Code TAVR With Confidence Under Medicare’s New Coverage Rules
Ask what type and severity of aortic valve disease the cardiologist documented. Medicare’s updated coverage policy for transcatheter aortic valve replacement (TAVR) creates new opportunities for patients with severe aortic stenosis, including those who do not yet have symptoms. For cardiology coders, the change raises an important question: Does expanded coverage mean you should report TAVR differently? The answer is — not necessarily. The Sept. 10, 2026, decision from the Centers for Medicare & Medicaid Services (CMS) changes coverage requirements, not the fundamental process for selecting procedure and diagnosis codes. Your job remains to identify the service performed, confirm the documented diagnosis, select the appropriate codes, and check the applicable coverage and billing rules. Understand What CMS Changed TAVR replaces a diseased aortic valve with a bioprosthetic valve delivered through a catheter, rather than through traditional open-heart surgery. The procedure is also called transcatheter aortic valve implantation (TAVI). CPT® code 33361 (Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach) describes the femoral artery approach for this service. Historically, Medicare’s national coverage determination (NCD) required patients to have symptomatic severe aortic stenosis for routine coverage under the policy. The earlier policy also required coverage with evidence development (CED), which tied covered procedures to approved evidence-gathering requirements, including registry participation. The Society of Thoracic Surgeons and American College of Cardiology (STS/ACC) Transcatheter Valve Therapy (TVT) Registry was approved to meet the prior registry requirements. Under the previous policy, Medicare also required independent evaluations by a cardiac surgeon and an interventional cardiologist, and TAVR generally had to be performed jointly by both physicians. These requirements affected not only how hospitals organized their TAVR programs but also how physicians billed for the procedure. >CMS finalized three major changes in September 2026: The revised policy allows a qualified TAVR operator to perform the procedure without requiring a second operator. CMS also permits portions of the heart team evaluation to occur asynchronously and removes previous minimum hospital procedure-volume thresholds. Two operators remain covered when the heart team determines that both are appropriate. However, the new policy does not mean every asymptomatic patient with aortic stenosis automatically qualifies for TAVR. CMS specifies severe aortic stenosis, a U.S. Food and Drug Administration (FDA)-approved valve system used for an approved indication, and compliance with the applicable coverage criteria. Asymptomatic cases must meet the CED study requirements. Importantly, Medicare coverage for asymptomatic severe aortic stenosis is not automatic. The patient must participate in a qualifying CMS-approved CED study. At the time of the September 2026 policy announcement, no studies had yet been approved for this new indication. Check CMS’ current list of approved studies before assuming an asymptomatic case qualifies for payment. CMS also addressed investigational TAVR procedures. Certain studies previously covered under the former CED requirements transitioned to the investigational device exemption (IDE) coverage pathway. If you’re working with investigational devices, you should verify the applicable study approval, device status, and Medicare billing requirements rather than applying routine TAVR coverage rules. Step 1: Select the CPT® Code and Modifier That Match the Procedure Do not select a TAVR code based solely on the patient’s diagnosis or Medicare coverage status. Review the operative report to identify the procedure and access approach, and check to make sure the codes are current. The CPT® code family includes: Example: Suppose a cardiologist performs TAVR through a percutaneous femoral artery approach. The operative report confirms the access method and valve implantation, so 33361 is the relevant starting point for the professional procedure coding. If the surgeon instead uses an open femoral artery approach, do not automatically report 33361. Review the documentation and the applicable code descriptor to determine whether 33362 is appropriate. Check Modifier 62 Under the New Single-Operator Rule One of the most significant coding changes involves the number of physicians required to perform TAVR and the potential implications for modifier 62 (Two surgeons). However, participation in the heart team evaluation does not, by itself, establish that a physician performed the procedure as a co-surgeon. Under the previous Medicare billing instructions, professional TAVR claims generally required modifier 62 to identify the two physicians performing the procedure. CMS instructed Medicare contractors to return certain TAVR claims submitted without modifier 62 as unprocessable. The revised NCD now permits a single qualified TAVR operator. However, a change in Medicare coverage policy does not automatically establish that every claims-processing instruction or payment edit has been updated. Step 2: Report the Documented Aortic Valve Diagnosis For a patient with documented nonrheumatic aortic valve stenosis, ICD-10-CM code I35.0 (Nonrheumatic aortic (valve) stenosis) may be appropriate. Warning: Do not assume every patient with aortic stenosis belongs in I35.0. The record may identify rheumatic disease, congenital disease, or stenosis with insufficiency, which can lead to a different code. For example, I35.2 identifies “Nonrheumatic aortic (valve) stenosis with insufficiency.” Check the documentation and tabular instructions before assigning the code. The diagnosis code does not change simply because CMS now covers a particular patient category. An asymptomatic patient with documented severe nonrheumatic aortic stenosis may still have I35.0 as the appropriate diagnosis code. The absence of symptoms does not erase the documented valve disease. Keep in mind that I35.0 does not distinguish moderate from severe aortic stenosis or symptomatic from asymptomatic disease. Those distinctions must appear in the clinical documentation when they are necessary to establish Medicare coverage. You cannot rely on the ICD-10-CM code alone to demonstrate that the patient meets the NCD criteria. Step 3: Verify Documentation and Coverage Separately One of the most important lessons from the new policy is that code assignment and coverage review answer different questions. Your coding review of your claim should provide answers to the following questions: Your coverage review should separately establish whether the patient and procedure meet the applicable Medicare NCD requirements. For asymptomatic severe aortic stenosis, do not stop after confirming I35.0 and the appropriate TAVR CPT® code. Check the required CED study information and current CMS billing guidance. For symptomatic severe aortic stenosis, do not continue applying the former CED requirement as though the policy had not changed. CMS also continues to require a multidisciplinary heart team that includes at least one cardiac surgeon and one interventional cardiologist experienced in aortic valve disease. The final policy specifies an initial evaluation with input from cardiac surgery and interventional cardiology and an in-person evaluation by a heart team TAVR operator. An additional operator evaluation is not required but is covered if performed. Hospital infrastructure requirements also remain in place. These are coverage requirements, not separate diagnoses to add to the claim. The revised policy also provides flexibility in how the heart team completes its evaluation, including asynchronous participation. However, you should not confuse participation in the heart team with performance of the TAVR procedure itself. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
