Payment for Carotid Artery Stenting

Note: Currently, carotid artery stenting is covered and paid only as an inpatient procedure.

Medicare Hospital In-Patient Payment

The hospital inpatient payment system is a prospective payment system (PPS) that classifies patients according to diagnosis, type of treatment, age and other relevant criteria using the ICD-9-CM coding system. Under this system, hospitals normally receive a predetermined payment for treating patients within a particular category or Medicare-Severity Diagnosis-Related Group (MS-DRG).

DRGs are assigned a ‘weight’ by Medicare. This weight is based on factors which may include comparative use of resources; a patient’s admitting diagnosis, procedures performed and complications or co-morbidities. A national average is calculated by CMS and is then adjusted for each hospital based on factors including geography, disproportionate share, and whether or not the institution is a teaching facility.

The DRG assignment for carotid artery stenting was changed with the Fiscal Year 2008 Hospital In-Patient Prospective Payment Rule (effective October 1, 2007). The table below lists the change in DRG assignment for carotid artery stenting and the national base payment calculated using the CMS assigned weight.

Beginning Fiscal Year 2008 (October 1, 2007), there are three different Medicare Severity DRGs (MS-DRGs) that carotid stent can qualify for, depending on if the patient has Major Complications or Comorbidities (MCC) or Complications or Comorbidities (CC). 

Note: Medicare hospital inpatient information is effective for the fiscal year (FY) (October 1 through September 30).

Medicare Physician Professional Payment

* Bundled codes, include all work done on treatment side (catheter placement, angioplasty, angiography and stent placement).

¹ CMS non-covered service.

References:

Centers for Medicare and Medicaid Services at www.cms.hhs.gov

ICD-9-CM for Hospitals – Volumes 1,2 & 3; 2006 Professional; 6th edition; edited by Anita C. Hart, RHIA, CCS, CCS-P, Catherine A. Hopkins, Beth Ford, RHIT, CCS; Ingenix

CPT^® is a trademark of the American Medical Association.

Current Procedure Terminology (CPT^®) is copyright 2005. American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

American Medical Association. Current Procedural Terminology (CPT^®) 2005. Professional Edition. Chicago, IL: 2005.

Last updated: January 2008

Disclaimer: The information provided on this website was obtained from third-party sources and is subject to change without notice, as a result of changes in reimbursement laws, regulations, rules and policies. All content on this website is informational only, general in nature and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct medical providers on how to use or bill for healthcare procedures including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that Abbott Vascular assumes will have been made prior to assigning codes or requesting payments. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing and payment levels for healthcare procedures.

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