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Outline of process and codes for medical cost reimbursement
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October 2007 Dickson Consulting
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Medical Cost Reimbursementof Medical Devices
Dickson Consulting351 Old Babcock TrailGibsonia, PA 15044
www.dicksonconsulting.biz
October 2007 Dickson Consulting
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Overview of Reimbursements
• Administered by Centers for Medicaid & Medicare (CMS) Inpatient Prospective Payment System (IPPS)Codes for hospital reimbursement, not doctors
• American Medical Association (AMA) administers codes for reimbursement of physicians
• Other systems for reimbursement-private insurance companies
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Types of Codes
• ICD-international classification of diseases
• DRG’s-diagnosis related groups
• CPT-current procedural terminology
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ICD Codes
• Administered by CMS
• ICD-9-CM diagnostic codesA system for the international classification of
diseases Identify why a patient was provided health care
services
• ICD-9-CM procedure codes Actual procedures performed by health care providers
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Examples of ICD-9-CM Codes
• ICD-9-CM Diagnostic Codes410 Acute myocardial infarction
410.0 Acute myocardial infarction of anterolateral wall411 Other acute and subacute forms of ischemic
heart disease411.0 Postmyocardial infarction syndrome
• ICD-9-CM Procedure Codes37.68 Insertion of percutaneous external heart assist
device37.22 Left heart cardiac catheterization37.65 Implant of external heart assist system37.64 Removal of heart assist system
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DRG Codes
• Diagnosis Related Groups=DRG• New codes effective October 1, 2007• New codes based on indication of severity
MCC=major co-morbidity and complicationCC=Co-morbidity and complication
• Payments vary based on geographic region, training hospital, etc.
• When more than one procedure is performed reimbursement is based on highest value DRG
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Examples of DRG Codes
• 216= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with MCC
• 217= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with CC
• 218= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization without MCC/CC
• 1= Heart transplant or implant of heart assist system with MCC
• 2= Heart transplant or implant of heart assist system with CC
• 215= Other heart assist system implant
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CPT Codes
• Used for payment of physician services
• Determined by the AMA Based on Resource Based Relative Value Scale (RBRVS)
• Cost is divided into three components– Physician work– Practice expense– Professional liability insurance– Translated into relative value units
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Examples of CPT Codes
• 33975= Implantation of single extracorporeal ventricular assist device (VAD)
• 33977= Removal of single extracorporeal VAD
• 33960= Prolonged extracorporeal circulation for cardiopulmonary insufficiency
• 33961= Prolonged extracorporeal circulation for cardiopulmonary insufficiency for each additional 24 hours
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Example of Code Application
Circulatory assist system is utilized to stabilize a patient in a PCI procedure in a cardiac catheterization laboratory. The reimbursement would be determined as follows:
• Insertion of percutaneous heart assist device: ICD-9-CM code = 37.68 CPT code = 0048T
• Potential DRG codes: DRG 216 (with MCC and CC) DRG 217 (with CC) DRG 218 (without MCC or CC)
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Example of Code Application
Multiple facilities are involved or procedures are performed in connection with open heart surgery.
• Patient is transferred from an open heart center to a destination therapy or a transplant center, the transferring facility should receive a per diem derived from the expected DRG payment.
• If a longer term ventricular assist device is implanted or a heart transplant occurs the receiving facility should receive DRG 1 or 2.
• If at the receiving facility, a circulatory assist device is used for the patient in a heart surgery procedure, the circulatory assist device is removed, the patient recovers native heart function and is discharged home, then the receiving facility should receive DRG 1 or 2.
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Additional Information From CMS
• Home page: www.cms.hhs.gov • Regulations for new codes issued August 1,
2007: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
• Intermediary-Carrier Directory effective January 1, 2007:www.cms.hhs.gov/contractinggeneralinformation/downloads/02_ICdirectory.pdf
• ICD-9 Provider and Diagnostic Codes: www.cms.hhs.gov/ICD9providerdiagnosticcodes/06_codes.asp#topofpage
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Additional Information From AMA
• Home page: www.ama-assn.org
• CPT code information:
www.ama-assn.org/ama/pub/category/3113.html
• CPT Codebook, Professional Edition
• Physician ICD-9-CM Codebook
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Disclaimers
• This document is for informational purposes only, and is not intended to provide specific instructions on billing for medical procedures.
• Specific insurers should be consulted for their requirements for coding, billing and payments.
• Reliance on this document, does not guarantee that reimbursements will be made in accordance with this document.
• This document is not intended to encourage any healthcare provider to provide services to patients, or utilize any medical device.
• This presentation is not intended to address reimbursement for off-label procedures.
