National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Clarification of Percutaneous Transluminal Angioplasty (PTA) Billing Requirements Issued in CR 3811

Note: This article was revised on August 30, 2007, to correct the link to MLN Matters article MM3811 on page 2. A link was also added in the “Additional Information” section to another PTA-related article, MM5022, which provided clarification of MM3811. All other information remains unchanged.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FI), and/or Part A/B Medicare Administrative Contractors (A/B MAC)) for services provided to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5667, which adds ICD-9-CM diagnosis code 433.11 (occlusion of the carotid artery with infarct), to the list of payable claims for PTA to ensure all eligible Medicare beneficiaries are covered.

Background
On March 17, 2005, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) providing Medicare coverage for Percutaneous Transluminal Angioplasty (PTA) of the carotid artery concurrent with placement of an FDA-approved carotid stent when beneficiaries are at high risk for carotid endarterectomy (CEA). (This was announced in CR 3811, effective March 17, 2005; see related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf . ) The NCD provides coverage for patients with symptomatic carotid artery stenosis who meet the coverage criteria specified in the policy. As stated in the NCD,

• Patients who experience non-disabling strokes (modified Rankin scale < 3) are considered to be symptomatic and therefore are eligible for coverage; however,
• Patients who experience disabling strokes (modified Rankin scale ≥ 3) are not eligible for coverage.

Currently, there are no codes that distinguish between non-disabling and disabling strokes. In order to ensure that claims for all eligible patients can be paid, CR5667 adds the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of 433.11 (Occlusion and stenosis of carotid artery, with cerebral infarction) to the list of payable claims for carotid artery stenting (CAS).

Patients who experience disabling strokes remain ineligible for coverage.

Note that Medicare contractors will not search their files to reprocess claims already processed. However, they will adjust such claims if you bring the claims to their attention. Also, since the Centers for Medicare & Medicaid Services (CMS) considers this an administrative error, your Medicare contractor will follow the guidelines in the Medicare Claims Processing Manual (Chapter 1, Section 70.7.1) for allowing an extension to the timely filing limits. In essence, this allows your contractor to accept claims with 433.11 outside the timely filing limitations, since such claims were not previously payable due to the administrative error. Medicare manuals are available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

CR5667 also advises providers that they can correctly bill covered bilateral carotid services by coding both 433.30 (Occlusion and stenosis of multiple and bilateral arteries, without mention of cerebral infarction) or 433.31 (Occlusion and stenosis of multiple and bilateral arteries, with cerebral infarction) and 433.10 (Occlusion and stenosis of carotid artery, without mention of cerebral infarction) or 433.11 in any order on the same claim. Providers would code 433.30 with 433.10 or 433.31 with 433.11 to identify the multiple and bilateral condition and 433.10 or 433.11 to specifically identify the carotid artery.

Claims submitted by physicians to carriers or MACs may also contain a CPT code of 37215 (Transcatheter placement of intravascular stent(s), cervical carotid artery, Percutaneous; with distal embolic protection), 0075T (Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel), or 0076T (Each additional vessel). Claims submitted by institutional providers to FIs or MACs should contain the appropriate procedure codes of 00.61 (Percutaneous angioplasty or atherectomy of precerebral (extracranial) vessels) and 00.63 (Percutaneous insertion of carotid artery stent(s)).

Additional Information
MM3489, Percutaneous Transluminal Angioplasty (PTA), can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3489.pdf on the CMS Web site.

MM3811, Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA), is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf on the CMS Web site.

MM5022, Clarification on Billing Requirements for Percutaneous Transluminal Angioplasty (PTA) Concurrent with the Placement of an FDA-approved Carotid Stent, is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5022.pdf on the CMS Web site.

The official instruction, CR5667, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1315CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which is at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.