Revenue Cycle Insider

Question: A colleague mentioned that the Centers for Medicare & Medicaid Services (CMS) provides reimbursement for transcatheter tricuspid valve replacement (TTVR) surgery only if certain conditions are met, including the care team being comprised of providers with specialist knowledge of tricuspid regurgitation (TR). We have a Medicare beneficiary scheduling surgery and I want to make sure we meet all the criteria for payment. How do I find out more about this provider qualification information?

Codify Subscriber

Answer: According to a CMS Medicare Learning Network (MLN) national coverage determination (NCD), there are patient and physician criteria. The patient criteria include the patient exhibiting “symptomatic TR despite optimal medical therapy” and their care team considering treatment including tricuspid valve replacement.

CMS specifies that the specialist heart care team must have experience caring for and treating TR and be comprised, at a minimum, of:

• A cardiac surgeon
• An interventional cardiologist
• A cardiologist with training and experience in heart failure management
• An electrophysiologist
• A multimodality imaging specialist
• An interventional echocardiographer

See the MLN document above for more information regarding Medicare coverage of TTVR.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC