Shockwave IVL Reimbursement

CMS Issues New Outpatient and Inpatient Codes for Peripheral Intravascular Lithotripsy (IVL)

 

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.

Hospital Outpatient

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:

Hospital Inpatient

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.

Code Description
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

Payment:  Medicare 2021 Hospital Inpatient MS-DRGs

 

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.

 

 

Footnotes:

[1] The update to the OPPS is available here: https://www.cms.gov/files/document/12220-opps-final-rule-cms-1736-fc.pdf

[2] 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

[3] 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.

 

 

Disclaimer Info:

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.

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