedure performed.

Ambulatory Surgical Center (ASC):
Follow the designated CPT codes for procedures carried out in ASC. Choose the correct APC corresponding to the specific atherectomy procedure conducted.

FAQ:

• Q: Are there prior authorization requirements for atherectomy procedures?
  A: Traditional Medicare generally does not require prior authorization for lower extremity endovascular procedures. However, Medicare Advantage plans and some commercial payers may necessitate prior authorization. It is advisable to check with your payers for specific requirements.

• Q: Where can physicians access materials for seeking prior authorization?
  A: Physicians can access additional materials for seeking prior authorization for atherectomy and lower extremity endovascular procedures on the Abbott website under Peripheral Reimbursement & Coding section.

HEALTH ECONOMICS & REIMBURSEMENT
Atherectomy for Lower Extremity Revascularization Reimbursement Guide

ATHERECTOMY COVERAGE OVERVIEW

• Atherectomy for lower extremity revascularization procedures is utilized to remove plaque from a blood vessel in the peripheral area. Atherectomy can be performed in the following settings:
  • Facility setting: Hospital Inpatient, Hospital Outpatient, and Ambulatory Surgical Center (ASC)
  • Non-facility setting: Physician office / Office-Based Lab (OBL)

Prior Authorization Requirements

• Traditional Medicare has implicit coverage for lower extremity endovascular procedures and does not require prior authorization. Medicare Advantage plans are managed by commercial payers and may require prior authorization. Several commercial plans also require prior authorization; please check with your payers for any requirements.
• Additional materials are available for physicians when seeking prior authorization for atherectomy and lower extremity endovascular procedures. The materials can be accessed on Abbott website Peripheral Reimbursement & Coding

ATHERECTOMY CODING AND REIMBURSEMENT

ICD-10 PCS PROCEDURE CODES
The following ICD-10 PCS codes are commonly reported with atherectomy in the lower extremity area in the hospital inpatient setting. This is not an exhaustive list of relevant ICD-10 PCS codes.

Dilation, Percutaneous Approach 1| Extirpation, Percutaneous Approach 1
---|---
0 Medical and Surgical
4 Lower Arteries
7 Dilation| 0 Medical and Surgical
4 Lower Arteries
C Extirpation
Body Part Character|

• C Common Iliac Artery, Right
• D Common Iliac Artery, Left
• E Internal Iliac Artery, Right
• F Internal Iliac Artery, Left
• H External Iliac Artery, Right
• J External Iliac Artery, Left
• K Femoral Artery, Right
• L Femoral Artery, Left
• M Popliteal Artery, Right
• N Popliteal Artery, Left

|

• P Anterior Tibial Artery, Right
• Q Anterior Tibial Artery, Left
• R Posterior Tibial Artery, Right S Posterior Tibial Artery, Left
• T Peroneal Artery, Right
• U Peroneal Artery, Left
• V Foot Artery, Right
• W Foot Artery, Left
• Y Lower Artery

Approach Character| 3 Percutaneous
Device Character| Z No Device
Qualifier Character| Z No Qualifier

HOSPITAL INPATIENT

Effective October 1, 2023 – September 30, 2024. MS-DRG assignment is based on many factors including documented patient conditions as well as services rendered during an admission. This is not an all-inclusive list of possible MS-DRGs.

• MCC: major complications or comorbidities.
• CC: complications or comorbidities.

HOSPITAL OUTPATIENT
Effective January 1, 2024 – December 31, 2024.

CPT ‡ code 3| APC| Description| 2024 Medicare National Rate 4
---|---|---|---
0238T| 5194| Atherectomy (iliac)| $16,725
37225| 5194| Atherectomy (femoral/popliteal)| $16,725
37227| 5194| Atherectomy and stenting (femoral/popliteal)| $16,725
37229| 5194| Atherectomy (tibial/peroneal)| $16,725
37231| 5194| Atherectomy and stenting (tibial/peroneal)| $16,725
+37233| –| Atherectomy (tibial/peroneal), additional vessel| No separate payment
+37235| –| Atherectomy and stenting (tibial/peroneal), additional vessel| No separate payment

(+) Indicates add-on code. List add-on code separately in addition to code for primary procedure.

AMBULATORY SURGICAL CENTER (ASC)

Effective January 1, 2024 – December 31, 2024.

CPT ‡ code 3| APC| Description| 2024 Medicare National Rate 5
---|---|---|---
0238T| 5194| Atherectomy (iliac)| $9,910
37225| 5194| Atherectomy (femoral/popliteal)| $11,695
37227| 5194| Atherectomy and stenting (femoral/popliteal)| $11,873
37229| 5194| Atherectomy (tibial/peroneal)| $11,096
37231| 5194| Atherectomy and stenting (tibial/peroneal)| $11,981
+37233| –| Atherectomy (tibial/peroneal), additional vessel| No separate payment
+37235| –| Atherectomy and stenting (tibial/peroneal), additional vessel| No separate payment

(+) Indicates add-on code. List add-on code separately in addition to code for primary procedure.

PHYSICIAN

Effective January 1, 2024 – December 31, 2024.

$3,794

• (+) Indicates add-on code. List add-on code separately in addition to code for primary procedure.
• N/A: there is currently no Medicare reimbursement rate for physicians.

HCPCS C-CODE FOR OUTPATIENT PROCEDURES

Level II HCPCS codes, including C-codes, are used with Medicare outpatient procedures only. Medicare requires C-codes on claims to help improve data and update yearly payment rates.

ADDITIONAL REIMBURSEMENT RESOURCES

• Scanning the QR code will take you to the Abbott Reimbursement & Coding page:
• For additional information or questions, please contact the Abbott Vascular Reimbursement Hotline at 855-569-6430 or abbotteconomics@abbott.com .

References:

1. CMS ICD-10-PCS 2024: https://www.cms.gov/medicare/icd-10/2024-icd-10-cm

2. Hospital Inpatient Prospective Payment – Final Rule FY2024 Payment Rates. CMS-1785-F: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page

3. CPT‡ Coding Guidelines. AMA. CPT‡ 2023 Professional Edition. American Medical Association. 2023

4. Hospital Outpatient Prospective Payment- Notice of Final Rulemaking with Comment Period (NFRM) CY2024. CMS 1786-FC.
   https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital- outpatient/regulations-notices/cms-1786-fc

5. Ambulatory Surgical Center Payment-Notice of Final Rulemaking with Comment Period (NFRM) CY2024. CMS-1786cms-FC:
   https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory- surgical-center-asc/asc-regulations-and/cms-1786-fc

6. Physician Prospective Payment-Final rule with Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY2024. CMS-1784-F: https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-federal-regulation-notices/cms-1784-f

7. CMS, 2020 Alpha-Numeric Index HPCPS file. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2020-Alpha-Numeric-HCPCS-File

Disclaimer

• This material and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal, reimbursement, business, clinical, or other advice. Furthermore, it is not intended to and does not constitute a representation or guarantee of reimbursement, payment, or charge, or that reimbursement or other payment will be received. It is not intended to increase or maximize payment by any payer. Abbott makes no express or implied warranty or guarantee that the list of codes and narratives in this document is complete or error-free. Similarly, nothing in this document should be viewed as instructions for selecting any particular code, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently and is subject to change without notice. The customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding, or reimbursement specialist for any questions related to coding, billing, reimbursement, or any related issues. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.
• Information contained herein for DISTRIBUTION in the U.S. ONLY.

Abbott

• 3200 Lakeside Dr., Santa Clara, CA 95054 USA Tel: 1.800.227.9902
• One St. Jude Medical Dr., St. Paul, MN 55117, USA, Tel: 1 651 756 2000
• www.cardiovascular.abbott
• ™ Indicates a trademark of the Abbott group of companies
• ‡ Indicates third party trademark, which is the property of its respective owner. @2023 Abbott. All rights reserved.
• MAT-2310973 v2.0 | Item approved for U.S. use only
• HE&R approved for non-promotional use only.

References

• Peripheral Resources for Medical Reimbursement | Abbott
• Home - Centers for Medicare & Medicaid Services | CMS
• FY 2024 IPPS Final Rule Home Page | CMS
• 2024 ICD-10-CM | CMS

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