DRG 266 and DRG 267: Endovascular Cardiac Valve Replacement

Published 10/21/2021

Transcatheter aortic valve replacement (TAVR), also known as Transcatheter Aortic Valve Implantation (TAVI), is used to treat aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the aortic valve. 

TAVRs are performed in a cardiac catheterization lab or a hybrid operating room/cardiac catheterization lab with advanced quality imaging and with the ability to safely accommodate complicated cases that may require conversion to an open surgical procedure. The interventional cardiologist and cardiothoracic surgeon jointly participate in the intra-operative technical aspects of TAVR.

National Coverage Determination (NCD) 20.32 allows for coverage of the TAVR for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication and when all the following conditions are met:

  • The procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system's FDA approved indication
  • The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. The heart team must include the following: 
    • Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have: 
      • Independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy 
      • Documented and made available to the other heart team members the rationale for their clinical judgment
    • Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators
  • The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR
  • TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to:
    • On-site heart valve surgery and interventional cardiology programs
    • Post-procedure intensive care facility with personnel experienced in managing patients who have undergone open-heart valve procedures
    • Appropriate volume requirements per the applicable qualifications

A cardiothoracic (CT) surgical consult is required prior to the performance of the procedure. This consult has the additional benefit of increasing the likelihood of a successful outcome.

This above list is not all-inclusive for Medicare requirements. The process for submitting a clinical research study to Medicare is outlined within CMS NCD 20.32. Sponsors are required to submit their requests to CMS for approval of their TAVR clinical trial. Once CMS approves a TAVR clinical trial, it is added to the CMS TAVR website. Sites that will participate in and recruit patients for the approved TAVR study are determined by sponsors and approved study sites are also included on the TAVR website. Prior to claim submission, it is the providers responsibility to verify participation as an approved TAVR study location.

Are you coding your procedures correctly? Always double check your documentation to ensure that all secondary diagnoses have been documented to the highest possible level of specificity to facilitate coders in accurate DRG assignment. Patient selection and preparation are an intricate part. TAVR procedures are not covered for patients in whom existing co-morbidities would preclude the expected benefit from correction of the aortic stenosis. Addressing patient health issues prior to the procedure greatly lowers readmissions. Collaboration between your care team, interventional cardiologists and surgeons is key and submitting documentation to substantiate this continuum of care is critical in preventing your claims from denying.

Common CERT Denials: Insufficient documentation 

  • Preoperative evaluation prior to the billed TAVR by the interventional cardiologist as required by the NCD was missing
  • Documentation of preoperative evaluations by Cardiothoracic surgeon and Interventional Cardiologist to support the TAVR billed. The submitted medical record has insufficient documentation to support TAVR coverage criteria. Preoperative TAVR face-to-face evaluations by both a CT surgeon and by an interventional cardiologist are missing. The submitted medical record has insufficient documentation to support TAVR and thus elective admission was not reasonable and necessary.
  • Pre-operative authenticated face to face independent evaluation by Interventional Cardiologist for TAVR. The submitted medical record has insufficient documentation to support TAVR coverage criteria. The medical record contains a single face-to-face TAVR evaluation by Cardiothoracic Surgeon. A preoperative TAVR face-to-face evaluation by the NP is not signed by the interventional cardiologist after surgery. It is unclear whether the beneficiary was evaluated by the interventional cardiologist prior to surgery. The elective TAVR admission was not reasonable and necessary as the submitted medical record has insufficient documentation to support TAVR coverage criteria.
     

The following examples are actual denials received for insufficient documentation which resulted in a code change:

  • Insufficient Documentation to Support Procedure: Procedure code 02RF08Z (Replacement of Aortic Valve with Zooplastic, Open Approach) and accompanying procedure code 5A1221Z (Performance of Cardiac Output, Continuous) are removed from the coding sequence.

    The DRG was changed from billed DRG 219 to DRG 306. The submitted medical record has insufficient documentation to support TAVR coverage criteria. The following required documentation is missing:
    1. Preoperative TAVR face-to-face evaluation by an interventional cardiologist
    2. Documentation that an interventional cardiologist jointly participated in the TAVR surgery
    3. Preoperative office notes. Inpatient admission was reasonable and necessary.
       
  • Insufficient Documentation to Support Procedure: Procedure codes 02RF38Z, (Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Approach), 027F3ZZ, (Dilation of Aortic Valve, Percutaneous Approach), 4A023N7, (Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach) and B3101ZZ, (Fluoroscopy of Thoracic Aorta using Low Osmolar Contrast) are removed from the coding sequence.

    The DRG was changed from billed DRG 266 to DRG 306. Submitted record does not support billed procedure. Missing: 1) Preoperative evaluation by Interventional Cardiologist to support the TAVR billed.

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