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Coronary IVL Reimbursement

Going Deep into Coronary IVL Payments

Since the launch of Coronary IVL in early 2021, Shockwave has made deep and significant progress on reimbursement. We now have reimbursement in the outpatient, ASC and inpatient setting. In addition, we have the opportunity for physician reimbursement via our Coronary Category III CPT code.

To learn more, you can review the information and resources below or connect directly with our dedicated team of Reimbursement Specialists. They’re available to answer your questions in real time and help you navigate the various Coronary IVL reimbursement pathways.

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Category III CPT for Shockwave Coronary IVL

Effective July 1, 2022, physicians are required to report Coronary IVL procedures using the Category III CPT Code: +0715T in conjunction with a primary procedure code. Category III CPT codes facilitate the collection of data for emerging technologies, services and service paradigms. Category III CPT codes may be payable when medically necessary and reported with appropriate documentation. Please see below and refer to the Coronary IVL Physician Coding Guide for additional information.

Coronary IVL Physician Coding Guide

Overview of Coronary IVL Category III CPT

In order to allow tracking of procedures, the AMA has established Category III CPT code +0715T for Shockwave Coronary Intravascular Lithotripsy. This Category III code is an add-on code which identifies coronary lithotripsy as its own defined therapy and should be used in conjunction with a primary procedure code.

Physician Reimbursement

Category III CPT codes may be payable when medically necessary and reported with appropriate documentation. Payers and local contractors may cover procedures they believe are medically necessary and offer a safe and long-term alternative.

CPT Code +0715T does not have an established RVU value. In the absence of established RVUs, payers rely on the use of a comparator code to set an RVU rate for codes without established payment. Payers will require supporting documentation to assign payment. It will be important to document the services provided in regard to resources and time for appropriate payment valuation. Physicians should be prepared to submit information to assist in coverage and payment decisions. Recommended items to support your Category III claims submissions include:

  • Copy of operative or procedure report
  • Letter of medical necessity
  • Clinical notes (severity of calcification)
  • Relevant crosswalk CPT code with anticipated payment indicated
  • Copy of relevant published clinical literature or Shockwave Coronary IVL bibliography
  • Copy of the FDA approval letter
FDA Approval Letter

FAQs

More FAQs can be found in the Physician Coding Guide.

  1. How do physicians bill for IVL when used in a coronary procedure?

    Effective July 1, 2022 physicians should report CPT code +0715T when IVL is utilized for a coronary procedure. Please see our Physician Coding Guide for a further overview and information on utilization of this code.

  2. Do physicians get additional reimbursement for using more than one IVL catheter?

    No, there is no additional physician reimbursement associated with the use of multiple catheters.

  3. Are there any RVUs established for physician payment when IVL is performed?

    There currently are no RVUs established for utilization of IVL in coronary procedures; however there is a process for the physician to request a level of reimbursement associated with CPT code +0715T. Please refer to our Physician Coding Guide for further information.

Outpatient and ASC Reimbursement for Shockwave Coronary IVL

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.

TPT Guide
  1. https://www.cms.gov/files/document/r10825cp.pdf and https://www.cms.gov/files/document/r10997cp.pdf

Overview of Coronary IVL TPT

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.

  1. https://www.cms.gov/files/document/r10825cp.pdf and https://www.cms.gov/files/document/r10997cp.pdf
  2. Healthcare Common Procedure Coding System (HCPCS)

TPT Calculation Example:
One Coronary IVL Catheter with DES

One Coronary IVL Catheter is utilized in a PCI with a DES; example below shows TPT payment with three different charge adjustments.

TPT Calculation Example: One Shockwave C2 Catheter with DES
  1. In accordance with CMS’ payment policies, Total Hospital Payments may be adjusted geographically.

TPT Calculation Example:
Two Coronary IVL Catheters with DES

Two Shockwave C2+ IVL catheters are utilized in a PCI with a DES; example below shows TPT payment with three different charge adjustments.

TPT Calculation Example: Two Shockwave C2 Catheters with DES
  1. In accordance with CMS’ payment policies, Total Hospital Payments may be adjusted geographically.

TPT Calculation Example:
Coronary IVL Catheter with Atherectomy and DES

One Coronary IVL catheter is utilized in a PCI with Atherectomy and a DES; example below shows TPT payment with three different charge adjustments.

TPT Calculation Example: Shockwave C2 Catheter with Atherectomy and DES
  1. In accordance with CMS’ payment policies, Total Hospital Payments may be adjusted geographically.

FAQs

Additional FAQs found in the TPT guide.

  1. 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).

  2. 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 reimbursement@shockwavemedical.com with the name and location of your hospital and we can look it up for you.

  3. 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:

    • Ensure that the correct CPT/HCPCS procedure code(s) for the procedure performed is submitted with C1761, as well as the appropriate device codes for other devices used (e.g., C1874, stent, coated/covered, with delivery system)
    • Specify the number of units of Coronary IVL catheters used
    • Include the appropriate revenue code from the 027X series
    • Ensure the charges reflect the number of Coronary IVL catheters used in the procedure

  4. 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.

  5. 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.

Inpatient Reimbursement for Shockwave IVL

Effective October 1, 2021, Percutaneous Coronary Intervention (PCI) cases utilizing Coronary IVL in the hospital inpatient setting are eligible for an incremental payment from Medicare (in addition to the MS-DRG payment) to help cover the additional costs of using IVL1. In the inpatient setting, this incremental reimbursement is called the “New Technology Add-on Payment” or NTAP. The Coronary IVL NTAP provides additional payment based on the hospital’s reported cost of each case. NTAP payment is based on the hospital’s reported cost. The maximum NTAP incremental payment for Coronary IVL is $3,666. Please review the NTAP guide for more information.

NTAP Guide
  1. https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page

Overview

The incremental NTAP is based on the total covered cost to hospitals for a Coronary IVL case. CMS has determined that the maximum NTAP incremental payment for a case involving IVL will be $3,666.

If the total covered costs of a discharge (derived by multiplying the hospital’s inpatient operating cost-to-charge ratio (CCR) to the total covered charges for the case) exceed the full MS-DRG payment (including payments for indirect medical education and disproportionate share hospitals, but excluding outlier payments), Medicare will provide the NTAP add-on payment equal to 65% of the difference between the full MS-DRG payment and hospital’s reported cost for the discharge.

CMS finalized a set of new ICD-10-PCS codes approved for procedures involving IVL. The complete list of procedure codes is provided below and describes the use of IVL in one or more coronary arteries. These codes must be billed in order to receive an NTAP payment.

NTAP Calculation Example:
PCI with DES without Major Complications and Comorbidities

  1. Determine total covered charges for the entire hospital stay involving Coronary IVL
  2. Determine the Hospital-Specific Operating cost-to-charge ratio (CCR)2
  3. Derive total covered costs of the case = Total charges * CCR
  4. Determine the hospital specific MS-DRG payment3
  5. Subtract the MS-DRG payment from the total covered costs of the case
  6. If the difference is > $0, Medicare will make an add-on payment equal to the lesser of 65% of the difference or $3,666
  7. Final NTAP Payment; determine the lesser of Step 6 or $3,666
  8. Total Case Payment; NTAP plus MS-DRG
  1. The CY 2022 CCRs by provider number are available at: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page#Data
  2. Hospital Specific DRG payments may be obtained by contacting the Shockwave Reimbursement Hotline at (877) 273-4628.

NTAP calculation for a Percutaneous Coronary Intervention (PCI) with a Drug Eluting Stent (DES) or Bare Metal Stent (BMS) admission including Coronary IVL.

NTAP Calculation Example: PCI with DES without Major Complications and Comorbidities

MCC - Major complications and comoribidities

  1. Average hospital total charges specific to inpatient discharges for coronary interventions (MS-DRGs 246-249) assessed using FY2018 Medicare claims data.
  2. The CY 2022 CCRs by provider number are available at: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page#Data. Download the FY2022 Impact File and search the excel file by Medicare provider number. The CCR is listed in Column AG (Operating CCR). If you do not know your Medicare provider number, please contact us via email at reimbursement@shockwavemedical.com with the name and location of your hospital and we can look it up for you.
  3. Hospital Specific DRG payments may be obtained by contacting the Shockwave Reimbursement Hotline at (877) 273-4628.

FAQs

More FAQs can be found in the NTAP guide.

  1. How should a IVL case be billed in the hospital inpatient setting?

    There are no special billing requirements placed on the hospital for processing the NTAP payment, other than using the appropriate ICD-10-PCS codes that describe the use of IVL as part of the Coronary intervention procedure. The procedure codes listed above indicate a procedure involving the use of IVL. The use of any one of these codes will trigger a calculation of the NTAP payment by your Medicare Administrator Contractor’s claims processing system.

  2. Is there a fixed payment amount for each inpatient IVL case?

    The NTAP amount is not a fixed amount and can vary for each case. It is calculated on a case-by-case basis. As explained in the examples above, CMS has determined that the maximum incremental NTAP amount that a hospital can receive (in addition to the full DRG payment) is $3,666 per discharge. The exact payment amount per case is not fixed and depends on the total costs of the discharge.

  3. Is the IVL NTAP amount paid per device (unit) used, or once per discharge?

    The NTAP amount is paid once per discharge and not per unit of new technology used; however, the total costs of the new technology (including multiple units) are part of the total case discharges that go into the calculation of both the eligibility for NTAP and the NTAP amount.

  4. What is the total payment amount for the IVL case if it qualifies for an NTAP?

    The total payment amount for a IVL case that qualifies for an NTAP will consist of the full MS-DRG payment + 65% of the difference between the reported cost of the discharge and the MS-DRG payment, up to a maximum of $3,666 per case. The NTAP payment amount is then added to the hospital assigned DRG payment.

  5. Can the NTAP amount be less than the $3,666 allowed?

    Yes, the $3,666 is the maximum amount allowed for the NTAP portion on the hospital payment. Should the hospital specific calculation of 65% of the hospital costs minus the DRG payment be less than $3,666, then the lower amount is paid.

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