The Centers for Medicare & Medicaid Services (CMS) has finalized new codes for IVL procedures performed in peripheral arteries in both the hospital outpatient and inpatient settings. The new Healthcare Common Procedure Coding System (HCPCS) outpatient and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) inpatient codes will go into effect on January 1, 2021 and October 1, 2020, respectively.
In the calendar year 2021 Medicare Hospital Outpatient Prospective Payment System (OPPS) final rule issued on December 2, 2020, the Centers for Medicare & Medicaid Services (CMS) has created four new HCPCS codes (C9772-C9775) for IVL procedures performed in the tibial and peroneal (a.k.a. below-the-knee or BTK) arteries. In addition, CMS has amended the descriptions of the initial HCPCS codes (C9764-C9767) created in July 2020 to report IVL procedures performed in lower extremity arteries, except tibial and peroneal. These changes are effective on January 1, 2021.
The IVL HCPCS codes and their APC assignments are summarized in the following table:
Effective October 1, 2020, CMS published new International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS) codes specifically identifying IVL. These codes are used for hospital reporting of inpatient procedures, which are assigned to Medicare-Severity Diagnosis Related Groups (MS-DRGs) for payment for the hospital admission.
|04fc3zz||Fragmentation of Right Common Iliac Artery, Percutaneous Approach|
|04FD3ZZ||Fragmentation of Left Common Iliac Artery, Percutaneous Approach|
|04FE3ZZ||Fragmentation of Right Internal Iliac Artery, Percutaneous Approach|
|04FF3ZZ||Fragmentation of Left Internal Iliac Artery, Percutaneous Approach|
|04FH3ZZ||Fragmentation of Right External Iliac Artery, Percutaneous Approach|
|04FJ3ZZ||Fragmentation of Left External Iliac Artery, Percutaneous Approach|
|04FK3ZZ||Fragmentation of Right Femoral Artery, Percutaneous Approach|
|04FL3ZZ||Fragmentation of Left Femoral Artery, Percutaneous Approach|
|04FM3ZZ||Fragmentation of Right Popliteal Artery, Percutaneous Approach|
|04FN3ZZ||Fragmentation of Left Popliteal Artery, Percutaneous Approach|
|04FP3ZZ||Fragmentation of Right Anterior Tibial Artery, Percutaneous Approach|
|04FQ3ZZ||Fragmentation of Left Anterior Tibial Artery, Percutaneous Approach|
|04FR3ZZ||Fragmentation of Right Posterior Tibial Artery, Percutaneous Approach|
|04FS3ZZ||Fragmentation of Left Posterior Tibial Artery, Percutaneous Approach|
|04FT3ZZ||Fragmentation of Right Peroneal Artery, Percutaneous Approach|
|04FU3ZZ||Fragmentation of Left Peroneal Artery, Percutaneous Approach|
|04FY3ZZ||Fragmentation of Lower Artery , Percutaneous Approach|
The ICD-10 procedure codes listed above group to MS-DRGs 252-254. When other procedures are performed in addition to IVL, other MS-DRGs may apply.
Third party reimbursement amounts for specific procedures will vary by payer and by locality. This information is current as of September 2, 2020 but is subject to change without notice. Amounts do not necessarily reflect any subsequent changes in payment since publication. To confirm reimbursement rates, you should consult with your local Medicare Administrative Contractor (MAC) for specific codes.
 The update to the OPPS is available here: https://www.cms.gov/files/document/12220-opps-final-rule-cms-1736-fc.pdf
 National payment averages from Addendum B of CY2021 Final Rule available here https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1736-fc
 All rates shown are national averages for operating and capital payments, not adjusted for geographic variations in costs, disproportionate share hospital payments, or graduate medical education payments. All these factors can have a significant impact on a hospital's payment rates.
The coding, coverage, and payment information contained herein is gathered from various resources and is subject to change without notice. Shockwave Medical cannot guarantee success in obtaining third-party insurance payments. Third-party payment for medical products and services is affected by numerous factors. It is always the provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are rendered. Providers should contact their third-party payers for specific information on their coding, coverage, and payment policies.
But, right now we're in the early phases of the R&D program. In the meantime, don't miss the IVL application that heart teams are embracing already — maintaining transfemoral TAVR access through heavily calcified iliacs by using IVL.