The Edge Blast E-Newsletter
posted 03/07/2007
Electronic news for March 2007
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Stenting Improves Lives of Patients and Manufacturers

by Chris Fraizer, MA, CPC

Medicare beneficiaries and the carotid artery stenting industry stand to make big gains based on a request by stent manufacturers to change Medicare policy for patients at risk for stroke due to the build up of plaque in the carotid artery.

Under the proposed National Coverage Decision (NCD) issued by the Centers for Medicare & Medicaid Services (CMS), Medicare would cover carotid artery stenting (CAS) for patients with sufficiently narrowed arteries, although asymptomatic for carotid artery stenosis.

Current policy restricts coverage of asymptomatic patients who are at high risk for carotid endarterectomy to FDA Category B Investigational Device Exemption (IDE) trials, FDA-approved post approval studies, or in accordance with Medicare clinical trial policy.

Physicians and Medicare officials have hailed the proposal as a benefit to patients because of the risk factors associated with stenting compared to the more invasive carotid endarterectomy. Carotid artery stenting involves the insertion of the slender tube, called a stent, into the carotid artery. The stent expands to increase blood flow in areas blocked by plaque. A carotid endarterectomy may be done to remove plaque in narrowed arteries in, sometimes, asymptomatic patients. Tests such as a duplex ultrasound or angiography may be used to determine the amount of build-up.

The CMS proposal would be also a boon for manufacturers.

According to an article published in the AMNews, the market for stents could increase by 50 to 75 percent, as a result of the proposed change in policy. The writer cites Abbott Vascular as the company that requested the policy change.

A CMS news release states that the NCD resulted from collaborations between CMS and various CAS stakeholders including medical professional organizations, other government agencies and hospitals.

According to the proposal:

  • Expanded coverage would apply to patients who are symptomatic with greater than 50 percent stenosis or asymptomatic with greater than 80 percent stenosis of the carotid artery
  • Coverage of CAS procedures for patients age 80 and above would be restricted to Category B Investigational Device Exemption (IDE) trials, FDA-approved post approval studies, or in accordance with the clinical trial policy

Approximately 70 percent of all strokes occur in people age 65 and older, and it is the third leading cause of death in the United States and the leading cause of serious, long-term disability.

The CMS tracking sheet is available

Medicare Policy (standing – the change to the NCD is in the proposal stage)

Carotid artery stenting is covered and paid only as an inpatient procedure. Medicare covers PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent under specific patient indications found in The National Coverage Determinations Manual, chapter 1, part 1, section 20.7. In addition to the specific patient indications, CMS determined that CAS with embolic protection is reasonable and necessary only if performed in facilities meeting specified facility requirements. Facilities meeting facility standards for coverage are deemed "approved" for receiving Medicare payment for CAS with embolic protection and are available at

CPT® Description 2006 Base Payment Physician
37215* Transcatheter placement of intravascular stent(s) cervical carotid artery, percutaneous; with distal embolic protection $1,096
37216*1 Transcatheter placement of intravascular stent(s) cervical carotid artery, percutaneous; without distal embolic protection Noncovered service, no payment.
* Bundled codes, include all work done on treatment side (catheter placement, angioplasty, angiography and stent placement)
1 CMS noncovered service

Coding Guidance

If the physician intends to place a carotid stent prior to initiating percutaneous transluminal angioplasty (PTA), the PTA is not reported separately. If the original intent of the procedure is to perform PTA and a stent is unexpectedly placed due to PTA failure or the need for a stent in a different area, the physician may report PTA separately and use modifier 51 with code 37215 or 37216 to note multiple procedures. The procedure will be subject to the multiple procedure reduction.


Nadiiiya Zakrevsky, CPC-A, Seattle, Washington
David Glendinning, staff writer, AMNews, February 26, 2007
CMS Transmittal 1042 (August 25, 2006)
Abbott Vascular at

Medicare Quality Reporting Program Offers Bonus Pay to Players

by Chris Fraizer, MA, CPC

The Medicare voluntary Physician Quality Reporting Initiative (PQRI) is up and running, which can only mean two things:

  • Expect more CPT® Category II codes and HCPCS codes for reporting quality measures
  • Prepare to learn new acronyms

The program gives financial incentives to "eligible professionals" willing to report quality measures on Medicare claims. The category "eligible professionals" refers to those getting paid under the Medicare Physician Fee Schedule. Under the PQRI, The voluntary program gives providers the option of reporting on at least three quality measures on 80 percent of their eligible patients to receive a bonus. The bonus cannot exceed 1.5 percent of their total Medicare payments during that given period. The reporting period runs from July 1 to December 31, and the providers will be eligible for a single consolidated incentive payment in mid 2008.

Representatives from the Centers for Medicare & Medicaid Services (CMS) discussed the program at the January 23 Physician Open Forum, from its transition from the PVRP (Physician Voluntary Reporting Program) to the PQRI.

According to Susan Nezda, M.D.:

  • There is no formal enrollment
  • Physicians simply provide the information on their claim forms to participate
  • CMS is still working out the details, such as separating individual physicians from group practices when it comes to the bonus pay and tracking the number of quality measures in relation to the required 80 percent of relevant cases

So far, CMS has released 74 quality measures applicable to 25 medical and surgical associations.

Additional measures from the AQA Alliance could add at least another 10 measures prior to the reporting period. CMS expanded an AQA six site pilot project to measure physician practice to the national level for measurement and data reporting.

Health care providers can report the measures using the applicable G codes or CPT® Category II codes. Claims eligible for the incentive pay must be submitted by February 2008. CMS will use the taxpayer identification number (TIN) as the billing unit, so any bonus incentive payments earned will be paid to the holder of the TIN.

The PQRI stems from the Tax Relief and Health Care Act of 2006 (TRHCA), which the President signed on December 20, 2006 (the same act that repealed the 2007 negative conversion factor). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS.

Not everyone is happy about the program.

A caller to the January 23 open forum commented about the potential danger quality measures could have on patient-centered care since the necessity to report the quality measures could detract from individual-based care.

The tax relief act does establish the framework to continue the voluntary reporting program; however, for 2008 the 110th Congress, which took office in January, must enact legislation to set the bonus amount, if any, given to participants. Congress could also alter the reporting program for 2008.

On a related note, the Delmarva Foundation for Medical Care has entered into four regional CMS subcontracts as part of the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) Project. The subcontractors will combine Medicare and other insurer data to produce provider performance standard reports.

The BQI project relies on national consensus-based measures that have been adopted by AQA. For example, all people with Type 2 diabetes should have a simple lab test twice per year that shows the average amount of sugar in the blood over the last two to three months. Running this measure will show how many of a physician’s diabetic patients received this test and allow a physician to improve his or her performance if the test is not being conducted as indicated.

More information about the 2007 PQRI is available from the CMS Web site at

The PQRI quality measures are available at (available for download at

Coding is a Step Ahead of Fast Food Dangert

by Chris Fraizer, MA, CPC

Once again, the agencies that develop codes are one-step ahead of the public, and this year in relation to the entrepreneur urge to super size our waistlines.

According to a study by the US Center for Science in the Public Interest (CSPI), some fast food chains are serving up such outrageous dishes that they could qualify for a full day’s calories packed into one sitting. The CSPI claims the giant size servings and over the edge calorie stuffed courses are only adding to America’s obesity epidemic and weight-related heart disease.

The high-end appetizers, entrees and desserts the restaurants offer can easily tip the scale at 2,000 calories per oversized serving, which is the average recommended daily intake for a woman is 2,000 calories. For a man it is 2,500 calories.

Restaurants CSPI finds over-the-top for dishes heavy in calories and fat include Ruby Tuesday, Chicago Grill and Cheesecake Factory. Featured high calorie selections at one restaurant cited in the US Center for Science in the Public Interest (CSPI) study includes a chicken and broccoli entrée called the “Angioplasta” and a "Colossal Burger" that weighs in at 1,940 calories and 141 grams of fat. The recommended fat level for a person on 2,000 calories per day is about 65 grams.

ICD-9-CM codes relevant to our urge to overindulge, and effective October 1, 2006, include codes for obesity complicating pregnancy (649.10–649.14), bariatric surgery complicating pregnancy (649.20–649.24), and pediatric body mass indices (V85–V85.54). In codes effective October 1, 2005, the ICD-9-CM added adult body mass indices (V85.0, V85.1, V85.21–V85.25, V85.30–V85.39, and V85.4).

BMI is the first determination of a patient's weight in proportion to height and codes V85.0–V85.54 may be reported with codes from the 278.0 range (overweight and obesity) if the BMI is known.

Coding and Obesity FAQs

  • Minutes from the ICD-9-CM Coordination and Maintenance Committee, held in April 2005, shows that the panel recommended changing the description of subcategory 278.0 to “overweight and obesity” since the terms are not commonly documented and, consequently, not regularly coded.
  • A report published in the North American Association for the Study of Obesity (Obesity Research 13:290-300 (2005)) found: Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.
  • Medicare covers open and laparoscopic Roux-en Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in an approved facility. (MLN Matters Number: MM5013)
  • According to a study in the October 19, 2005, issue of JAMA (Journal of the American Medical Association), morbid obesity is an increasing health problem in the United States:
  • The prevalence of individuals with a BMI higher than 50 quintupled from 1:2000 to 1:400
  • The prevalence of individuals with a BMI higher than 40 quadrupled from 1:200 in 1986 to 1:50 in 2000
  • In 2002, 5.1 percent of U.S. adults had a body mass index (BMI) higher than 40
  • According to the American Society for Bariatric Surgery (ASBS), the number of procedures increased from about 16,000 in the early 1990s to more than 103,000 in 2003. The ASBS is at
  • The ASBS also notes new types of surgery on the horizon: The implantable gastric stimulation device uses small electrodes attached to the stomach which, when stimulated electrically, are supposed to create the feeling of fullness CPT® codes 43647–43648, 43881–43882, 0155T–0158T, added for 2007 and not covered by Medicare or most private payers). The intragastric balloon is being reintroduced as a simple procedure that can be placed through an endoscope. The balloon is designed to “take up space” and thereby decrease the amount of food patients can eat.

EdgeBlast Test Yourself

By answering the following questions you can earn .5 continuing education units to apply toward your annual Academy certification renewal. Simply answer the questions and send in a copy of your work when submitting your CEU package. Put the number of each EdgeBlast included in your submission. The number is available at the top of the page.

Answers to the questions are not always found directly (word for word) in the EdgeBlast in which they appear. While often related to the EdgeBlast content, they require additional resources such as your ICD-9-CM, CPT® and HCPCS manuals.

1. The vascular surgeon performs a CAS without distal embolism protection for a patient at risk for a stroke due to plaque build up on the carotid artery, as shown from a bilateral duplex scan. This is an inpatient procedure but what are the surgeon’s diagnosis and procedure codes (exclusive of the scan)?


2. Referring to Question #1, what is the code for the scan?


3. What is the range of codes in the 2007 HCPCS Level II code set that corresponds to the physician’s voluntary reporting program?


4. An adult patient considered morbidly obese (BMI 39.8) had a gastric band placed laparoscopically to help in weight reduction. What are the procedure and diagnosis codes?


5. Medicare covers open and laparoscopic Roux-en Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in an approved facility. What CPT® codes apply to these procedures?