New IVUS Codes from CMS: A Win for Hospitals, Physicians, Patients and Medicare

New IVUS Codes Were Adopted October 1 On October 1, 2004, Medicare adopted new intravascular ultrasound (IVUS) inpatient ICD-9-CM procedure codes to more accurately reflect the use of IVUS in hospitals. The new coding was developed through the joint efforts of the Society for Coronary Angiography and Interventions (SCAI) and Boston Scientific Corporation. The new Medicare ultrasound subcategory, Intravascular Vessel Imaging (seven 00.2 codes from 00.21-00.29), now enables separate tracking of IVUS procedures as differentiated from other types of ultrasound. With this new subcategory, specific IVUS use can now be tracked through hospital data to assist with resource alignment as Medicare reviews the costs of IVUS procedures and thus sets the stage for bringing reimbursement into line with costs. In terms of rationale, result and process, it is useful to explore this new development: How is IVUS technology uniquely beneficial? How is IVUS functionally different from cardiac ultrasound? Why were new, IVUS-specific codes necessary? How do hospitals, physicians, patients and Medicare all benefit from the new coding? How and why did the partnership process work in developing the new coding? What are the next steps for hospitals to begin using and benefiting from the new codes? Why Use IVUS? Intravascular ultrasound is a unique cardiovascular technology and adjunctive procedure that delivers distinct clinical benefits. Use of IVUS technology is growing rapidly, particularly with the increasing use of drug-eluting stents (DES) and stenting in more challenging cases. However, treatment of these more challenging cases and the use of DES may increase the need to ensure that stents are optimally deployed. For example, in cases involving long or complex lesions, physicians may need to double-check that complete stent apposition is present. IVUS images are the most accurate means to visually confirm that complete apposition has been achieved. Similarly, a physician might also take IVUS images to ensure that there is no gap in coverage when using multiple stents. How Is IVUS Different from Other Ultrasounds? IVUS is not a replacement technology for conventional external diagnostic ultrasound or intracardiac ultrasound (ICE). IVUS evaluates different anatomical structures, offers different resolution, implementation and application, and requires different training for both physician and technologist. IVUS functionality is also different from that of cardiac ultrasound. As a therapeutic adjunctive procedure, IVUS is now used pre-, mid- and post-intervention for: Lesion severity assessment; Therapeutic device selection; Stent implantation; Monitoring of atherosclerosis therapy. There are strong indications that in the future, IVUS will be used to: Identify the atherosclerotic burden and target expensive regression therapies; Provide guidance for increasingly complex percutaneous coronary interventions (PCI) and intracardiac interventions. The clinical and economic values of IVUS are becoming evident as more data about, and experience with, the procedure accumulate. IVUS technology: Enables more challenging disease states to be treated with greater physician information and confidence; Enables more accurate post-procedure monitoring and potentially fewer repeat procedures. To illustrate the role of IVUS in interventions, my presentation to the ICD-9 Coding Committee included data from the randomized SIPS Trial.¹ This data recorded favorable two-year outcomes in patients randomized to IVUS guidance of their interventions. The potentially favorable economics of IVUS is beginning to evolve. The presentation also cited SIPS Trial cost-effectiveness data, which determined a 60.9% probability that the IVUS procedure is less expensive and more effective based on two-year rates for major adverse cardiac events (MACE).² Why New Codes for IVUS? As we have seen, intravascular ultrasound has unique characteristics and clinical implications that justify separate tracking for data analysis. Before October 1, the full weight of IVUS use and utility was not able to be uncovered because reporting was buried in general ultrasound categories. A previous code assignment, 88.72, Diagnostic Ultrasound of Heart3 failed to capture the unique invasive, technical, training and clinical differences between IVUS and other forms of cardiac ultrasound. As a result, neither hospitals nor the Centers for Medicare and Medicaid Services (CMS) were able to specifically track the use and costs associated with IVUS; appropriate reimbursement was therefore difficult to determine. The newly developed codes enable separate tracking of IVUS procedures as distinct from other types of ultrasound. With the new codes, hospitals can realize several benefits: More accurate reimbursement for IVUS procedures may be possible as Medicare obtains IVUS-specific cost data; Easier hospital revenue tracking; Greater simplicity and ease in identifying and incorporating procedural resource utilization; Greater likelihood that subcategory codes 00.21“00.29 will be included in claims submissions, achieving more accurate coding; More accurate utilization reporting. Norm Linsky, Executive Director at SCAI, has praised the adoption of the new codes, saying, These codes represent an important win for hospitals, physicians, patients, CMS and manufacturers of IVUS devices. Because the new codes will mean more accurate reporting to CMS for IVUS procedures, said Linsky, this will lead to more appropriate Medicare reimbursements. As reimbursements come into line with costs, the use of IVUS technology which has the potential to revolutionize many procedures in the treatment of vascular disease will in all likelihood continue to increase. Industry-Society-Agency Effort Drove the Process Developing the new IVUS codes involved a cooperative effort among Boston Scientific Corporation (industry: IVUS device manufacturer), SCAI (medical specialty society: advocacy, education, standards) and CMS (government agency: Medicare administrator). These organizations all recognized that appropriate coding and concomitant resource-use tracking can play a key role in ensuring appropriate beneficiary access to medical procedures. Boston Scientific’s coding and reimbursement specialists researched the issues and challenges around appropriate IVUS coding, contacted CMS to better understand its needs and internal processes, solicited opinions from administrators and reimbursement specialists across the country, and initiated the Proposal for Change. Throughout the process of conceptualizing the new codes, requesting actions on them by CMS and ensuring promulgation of the agency's decision, the three groups engaged in ongoing consultation.4 This consultation included multiple meetings and discussions regarding crucial topics, including: Coding schematics; Terminology exclusions; Coding clarity. In addition to ongoing discourse, interactions included: Letters of request to CMS from SCAI and Boston Scientific; SCAI presentation to CMS ICD-9-CM Coordination and Maintenance Committee on December 4, 2003 on intravascular ultrasound (see figures 1 and 2, and the SIPS Trial data); Follow up letters and comments; Notice to stakeholders; Implementation. What Hospitals Should Do Now: Departmental Coordination Is Key Tom Meskan, Director of Reimbursement & Outcomes Planning at Boston Scientific, noted that the collaboration of SCAI, Boston Scientific and CMS reached a successful resolution with the adoption of the new IVUS ICD-9-CM subcategory. We're encouraging cath lab administrators, coding staff and billing specialists to familiarize themselves with the new codes and take coordinated action for the accurate coding of claims for their hospitals. Given the importance of accurate coding of claims to your hospital operations, Meskan said, It is important to take immediate action on these new codes. The cath lab staff needs to coordinate efforts with coders and the billing department for clear identification of when IVUS is used in a procedure and which of the 00.21-00.29 codes are applicable. How will your hospital make this happen? Here’s what departmental coordination should look like: The cath lab administrator should review current methods for identifying IVUS use in procedures. Make sure your current system clearly reflects when IVUS is used in a procedure and links IVUS to the appropriate chargemaster revenue center. Reporting all charges associated with the procedure is the foundation for resource tracking that leads to payment weights for Diagnosis Related Groups (DRG). The coder needs to be aware of what to look for in the patient’s medical record for IVUS procedures. If the lab has a check box system with IVUS as an option, be sure to use the new codes. If the coder relies solely on physician-dictated op notes, be sure to understand how IVUS is normally reported. Coders should understand the technology as it relates to the documentation to input the correct ICD-9-CM codes. The billing department needs to report the applicable IVUS code(s) on the UB92 as indicated by the coder. Claims that accurately reflect procedure(s) with aligned resource use assist with appropriating complete procedure charges for DRG rate-setting for future reimbursement. The physician needs to work with cath lab administrators to determine a process for the new documentation and should ensure that IVUS is clearly documented. Consult Resources to Learn More For more information about the new ICD-9-CM codes, you can contact: Society for Cardiovascular Angiography and Interventions (SCAI) (Wayne Powell, 800-992-7224 or wpowell@scai.org) Boston Scientific Corporation, Reimbursement and Outcomes Planning Tom Meskan, (763) 494-2016 or Deb Lorenz, (763) 494-2112 Centers for Medicare and Medicaid Services (CMS), www.cms.hhs.gov American Health Information Management Association (AHIMA), www.ahima.org American College of Cardiology (ACC), www.acc.org A useful reference book is The Education Annotation of ICD-9-CM by Channel Publishing. Publishers who provide ICD-9-CM coding manuals and/or information include: American Medical Association (AMA), (800) 621-8335 Channel Publishing, (800) 248-2882 Ingenix, Inc., St. Anthony Publishing/Medicode, (800) 464-3649 Start Coding for Inpatient IVUS Help Medicare Do Its Job, and Help Your Hospital, Too With the new 00.2 Intravascular Vessel Imaging subcategory, Medicare has committed itself to using accurate hospital data to bring reimbursement into line with costs. Hospitals can help the process, and themselves, by utilizing the new codes as soon as possible. Accurate IVUS claims and reporting with the goal of fairer Medicare reimbursement serves your hospital’s patients and helps the hospital’s cardiovascular program to meet operating and revenue objectives.

1. Frey AW, Hodgson J McB, Miller C, Bestehorn H-P, Roskamm H. Ultrasound-guided strategy for provisional stenting with focal balloon combination catheter: Results from the Randomised Strategy for Intracoronary Ultrasound-guided PTCA and Stenting (SIPS) trial. Circulation 2000;102:2497-2502.

2. Mueller C, Hodgson J McB, Schindler C, Perruchoud AP, Roskamm H, Buettner HJ. Cost-effectiveness of intracoronary ultrasound for percutaneous coronary interventions. Am J Cardiol 2003;91:143-147.

3. Other ultrasound categories: Therapeutic Ultrasound (00.1); Intracardiac Echocardiography (37.28); Diagnostic Ultrasound (88.7).

4. For inpatient DRGs, a new Proposed Rule is typically published in May and open to comments for 60 days thereafter. The Final Rule is typically published in August, and the change, if any, takes effect on October 1. ICD-9 Codes are typically -final-versions in the Proposed Rule.