2019 REIMBURSEMENT CHANGES FOR SUBCUTANEOUS CARDIAC RHYTHM MONITORS
PRESENTED BYKATIE SHEPARD, SR. RBT & HEALTH POL ANALYSTMEDTRONIC CARDIAC RHYTHM & HEART FAILURE
Recorded December 6, 2018
DISCLAIMER
Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (e.g., instructions for use, operator’s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service.
CPT® copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use.
2 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
2019 REIMBURSEMENT CHANGESSUBCUTANEOUS CARDIAC RHYTHM MONITORS
New! CPT Codes for Insertion/Removal Procedures
New Code Numbers
New Code Descriptors
Payment Changes
New! Office Place of Service
Non-physician Practitioners (NPPs)
Device Monitoring Editorial Changes, Clarifications
Frequently Asked Reimbursement Questions
Contact Information
3 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
NEW NOMENCLATURE/CODE DESCRIPTOR LANGUAGE
Implantable Cardiac Monitor (ICM)
Measures physiologic parameters
(e.g. Optivol)
Implantable Loop Recorder (ILR)
Existing Reveal LINQ™ device descriptor
(no physiologic parameters)
Subcutaneous Cardiac Rhythm Monitor
New Reveal LINQ™ device descriptor
(no physiologic parameters)
CURRENT STARTING 1/1/2019
Implantable Cardiac Physiologic Monitor (ICPM)
Measures physiologic parameters
(e.g. Optivol)
4 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
2019 CPT® CODE CHANGES
CPT®
Code Descriptor
33282 Implantation of patient-activated cardiac event recorder
33284 Removal of an implantable, patient-activated cardiac event recorder
CPT®
Code Descriptor
33285 Insertion, subcutaneous cardiac rhythm monitor, including programming
33286 Removal, subcutaneous cardiac rhythm monitor
Procedures Performed on or Before
12/31/2018
Procedures Performed on or After
1/1/2019
5
Source: AMA 2018 & 2019 Codebooks.
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
2019 CPT® CODE CHANGES
CPT®
Code Descriptor
33282 Implantation of patient-activated cardiac event recorder
33284 Removal of an implantable, patient-activated cardiac event recorder
CPT®
Code Descriptor
33285 Insertion, subcutaneous cardiac rhythm monitor, including programming
33286 Removal, subcutaneous cardiac rhythm monitor
Procedures Performed on or Before
12/31/2018
Procedures Performed on or After
1/1/2019
6
Source: AMA 2018 & 2019 Codebooks.
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
2019 RELATIVE VALUE UNITS
CPT®
Code Description wRVUPE RVU
(Facility)
PE RVU
(Non-fac)
MP RVU
Total Facility
RVU
Total Non-Facility
RVUINSERTION
33285
Insertion, subcutaneous cardiac rhythm monitor, including programming
1.53 0.70 144.18* 0.36 2.59 146.07
REMOVAL
33286Removal, subcutaneous cardiac rhythm monitor 1.50 0.69 1.95 0.35 2.54 3.80
*Non-facility PE RVU includes the device.
Source: 2019 Final Medicare Physician Fee Schedule (MPFS) Released November 1, 2018.
7 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
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SPOTLIGHT RVU & RATE CHANGES: PHYSICIANCMS NATIONAL RATES
RVUs Professional Rates Rate Change
% ChangeCPT Short
Descriptor2018 2019 2018 2019
Implant/Insertion
3.25 1.53 $236 $93 -$143 -61%
Removal 2.75 1.50 $207 $92 -$115 -56%
Valued by physician specialty societies using surveys of physicians who are familiar with the service: Time Technical skill required Mental and physical effort (intensity)
Changes reflect several factors including a decrease in time associated with the evolution (e.g. miniaturization) of the devices
Medicare Physician Fee Schedule Files available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
2019 MEDICARE NATIONAL PAYMENTS OFFICE & OUTPATIENT PLACE OF SERVICE
CPT®
Code Description
2019 National
Rate (Non-
facility)
2019 Professional
National Rate
(Facility)
2019 OPPS
National Rate
2019 ASC
National Rate
Insertion
33285Insertion, subcutaneous cardiac rhythm monitor, including programming
$5,264 $93 $7,404 $6,375
Removal
33286Removal, subcutaneous cardiac rhythm monitor $137 $92 $579 $298
2019 MPFS Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html2019 OPPS Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html
9 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
NEW! OFFICE PLACE OF SERVICEHOW DO WE KNOW?
How do we know that LINQ procedures will now be paid by CMS in the office setting starting 1/1/2019?
From the Medicare Physician Fee Schedule:
“For procedures that can be furnished in a physician’s office, as well as in a facility setting, where Medicare makes a separate payment to the facility for its costs in furnishing a service, we establish two PE RVUs: facility and nonfacility.”
Previous codes for these procedures did not have non-facility PE RVUs assigned.
New codes for these procedures have non-facility PE RVU assignments.
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Source: 2019 MPFS Files Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
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GLOBAL SURGICAL PACKAGE CHANGES
2018 2019
CPT Short Descriptor
Global Period Assignment
Procedure Classification
Global Period Assignment
Procedure Classification
Implant /Insertion
090Major
Procedures000
Endoscopies and Some
Minor Procedures
Removal 090Major
Procedures000
Endoscopies and Some
Minor Procedures
CMS assigns a global surgical package to all CPT codes.
Global surgical packages impact physician coding and payment only for procedures performed within the specified number of days after a surgical procedure.
The reclassification of these procedures to 000-day globals opens the door for non-physician practitioners (NPPs) to perform these services when additional specified criteria are met.
MPFS Files Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
NON-PHYSICIAN PRACTITIONERS (NPP)
What is an NPP? Examples of non-physician practitioners are nurse practitioners and physician assistants
What has changed for NPP performing LINQ insert/removal procedures? The global period change opens the door for non-physician practitioners (NPPs) to perform these procedures for Medicare benefeciaries
Does this all mean that an NPPs can start performing these procedures on 01/01/2019? No. There are several considerations to be investigated and addressed individually by location before an NPP performs these procedures
How are NPPs paid for their work?
• NPPs are paid at 85% of the physician rate
• Under specific criteria, NPP procedures can be billed “incident to” a physician (i.e. under the physician NPI) to receive the full 100% physician payment rate
• The requirements for “incident to” billing are complex and vary by payer, both Medicare MACs and private payers
New codes classified as “minor surgical procedures”
CPT Coding Changes
Varying licensure requirements by NPP (e.g. NP, PA)
State Licensure
Credentialing Malpractice Insurance
Individual Payer Policy (MAC, Private Payer)
? ? ? ?
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Medicare Benefit Policy Manual Chapter 15 (190)—Physician Assistant (PA) Services; (200)—Nurse Practitioner (NP) ServicesMedicare Benefit Policy Manual Chapter 15 (60.2)—Services of Nonphysician Personnel Furnished Incident To Physician’s Services
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
DEVICE MONITORING—DESCRIPTOR CHANGES
2018 2019
CPT®
Code Descriptor DescriptorIn Person Interrogation or Programming Evaluation
93285ILR system programming device evaluation
Subcutaneous cardiac rhythm monitor systemprogramming device evaluation
93291Interrogation device evaluation; ILR system, including heart rhythm derived data analysis
Interrogation device evaluation; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis
Remote Interrogation Evaluation
93298Interrogation device evaluation(s), (remote) up to 30 days; ILR system [professional service]
Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system [professional service]
93299Interrogation device evaluation(s), up to 30 days; ICM/ILR system [technical service]
Interrogation device evaluation(s), up to 30 days; ICPM/ILR system [technical service]
13 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
Parameters that must be Checked During Interrogation Evaluation
All programmed parameters
The heart rate and rhythm during recorded episodes from both patient-initiated and device algorithm detected events, when present
Differentiating Programming Evaluation from Interrogation Evaluation
Iterative adjustments of the programmable parameters are conducted
Iterative adjustments provide information that permits the operator to assess and select the most appropriate final program parameters to:
Provide for consistent delivery of the appropriate therapy; and
Verify function of the device
Final program parameters may or may not change after evaluation
(Specific to subcutaneous cardiac rhythm monitors) Often, but not always, the tachycardia and bradycardia detection criteria will be adjusted
DEVICE MONITORING—INTRODUCTORY TEXT CHANGES
Source: AMA CPT Codebook 2019.
14 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
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FREQUENTLY ASKED REIMBURSEMENT QUESTIONS
1. What CPT code should be reported when the Reveal LINQ requires repositioning?
2. How does payment to the physician vary by site of service?
3. Is there a separate code I need to report for the device when the insertion is performed in the office?
4. What is the minimum number of days that the patient needs to be in the remote monitoring program for the services (PC/TC) to be billable?
5. Can an NPP serve as a supervisor for in person monitoring?
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
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CUSTOMER-FACING RESOURCESAVAILABLE ON CRHF REIMBURSEMENT WEBSITE
Resources available at: http://Medtronic.com/crhfreimbursement
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
FOR MORE INFORMATIONCONTACT CRHF REIMBURSEMENT SERVICES
17 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
APPENDIX
REFERENCES/RESOURCES
AMA CPT 2019 Codebook. CPT codes and descriptions only are copyright ©2018 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein.
2019 Medicare Final Inpatient Prospective Payment System. Released Aug 2, 2018.
2019 Medicare Final Outpatient Prospective Payment System. Released Nov 2, 2018.
2019 Medicare Final Physician Fee Schedule. Released Nov 1, 2018.
Medicare Benefit Policy Manual Chapter 15 (60.2)—Services of Nonphysician Personnel Furnished Incident To Physician’s Services
Medicare Benefit Policy Manual Chapter 15 (190)—Physician Assistant (PA) Services; (200)—Nurse Practitioner (NP) Services; (210)—Clinical Nurse Specialist (CNS) Services
19 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
INPATIENT RATE CHANGES FY 2018 - FY 2019For Cardiac Diagnoses
MS-DRG MS-DRG Description
FY 2018 National
Rate
FY 2019 National
Rate % Change
260CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC
$21,620 $22,112 2.3%
261CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC
$11,680 $12,168 4.2%
262CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC
$9,950 $9,964 0.1%
WEIGHTED AVERAGE--------------------------------------- $14,336 $15,071 5.1%
For Cryptogenic Stroke
MS-DRG MS-DRG Description
FY 2018 National
Rate
FY 2019 National
Rate % Change
040PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC
$22,948 $23,998 4.6%
041PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM
$14,048 $14,408 2.6%
042PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC
$11,514 $11,433 -0.7%
WEIGHTED AVERAGE--------------------------------------- $16,908 $17,132 1.3%
20 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
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OUTPATIENT RATE CHANGES CY 2018 - CY2019IMPLANT/INSERTION & REMOVAL
CPT Code
Short Descriptor
Ambulatory Surgical Center
Hospital Outpatient
2018 2019 % Change
2018 2019 % ChangeAPC Rate APC Rate
33285 Insertion $6,403 $3,701 -42% 5222* $7,371 5222 $7,404 0%
33286 Removal $298 $298 0% 5071* $573 5071 $579 0%*Previous codes 33282 (implant) and 33284 (removal) were assigned to the same APCs as the new 2019 codes.
2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
DEVICE EVALUATION RATE CHANGES CY 2018 – CY 2019 2018 2019
CPT®
Code Short Descriptor
Medicare National
Physician Rate (non-facility)
Medicare National
Physician Rate (non-facility)
Medicare National OPPS
Rate
Medicare National OPPS
Rate
In Person Interrogation & Programing Evaluation
93285
Device programming $44 $49
$38 $37$27 (26) $27 (26)
$17 (TC) $22
93291
Device interrogation $33 $39
$17 $17$19 (26) $19 (26)
$15 (TC) $20 (TC)
Remote Interrogation Evaluation
93298
Device interrogation—professional service
$27 $27Physician
OnlyPhysician
Only
93299
Device interrogation—technical service Contractor
PricedContractor
Priced$38 $37
22 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
23 2019 Reimbursement Changes for Subcutaneous Cardiac Rhythm Monitors
BRIEF STATEMENT
BRIEF STATEMENT
Indications: Reveal LINQTM LNQ11 Insertable Cardiac Monitor and Patient Assistant
The Reveal LINQTM Insertable Cardiac Monitor is an implantable patient-activated and automatically-activated monitoring system that records subcutaneous ECG and is indicated in the following cases:
Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias
Patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia
This device has not specifically been tested for pediatric use.
Patient Assistant: The Patient Assistant is intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates the data management feature in the Reveal LINQTM Insertable Cardiac Monitor to initiate recording of cardiac event data in the implanted device memory.
Contraindications: There are no known contraindications for the implant of the Reveal LINQTM Insertable Cardiac Monitor. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated.
Warnings/Precautions: Reveal LINQTM LNQ11 Insertable Cardiac Monitor
Patients with the Reveal LINQTM Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external de brillation, lithotripsy, therapeutic ultrasound, and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing as described in the Medical procedure and EMI precautions manual. MRI scans should be performed only in a specified MR environment under specified conditions as described in the Reveal LINQTM MRI Technical Manual.
Patient Assistant: Operation of the Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device.
Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin.
See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events.
For further information, please call Medtronic at 1 (800) 328-2518 or consult Medtronic’s website at www.medtronic.com.
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.