Abbott Hospital Outpatient Coronary Physiology Reimbursement User Guide
- June 1, 2024
- Abbott
Table of Contents
Abbott Hospital Outpatient Coronary Physiology Reimbursement
INTRODUCTION
CY2024 HOSPITAL OUTPATIENT CORONARY PHYSIOLOGY REIMBURSEMENT GUIDE
Hospital Outpatient Vascular Ambulatory Payment Classifications (C-APCs) and
Complexity Adjustments Centers for Medicare & Medicaid Services (CMS) adopted
a C-APC payment policy effective 2015. The C-APC payment policy makes a single
payment for all related or adjunctive hospital items and services provided to
a patient receiving certain primary procedures that take place in the hospital
outpatient.1 Hospital outpatient claims that contain at least one J1 procedure
code are assigned to C-APCs.2 C-APC claims that contain two or more J1
procedures or that contain certain add-on procedure codes may be eligible for
complexity adjustments that promote the claim to the next higher-cost APC
within the primary procedure’s clinical family. Presented in the table below
are CMS CY2024 National Reimbursement Rates for Endovascular Procedure C-APCs.
These C-APCs apply to both coronary and peripheral vascular procedures.
Complexity Adjustments for Coronary Physiology Assessments
When certain Diagnostic Cardiac Catheterization procedures are performed in conjunction with fractional flow reserve (FFR) or coronary flow reserve (CFR), CMS will allow for a complexity adjustment from APC 5191 (Level 1 Endovascular Procedures) to APC 5192 (Level 2 Endovascular Procedures). Presented in the table below are a list of applicable CMS CY2024 Complexity Adjustments.3
Primary
CPT ‡
Code
|
Short Description
| Primary CPT ‡ Code C-APC|
Secondary
CPT ‡ Code
|
Short Description
| Complexity Adjusted C-APC a| Final National Reimbursement
Rate| Qualifying Complexity Adjustment a
---|---|---|---|---|---|---|---
93454| Coronary artery angio s&i| 5191| +93571| Coronary flow reserve
measure| 5191b| $3,108| NO b
93455| Coronary art/grft angio s&i| 5191| +93571| Coronary flow reserve
measure| 5191| $3,108| NO
93456| R hrt coronary artery angio| 5191| +93571| Coronary flow reserve
measure| 5192| $5,452| YES
93457| R hrt art/grft angio| 5191| +93571| Coronary flow reserve
measure| 5191| $3,108| NO
93458| L hrt artery/ventricle angio| 5191| +93571| Coronary flow reserve
measure| 5192| $5,452| YES
93459| L hrt art/grft angio| 5191| +93571| Coronary flow reserve
measure| 5192| $5,452| YES
93460| R&l hrt art/ventricle angio| 5191| +93571| Coronary flow reserve
measure| 5192| $5,452| YES
93461| R&l hrt art/ventricle angio| 5191| +93571| Coronary flow reserve
measure| 5192| $5,452| YES
All complexity adjustment combination codes are found in Addendum J of the OPPS Final Rule
- Effective 1/1/2024, the combination of coronary physiology (add-on CPT code +93571) and coronary angiography without left heart catheterization (CPT code 93454), coronary angiography in graft (CPT code 93455) and coronary angiography in graft with right heart catheterization (CPT code 93457) no longer qualify for a complexity adjustment from C-APC 5191 to C-APC 5192 in the hospital outpatient setting.
HEALTH ECONOMICS & REIMBURSEMENT
Coronary Angiography and Physiology Assessment Primary CPT‡ Codes with Description
CPT ‡
Code
|
CPT ‡ Code Description
|
C- APC
| Medicare Reimbursement
---|---|---|---
CORONARY ANGIOGRAPHY
93454| Catheter placement in coronary artery(s) for coronary
angiography, including intraprocedural injection(s) for coronary angiography,
imaging supervision and interpretation| 5191| $3,108
93455
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for cor- onary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography|
5191
|
$3,108
93456| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coro- nary angiography, imaging supervision and interpretation; with right heart catheterization| 5191| $3,108
93457
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for cor- onary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization|
5191
|
$3,108
93458
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coro- nary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed|
5191
|
$3,108
93459
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coro- nary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography|
5191
|
$3,108
93460
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed|
5191
|
$3,108
93461
| Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography|
5191
|
$3,108
CORONARY PHYSIOLOGY ASSESSMENT
+93571
| Intravascular Doppler velocity and/or pressure-derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure)|
N/Aa
|
Package
+93572
| Intravascular Doppler velocity and/or pressure-derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List sepa- rately in addition to code for primary procedure)|
N/Aa
|
Package
- OPPS status indicator = N (Items and Services Packaged into APC rate) + denotes an add-on code
Coronary Microvascular Dysfunction ICD-10 Diagnosis Codes Effective October
1, 2023
Coronary microvascular dysfunction is now formally recognized as a diagnosis
through the creation of four ICD-10-CM codes. Visit the CDC’s website for a
comprehensive list of ICD-10-CM codes.
ICD-10-CM CODES
|
Description
---|---
I20.81| Angina pectoris with coronary microvascular dysfunction
I21.B| Myocardial infarction with coronary microvascular dysfunction
I24.81| Acute coronary microvascular dysfunction
I25.85| Chronic coronary microvascular dysfunction
References
- CMS. 2014. CMS Finalizes Hospital Outpatient and Ambulatory Surgical Centers Policy and Payment Changes for 2015. https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-hospital-outpatient-and-ambulatory-surgical-centers-policyand-payment-changes-2015. Accessed January 24, 2023
- CMS. 2021. Medicare CY 2021 Outpatient Prospective Payment System (OPPS) Proposed Rule Claims Accounting. https://www.cms.gov/files/document/2021-nprm-opps-claims-accounting.pdf. Accessed January 24, 2023
- CMS. 2024. CY2024 OPPS Final Rule Home Page. U.S. Centers for Medicare and Medicaid Services CMS-1786-FC. https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1786-fc
- Comprehensive Listing of ICD-10-CM Files. Available at https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm
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 the 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.
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