The Centers for Medicare & Medicaid Services (CMS) has established relative value units (RVUs) and associated Calendar Year (CY) 2024 Medicare Physician Fee Schedule (PFS) payment rates for Current Procedural Terminology (CPT®) code +92972, a Category I Add-on code for procedures involving Coronary IVL. CPT® +92972 provides an additional 2.97 work RVUs and $140 payment in addition to the primary procedure. This code and the associated PFS payment rates are effective January 1, 2024. Prior to the establishment of +92972, there were no additional RVUs or professional fees for performing Coronary IVL.
CPT® code +92972 is an add-on code that must be used in conjunction with a primary procedure CPT® code. The payment rate for +92972 is in addition to payment for the primary procedure CPT® code and can be used regardless if adjunctive technologies (i.e. atherectomy, PTCA) are used in conjunction with Coronary IVL. Please see the below tables for more information.
Please review the coding guide linked below for additional information related to Coronary IVL physician reimbursement.
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1: CMS-1784-F; Medicare Physician Fee Schedule Fiscal Year 2024 Final Rule.
2: Payment rates do not take into account geographical or additional adjustments. Providers should contact their local Medicare Administrative Contractor (MAC) or CMS for specific information as payment rates vary by region.
Starting October 1, 2023, three new Coronary IVL-specific Medicare Severity Diagnosis Related Group (MS-DRG) codes have been established for Percutaneous Coronary Intervention (PCI) procedures involving Coronary IVL in the hospital inpatient setting. The New Technology Add-on Payment (NTAP) for Coronary IVL will conclude on September 30, 2023.
Additionally, the final 2024 Medicare Inpatient Prospective Payment System (IPPS) rule consolidates the prior four MS-DRGs involving PCI with implant of a stent into two MS-DRGs, removing a previous distinction between stent type – Drug Eluting Stent (DES) or Bare Metal Stent (BMS). PCI with stent procedures utilizing alternative plaque modification therapies such as atherectomy, cutting or scoring balloons without the adjunctive use of IVL will map to PCI MS-DRGs 321-322. Please see the table below for more information.
*Coronary IVL is indicated for use prior to stent implementation
The following ICD-10-PCS codes are specific to procedures involving the use of IVL on one or more coronary arteries. Codes associated with stent procedures as well any other procedures performed may also be applicable. Coronary IVL ICD-10-PCS codes must be billed in order to obtain IVL MS-DRGs.
Please review the coding guide linked below for additional information related to Coronary IVL reimbursement within the hospital inpatient setting.
1. MCC: Major Complications and Comorbidities; CC: Complications and Comorbidities.
2. CMS-1785-F; National Average MS-DRG rates shown are based on Medicare Inpatient Prospective Payment System FY2024 Final Rule, Table 5. National average payment rates assume full update amount for hospitals which have submitted quality data and hospitals have a wage index greater than 1. Site specific payment rates will vary based on regional area wage differences, teaching hospital status, indirect medical education costs, quality data, additional payments to hospitals that treat a large percentage of low income patients (“disproportionate share payments”), etc.
Effective July 1, 2021, Medicare approved a Transitional Pass-Through (TPT) payment when a Coronary IVL catheter is utilized in procedures performed in the hospital outpatient setting. TPT provides incremental payment in addition to the applicable Ambulatory Payment Classifications (APC) payment to recognize the additional cost of the Coronary IVL device(s)1. HCPCS C-Code C1761 must be reported on the hospital outpatient claim along with an appropriate stenting procedure code to receive the incremental TPT payment for the Coronary IVL catheter.
Providers in the ASC setting of care are typically eligible for TPT payments. However, the formula in calculating the incremental TPT payment amount is different and is set by each Medicare Administrative Contractor (MAC). Additional information may be required by the MAC to support the claim and determine the appropriate amount of TPT payment in the ASC setting.
Please review the TPT guide for additional information regarding Coronary IVL outpatient and ASC reimbursement.Coronary IVL Hospital Outpatient TPT Coding Guide
TPT provides incremental payment in addition to the applicable Ambulatory Payment Classifications (APC) payment to recognize the additional cost of Coronary IVL device(s)2. In order to secure the incremental payment, hospitals must report the new C-code for IVL, C1761, along with the relevant HCPCS3 or CPT codes. Please see the below table for a list of procedure CPT and HCPCS codes to associate with C1761.
One Coronary IVL Catheter is utilized in a PCI with a DES; example below shows TPT payment with three different charge adjustments.
Two Shockwave C2+ IVL catheters are utilized in a PCI with a DES; example below shows TPT payment with three different charge adjustments.
One Coronary IVL catheter is utilized in a PCI with Atherectomy and a DES; example below shows TPT payment with three different charge adjustments.
Additional FAQs found in the TPT guide.
What procedure codes are eligible for TPT in the hospital outpatient setting?
The TPT was awarded to Coronary IVL, and the incremental payment calculation is applicable when HCPCS code C1761 is included on the hospital claim. As Coronary IVL is indicated for use prior to the placement of a coronary stent, the most appropriate procedure codes that should be billed are typically those that include the placement of a coronary stent (e.g., CPT 92928, 92933, 92943, HCPSC C9600, C9602, C9607).
Where can a hospital find its hospital specific cost-to-charge-ratio (CCR) used in the TPT payment calculation?
The hospital specific CCRs are part of the Outpatient Rate Setting Files at CMS. Hospital specific CCRs are available by calling the Shockwave Reimbursement Hotline at (877) 273-4628. Please have your Medicare provider number available. If you do not know your Medicare provider number, please contact us via email at firstname.lastname@example.org with the name and location of your hospital and we can look it up for you.
How should a hospital bill for procedures that include the use of Coronary IVL in the outpatient setting?
We offer the following suggested best practices for billing a PCI procedure that utilizes Coronary IVL and includes the placement of a coronary stent in the hospital outpatient setting to Medicare:
Does the TPT apply to non-Medicare patients?
TPT payment ONLY applies to Medicare FFS claims that include the C-Code identifying that Coronary IVL was utilized. While commercial and Medicare Advantage plans often use Medicare FFS payment rates as a reference when establishing their own payment rates, the coding and payment policies of commercial payers may vary. Providers should contact these payers to ensure appropriate coding and billing for non-Medicare FFS patients.
How are physician payments impacted by the C-Code for Coronary IVL?
Physicians do not bill C1761 when utilizing Coronary IVL catheters in procedures. C1761 is specifically designated for use in the hospital outpatient setting for the purposes of providing incremental payment. If hospitals do not report C1761 with one of the appropriate associated stenting procedure codes, they will not receive the incremental TPT payment for the Coronary IVL.
Physicians now have their own reportable code. For more information please view our Physician Coding Guide.