TAVR 0256T Billing & Modifiers HELP - I am getting ready to submit

gski

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Indian River, MI
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I am getting ready to submit our first billings for 4 separate physicians from 2 separate practices and would appreciate some feedback on this.

Per the CCI edits, 34812 does not bundle into 0256T. It does bundle the 92986 valvuloplasty (no modifier is allowed), the temporary PM insert 33210 and 93318 TEE intraop (modifiers are allowed).

Practice 1 Surgeon performing TAVR/temp PM/valvuloplasty
0256T TAVR Modifier 66 for Team surgery?
(33210 Temp PM insert unbillable per CPT) When is it allowed to add the 59 modifier?
(92986 valvuloplasty is unbillable per CCI)

Practice 1 First Assist to Surgeon performing TAVR/temp PM/valvuloplasty:
0256T,? TAVR Mod 66 for Team surgery? Or Modifier 80 for 1st assist?
(33210 Temp PM insert unbillable per CPT) When is it allowed to add the 59 modifier?
(92986 valvuloplasty is unbillable per CCI)

Practice 1 Cardiologist #3 performing TEE placement/monitoring throughout TAVR:
93318,59 TEE intraop When is it allowed to add the 59 modifier?
76376,26 3D with TEE


Practice 2 Cardio-Thoracic Surgeon performing femoral cut-down & closure only
0256T, 66 Modifier 66 for Team Surgery?
Or 34812 for cut-down Does it need a modifier?

When I looked at the Medicare policies, the Local Coverage Article (A46075) states you can NOT use modifiers 62, 66 but you can use modifier 80 for the 0256T. In LCD L25275, modifiers are not specified at all. Since the LCD did not clarify the modifiers, I called Medicare. I was directed to the “2012 National Physician Fee Schedule Relative Value File July Release” File: PPRRVU12_V0606.xlsx, which states 0256T you CAN use modifiers 80, 62, 66 and for 34812 you CAN use modifiers 51, 50, 80, and 62.

Since Medicare advised me to use the allowed modifiers on the Relative Value File shown above, these are contradicting the LCA. Since this is only a "Article", not a "Decision" in a LCD, are we required to follow the LCA over the Relative Value Files????

How is everyone else billing these? (I am in Michigan).

I would greatly appreciate any feedback you can give me on this. Thank you!!
 

lisigirl

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Oakpark, Illinois
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At our practice, this procedure is done by a cardiac surgeon and an interventional cardiologist working together. We bill as co-surgeons, so 0256T-62. If the surgeon performs a cut down of the femoral artery (rather than percutaneous access), then I will bill 34812 under him alone (you cannot bill for the cutdown and then the closure - because, if you open something, you HAVE to close it. If it turns into a complex closure, then you could bill for the repair).

We do not bill separately for the balloon valvuloplasty, this is included in 0256T-0257T. We never bill for something placed temporarily (ie: pacemaker) because this is an integral part of the larger procedure & therefore not separately billable.

A 3rd cardiologist usually performs the intraop TEE and he bills separately for that. The only modifier needed for us is a -26 because we are only billing for the professional component.

I would not recommend billing with modifier -66. Team surgeries, in my opinion, are very hard to get paid and the documentation would have to make it very clear why all those physicians were needed and what each one did.

Overall, we are having a very hard time getting these paid. Although the MFSDB states that we can bill as co-surgeons (or as a primary with an assistant surgeon), Medicare is continuing to deny every claim with the denial "modifier inconsistent" or "multiple physicians not allowed." I've been appealing these up the chain at Medicare all year.

I'm in Illinois so we have WPS. Is that the carrier for Michigan or did you switch? If you have WPS, you may want to email me directly.

Hope this helped!

Lisi, CPC
eharkler@nmh.org
 

dpeoples

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Birmingham, Alabama
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Our docs performed the first two yesterday. The documentation is vague as to what role each physician played as there is a team that has been trained for this and they were all present. The coding is easy, but the modifier(s) could be the real sticking point.

From my understanding, it is not appropriate to bill for a temp pacer with (or w/o) a modifer 59. This is a component of the procedure, as is a heart cath and a valvoplasty. The echo can be billed separately as can the cutdown.

It will be interesting to see when/if we get reimbursed for this emerging technology. And (gski and lisigirl) I am interested in your results as well. Please update if you have time.

HTH :)
 
Last edited:

jewlz0879

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Richardson, TX
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Our diagnostic cath's are always done prior, to TAVR, but when you look at 0256T/0257T CPT states you can bill heart cath codes 93451-93572. Maybe I'm missing something there? I would not bill for valvuloplasty. We have billed a lot of these and have had to fight with Medicare but we have received some payments. We bill both non-trial and trial cases.

Might help

http://www.trailblazerhealth.com/Tools/Notices.aspx?ID=14891&DomainID=1
 

dpeoples

True Blue
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Birmingham, Alabama
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Our diagnostic cath's are always done prior, to TAVR, but when you look at 0256T/0257T CPT states you can bill heart cath codes 93451-93572. Maybe I'm missing something there? I would not bill for valvuloplasty. We have billed a lot of these and have had to fight with Medicare but we have received some payments. We bill both non-trial and trial cases.

Might help

http://www.trailblazerhealth.com/Tools/Notices.aspx?ID=14891&DomainID=1
Hi Julie,
The note under the code description states that 0256t does not include cardiac catheterization (93451-93572) when performed at the time of the procedure for diagnostic purposes"] but "includes all other catheterizations..."

I think in the future we will be at the point where diagnosis and treatment can be performed in the same session, but right now one of the requirements from CMS is that the patients undergoing this treatment must have been evaulated by more than one surgeon and/or cardiologist. It is likely that this would include a diagnostic heart catheterization IMO, so I woud be reluctant to code for heart caths at the time of TAVR.

But, each case is different...stay tuned
:)
 

kbritt77

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Vascular Surgeon performing conduit in TAVR

Our doctor performs an open aortoiliac closure with creation of a conduit for delivery of endovascular aortic valve prosthesis via retroperitoneal incision. The only code I can find to use is 34833. I'm skeptical about using that code because it states "delivery of aortic or iliac endovascular prosthesis" this is actually a cardiac endovascular prosthesis. Should I use an unlisted code??? thoughts please.
 
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