Coding and Reimbursement Guide

Transcription

1 Coding and Reimbursement Guide Fractional Flow Reserve derived from Computed Tomography (FFR CT ) January Seaport Blvd, Bldg B Redwood City, CA ph: reimbursement@heartflow.com heartflow.com

2 Introduction The Fractional Flow Reserve Computed Tomography (FFR CT ) Coding Guide is intended to provide reference material related to the reimbursement of the FFR CT procedure when used consistently with the product s labeling. Disclaimer The information provided in this document is general information only and is not provided as legal advice, nor is it advice about how to code, complete, or submit any particular claim for payment for health care services or goods. This information provides only an overview of HeartFlow s understanding of current coding policies, and may not provide all the information necessary to understand a particular situation. The information provided may not be comprehensive or complete. It is the responsibility of the health care provider, such as a hospital or a physician, to submit complete, accurate and appropriate bills or claims for payment that comply with applicable laws and regulations and third-party payer requirements, and to determine the appropriate codes, charges, and modifiers that the provider uses for those purposes. Third-party payers may have policies and coding requirements that differ from those described here, and such policies can change over time. HeartFlow disclaims any responsibility for claims submitted by health care physicians or others. Physicians should check and verify current policies and requirements with the payer for any particular patient. HeartFlow endorses the best practice that all coding and billing submissions to payers be truthful and not misleading, and that providers make full disclosures to the payer about how the service has been used. This reimbursement and coverage guide is not intended to provide specific guidance on how to utilize, code, bill, or charge for any product. HeartFlow cannot guarantee success in obtaining payment for products and services. CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2 HeartFlow, Inc. Coding and Reimbursement Guide January 2018

3 Coding for FFR CT These coding suggestions do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of services. The medical record must include documentation to support the medical necessity of the procedure and the diagnosis and procedure codes selected to report the service. CPT Code T Description Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report 0502T data preparation and transmission 0503T analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model 0504T anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report Report 0501T, 0502T, 0503T, 0504T one time per coronary CT angiogram Do not report 0501T in conjunction with 0502T, 0503T, 0504T 3 HeartFlow, Inc. Coding and Reimbursement Guide January 2018

4 Coding and Reimbursement for FFR CT Hospital Outpatient 2 In the calendar year 2018 hospital Outpatient Prospective Payment (OPPS) rulemaking, the Centers for Medicare & Medicaid Services (CMS) determined that FFR CT should be separately payable under the OPPS, assigning CPT code 0503T to New Technology Ambulatory Payment Classification (APC) 1516, with a national payment rate of $ A New Technology APC is intended to provide payment under the OPPS for complete services or procedures that cannot be appropriately reported by existing Healthcare Common Procedure Coding System (HCPCS) codes assigned to a clinical APC or be reported by a new HCPCS code that could be assigned to an existing APC. CPT Code 1 Description Status Indicator APC National Medicare Rate Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional 0501T data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid M N/A Not paid under OPPS dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report 0502T data preparation and transmission N N/A Packaged 0503T analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model S 1516 $1, T anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report M N/A Not paid under OPPS M = Items and services are not billable to the MAC. Not paid under OPPS. N = Items and services packaged into APC rates. No separate APC payments. S = Significant procedure not subject to multiple procedure discounting. 4 HeartFlow, Inc. Coding and Reimbursement Guide January 2018

5 Coding and Reimbursement for FFR CT Physician 3 Category III CPT codes reflect emerging technologies, and there are not assigned Relative Value Units (RVUs) for the calculation of physician payment. Medicare assigned XXX (the global concept does not apply) to all four codes; payment is at the discretion of the applicable Medicare Administrative Contractor (MAC). Because there is no assigned Medicare payment for Category III codes, physicians submitting a claim for the FFR CT Analysis are advised to reference an existing service or procedure that is comparable to the FFR CT Analysis in terms of costs and resources. CPT Code 1 Description Status Indicator Work RVU National Facility Medicare Rate Non Facility 0501T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report C N/A N/A N/A 0502T data preparation and transmission C N/A N/A N/A 0503T 0504T analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report C N/A N/A N/A C N/A N/A N/A C = Carriers/MACs priced code. Carriers/MACs will establish RVUs and payment amounts for these services, generally on an individual case-by-case basis following review of documentation such as an operative report. 5 HeartFlow, Inc. Coding and Reimbursement Guide January 2018

6 References 1 CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Please note that the use or reprinting of CPT content in any product or publication requires a license. For more information about the licenses available, see CPT License Information. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2 Hospital Outpatient Prospective Payment- Notice of Final Rulemaking (NFRM) with Comment Period. CMS-1678-FC: 3 CY 2018 Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B. CMS-1676-F: CMS-1676-F.html 6 HeartFlow, Inc. Coding and Reimbursement Guide January 2018

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