Ouch! No more PV reimbursement cuts, please!

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Coding expert expects more CMS cuts with peripheral vascular procedures. Image Source: ABC News  

If you think that there have been too many cuts in peripheral vascular reimbursement, grab a Band-Aid and get ready for more. There is some information regarding another potential problem that may affect your bottom line.

When the National Correct Coding Initiative (NCCI) was implemented by the Centers for Medicare & Medicaid Services (CMS) on January 1, 1996, there was a paragraph (Version 13.3, Chapter V, Section D, Cardiovascular system #16., Page V-11) addressing the performance of percutaneous angioplasty and percutaneous (or open) atherectomy in the same vessel at the same patient encounter. The paragraph stated that if a percutaneous angioplasty was followed by an atherectomy, only the atherectomy should be reported.

This news was bad enough, but then in 2007, the NCCI received an inquiry from a physician, who teaches interventional vascular coding, asking whether the same principle discussed in the paragraph applied to other interventional procedures as well. 

After reviewing his request and other information in the manual, CMS decided to revise the paragraph to clarify that the same principle applies to atherectomy, angioplasty and stenting. 

This paragraph in version 13.3 states: “If an atherectomy fails to adequately improve blood flow and is followed by an angioplasty at the same site/vessel during the same patient encounter, only the successful angioplasty may be reported. Similarly, if an angioplasty fails to adequately improve blood flow and is followed by an atherectomy at the same site/vessel at the same patient encounter, only the successful atherectomy may be reported. If atherectomy and/or angioplasty fail to adequately improve blood flow and are followed by a stenting procedure at the same site/vessel during the same patient encounter, only the successful stenting procedures may be reported. These principles apply to percutaneous or open procedures.” 

This paragraph replaced the paragraph that had been present in the manual since 1996. The purpose was to reinforce a standard coding policy for the cardiovascular system that CMS has had in place since the beginning of the NCCI which states that, “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the successful procedure may be reported.” 

The above policy is difficult to justify in the cardiovascular system, but for billing multiple therapeutic procedures in the peripheral vascular system, it does not work at all.

Unlike percutaneous transluminal coronary angioplasty (PTCA) and stenting, where the stent is the highest reimbursed service, for percutaneous transluminal angioplasty (PTA) the reimbursement varies by site of the PTA (i.e., the bracheocephalic and renal PTA reimbursement are higher than the stent placement, which would be considered the final “successful” procedure.) 

After numerous negative comments regarding this policy by medical societies, physicians and others, CMS decided to temporarily rescind the new paragraph and replace it with the one originally published in 1996, which states, “When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the most comprehensive atherectomy that was performed (generally the open procedure) is reported.” 

This change will be retroactive to Oct. 1, 2007 and will appear in version 14.3 of the manual published on the CMS website as early as possible. 

The bad news is that this decision is temporary. NCCI edits are effective quarterly (January, April, July and October). There continue to be concerns about this issue and CMS has encouraged national healthcare organizations to work with other interested parties to address coding for reporting atherectomy, angioplasty and stenting in non-coronary arteries. 

CMS owns the NCCI and makes all final decisions about its contents. These policies apply to all services where the NCCI is applied; however, currently, there are no NCCI edits supporting the new paragraph relating to peripheral vessels. This means that there is no mechanism in place to identify the multiple therapeutic services for bundling purposes. 

The issue is under further discussion and review. It is important for physicians to send their comments