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    Lessons From SCAI Webinar: Prepare for the New 2013 PCI Coding Paradigm

    January 08, 2013

    This content is from the Winter 2012 issue of SCAI News & Highlights.

    » Access the full issue of the newsletter

    In December, nearly 1,500 cardiologists and their billing staff logged on for an important webinar on new codes that will reshape how PCI procedures are submitted for reimbursement in 2013. The interest in the webinar, hosted by SCAI along with ACC and HRS, was fully warranted, as the newly published Final Rule on the Medicare Fee Schedule revealed a decision by the Centers for Medicare and Medicaid Services (CMS) to deviate from the coding conventions established through the American Medical Association’s (AMA) CPT Editorial Panel process for these procedures.

    “The new PCI codes and how CMS elected to handle them are a big-game changer for us in Interventional Cardiology,” said Clifford Kavinsky, M.D, Ph.D., FSCAI, who serves as SCAI’s RUC Advisor. “ While the new codes will support distinguishing between more complex and less complex procedures, CMS actions have created a significant disconnect between how physicians and facilities must now report these services.”

    Webinar Lesson 1: Master New PCI Codes

    The 13 new codes established by the AMA CPT Editorial Panel represent a huge shift from the six-codes-fit-all-PCI of the last two decades to more precise coding that acknowledges, and accordingly reimburses for, PCI cases of greater complexity and intensity. The new codes include a series of base codes for angioplasty, atherectomy, and stenting plus add-on codes for reporting interventions conducted in additional branches of one of the major coronary arteries, including specific codes for the percutaneous transluminal revascularization of:

    • Acute total/subtotal occlusion during acute myocardial infarction (STEMI and NSTEMI)
    • Chronic total occlusion
    • Bypass graft

    Webinar participants heard from, and asked many specific questions of, the cardiologists who helped first to develop the new CPT codes and then to garner their approval from the RUC. Robert Piana, M.D., FACC, Amit J. Shanker, M.D., FHRS, Arthur Lee, M.D., FSCAI, and Dr. Kavinsky each presented real-world examples how the 13 new codes should be used by practices to appropriately obtain fair reimbursement for the services they provide.

    “CMS’s decision to bundle the additional branch add-on codes really complicates matters,” explained Dr. Lee, who serves as SCAI’s Advisor to the CPT Editorial Panel. “Commercial carriers may elect to follow CPT—forcing practices to report the same exact service differently, depending on which insurance carrier is involved.

    Webinar Lesson 2: Get a Grasp on New Bundling Protocols

    The coding webinar was developed primarily to help cardiology teams understand the new PCI codes, but significant time was spent addressing the complication introduced by CMS in the Final Rule, which has created disconnect between CPT instruction regarding the correct use and reporting of the new codes and CMS’s decision to bundle the new additional branch vessel add-on codes.

    On one hand the CPT guide clearly instructs, “PCI performed during the same session in additional major coronary or in additional coronary artery bypass grafts should be reported using the applicable additional base code(s). PCI performed during the same session in additional coronary artery branches should be reported using the applicable additional add-on code(s).”

    But, on the other hand, the 2013 Medicare Physician Fee Schedule Final Rule states that CMS believes “unbundling the placement of branch-level stents in a fee-for-service system may encourage increased placement of stents. To eliminate that incentive, on an interim final basis for CY 2013, we are rebundling the work associated with the placement of a stent in an arterial branch into the base code for the placement of a stent in an artery.” In other words, CMS bundled “the work of each new add-on code into its respective base code.”

    SCAI will be assessing the ongoing impact of CMS’sdecision not to pay for additional add-on codes, as itcontinues to work with the AMA CPT Editorial Paneland CMS on this issue. For now, SCAI, ACC, and AMAare in agreement that physicians should still report theadditional branch add-on codes as intended by CPT,even though Medicare has elected not to allow forseparate, additional payment for these codes.

    SCAI urges all members and coding staff to monitorthe SCAI communications and www.SCAI.org forbreaking news on the use of the new code set.

    Webinar Lesson 3: Expand Your World to Include New Coronary Vessels

    Additionally, previously CMS recognized only three major coronary vessels for billing purposes: the left circumflex, left anterior descending coronary artery, and the right coronary artery. Through the AMA CPT process, SCAI and ACC succeeding in garnering recognition of five major coronary vessels—now including the left main coronary artery and ramus intermedius—as major coronary arteries supporting separate billing (see Figure 1).

    The reporting of multi-main-vessel interventions will require of the use of Level II Healthcare Common Procedure Coding System (HCPCS) modifiers to communicate to carriers which vessels are being treated. SCAI has received reports that many carriers struggle with processing of Level II HCPCS alpha-modifiers used to identify different vessels when multiple-main vessels are treated. SCAI advises members to have their billing offices take the following steps for all multivessel interventions:

    • Monitor all claims closely.
    • Report any carriers that do not recognize the alpha vessel modifier to coding@scai.org.
    • For multiple main coronary arteries interventions, if a non-Medicare carrier is known to have difficulty handling the required alpha-vessel modifiers, consider using the frequency unit field when reporting multiples of the same base code.

    Webinar Lesson 4: Make Way for Codes for New and Emerging Therapies

    The PCI codes are not the only new cardiovascular codes of interest to interventional cardiology. During the webinar, Dr. Lee discussed a new family of Category I codes that SCAI, ACC, and STS secured for endovascular transcatheter aortic valve replacement (TAVR). Dr. Lee also detailed the new percutaneous ventricular assist device (pVAD) codes SCAI was instrumental in creating that will now allow accurate reporting of insertion, repositioning, and removal of pVAD devices. Other new codes of interest to attendees included those for diagnostic cervicocerebral angiography as well as new Category III codes (reserved for emerging technologies) for optical coherence tomography used during diagnostic and therapeutic interventions.

    It is imperative that all practices have a current copy of the AMA CPT Manual on hand; copies of the 2013 edition can be can be ordered over the phone at 800-621-8335 for non-AMA-members or 800-262-3211 for AMA members. SCAI members who have questions regarding the new codes or wish to report claims processing issues associated with use of the new codes should contact coding@SCAI.org.

    Webinar Lesson 5: Invest Time in Documentation

    During the webinar, SCAI’s RUC Advisor Dr. Kavinsky clarified the indications supporting separate reporting of diagnostic cardiac catheterization with PCI for ad hoc procedures, which is now clearly spelled out in the 2013 CPT Manual. “This underscores the across-the-board importance of clear documentation in the patient medical record to support the services performed,” he stressed. “Carefully, capturing this information upfront will help ensure you get paid properly for your work and keep auditors at bay.”

    Webinar Lesson 6: Know the Back Story

    James C. Blankenship, M.D., FSCAI, who is the RUC Panel member for ACC, provided an essential overview of the valuations assigned to the new PCI codes. “Valuation boils down to how long the service takes (time) and the intensity of the service relative to other physicians’ services,” he explained.

    The scale ranges from work intensity =0.03 for an office visit to 0.14 for brain surgery or liver transplant surgery. There is no allowance for whether the service is life-saving or not, although life-saving services tend to have higher intensity; how the service affects hospital length of stay or other hospital costs; how long it takes to train to perform the service; or reductions in complication rates, although complication risk is factored into intensity.

    “This may not seem fair,” he said, “but it has been the rule of the game for the past two decades by which all societies have played, and it highlights how important it is for all of us who receive RUC surveys to complete them.”

    Each time the RUC undertakes a valuation (or revaluation) effort, SCAI and ACC send members surveys that guide assessment of the time and intensity for new codes. When the PCI codes were being revalued last year, the survey data clearly indicated that the time it takes to perform PCI has come down significantly since 1994, when the codes were initially valued.

    Dr. Blankenship explained: “Based on time alone, we should have gotten much bigger cuts than we did. The reason we didn’t get bigger cuts is because the RUC agreed that the procedures we perform are very intense, on par with liver transplant or brain surgery.” While this year’s 18 to 20 percent reductions in value for PCI procedures seems steep, he said, things could have been a whole lot worse.

    “There was significant concern that CMS was going to take the RUC’s recommendations for PCI and arbitrarily cut it by another 10 percent, as they had with the new diagnostic cardiac catheterization codes in 2011,” he added. “It is a win—let me add, a justified win—for Interventional Cardiology that CMS basically adopted the RUC’s recommendation for values for the new PCI.”

    Without the strong, collaborative work of the RUC and CPT experts within the SCAI and ACC leadership, the paradigm shift toward acknowledging the complexity and intensity of the work interventionalists likely would not have occurred, concluded Dr. Blankenship. “It’s likely the webinar would have been focused on how we would survive a much more severe reality.”

    To view the webinar—either for the first time or as a refresher, go to http://webinars.scai.org/archived.php.