Cardiology Coding Alert

Question: One of my colleagues said that CMS has proposed an update to its national coverage policy for TAVRs. I haven’t heard about this. Can you explain what the proposal entails?

Alaska Subscriber

Answer: CMS recently released a proposed decision memo for transcatheter aortic valve replacements (TAVRs). CMS will continue to cover TAVRs for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).

Under this proposal, CMS updates coverage criteria for hospitals and physicians to begin or maintain TAVR programs. This decision will “provide more flexibility in how providers can meet the requirements for performing TAVR, while continuing to ensure good health outcomes for patients receiving the procedure,” according to the proposal.

In its proposed decision, CMS gives providers requirements to perform a certain volume of procedures, due to the link between heart procedure volume and patient outcomes in medical literature and the risks from receiving care in low-volume settings. The proposal will give providers more flexibility in how they can meet these requirements to reflect the latest evidence on volume and outcomes.

In both the current and the proposal, CMS sets forth two sets of qualifications — one for hospital programs and heart teams without previous TAVR experience and one for those with TAVR experience.

To get a better idea of what changes the proposal entails, take a look at what it says about qualifications to begin a TAVR program for hospitals without TAVR experience: To begin a TAVR program without experience, the hospital program must have the following:

• ≥ 50 open heart surgeries in the previous year prior to TAVR program initiation, and;
• ≥ 20 aortic valve related procedures in the 2 years prior to TAVR program initiation, and;
• ≥ 2 physicians with cardiac surgery privileges, and;
• ≥ 1 physician with interventional cardiology privileges, and;
• ≥ 300 percutaneous coronary interventions (PCIs) per year.

The heart team who does not have TAVR experience must also meet the following qualifications:

Their heart team must include:

• A cardiovascular surgeon with ≥ 100 career open heart surgeries of which ≥ 25 are aortic valve related; and
• An interventional cardiologist with professional experience of ≥ 100 career structural heart disease procedures; or, ≥ 30 left-sided structural procedures per year and device-specific training as required by the manufacturer.

You can read the proposal in its entirety here: https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=293.