Heart Valve Procedures
» 2013 Coding and Payment Reference Guide
St. Jude Medical – Cardiovascular Division
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IMPORTANT: St. Jude Medical provides this reference for information purposes only. This reference guide
does not serve as reimbursement or legal advice, nor is it intended to increase payment from any payer.
Nothing in this reference guide guarantees that the levels of reimbursement, payment or charges are accurate
or that reimbursement will be received. The health care professional (HCP) is responsible for obtaining
reimbursement and for verifying the accuracy and veracity of all claims submitted to third-party payers.
Laws, regulations and coverage policies are complex and updated frequently, and therefore HCPs should
consult their payers directly regarding coverage policies.
Please find the coding and payment information for heart valve procedures, below. In addition, St. Jude
Medical offers a reimbursement hotline, which provides live coding and billing information from dedicated
reimbursement specialists. Hotline support is available from 8:00 a.m. to 5:00 p.m. Central Time,
Monday through Friday at (855) 569-6430. Hotline reimbursement assistance is provided subject to the
disclaimers set forth above.
Common PHYSICIAN Procedure Codes for Heart Valve Procedures
Effective January 1 – December 31, 2013
CPT Code1
Description
Medicare Average
National Payment
Rate2
33405
Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other
than homograft or stentless valve
$2,314
33411
Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus
$3,435
33412
Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno
procedure)
$3,260
33413
Replacement, aortic valve; by translocation of autologous pulmonary valve with
allograft replacement of pulmonary valve (Ross procedure)
$3,304
33420
Valvotomy, mitral valve; closed heart
$1,465
33422
Valvotomy, mitral valve; open heart, with cardiopulmonary bypass
$1,728
33425
Valvuloplasty, mitral valve, with cardiopulmonary bypass
$2,802
33426
Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring
$2,443
33427
Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with
or without ring
$2,503
33430
Replacement, mitral valve, with cardiopulmonary bypass
$2,855
33460
Valvectomy, tricuspid valve, with cardiopulmonary bypass
$2,486
33464
Valvuloplasty, tricuspid valve; with ring insertion
$2,506
33465
Replacement, tricuspid valve, with cardiopulmonary bypass
$2,825
33468
Tricuspid valve repositioning and plication for Ebstein anomaly
$2,513
33999
Unlisted procedure, cardiac surgery
Carrier Priced
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Common HOSPITAL INPATIENT Procedure Codes for Heart Valve Procedures
Effective October 1, 2012 – September 30, 2013
ICD-9-CM
Procedure
Code3
35.00
Closed heart valvotomy, unspecified valve
35.01
Closed heart valvotomy, aortic valve
35.02
Closed heart valvotomy, mitral valve
35.04
Closed heart valvotomy, tricuspid valve
35.10
Open heart valvuloplasty without replacement,
unspecified valve
35.11
Open heart valvuloplasty of aortic valve without
replacement
35.12
Open heart valvuloplasty of mitral valve without
replacement
35.14
237 – Major cardiovascular procedures
with MCC or thoracic aortic aneurysm
repair
238 - Major cardiovascular procedures
without MCC
$29,547
$18,398
216 – Cardiac valve and other major
cardiothoracic procedures with cardiac
catheterization with MCC
$54,965
217 – Cardiac valve and other major
Open heart valvuloplasty of tricuspid valve without cardiothoracic procedures with cardiac
replacement
catheterization with CC
$36,664
35.20
Open and other replacement of unspecified heart
valve
35.21
Open and other replacement of aortic valve with
tissue graft
35.22
Open and other replacement of aortic valve
35.23
Open and other replacement of mitral valve with
tissue graft
35.24
Open and other replacement of mitral valve
35.27
Open and other replacement of tricuspid valve
with tissue graft
35.28
Open and other replacement of tricuspid valve
35.99
Common Medicare MS-DRG
Assignment
Description
Medicare
National
Average MSDRG Payment4
Other operations on valves of heart
218 Cardiac valve and other major
cardiothoracic procedures with cardiac
catheterization without CC/MCC
219 – Cardiac valve and other major
cardiothoracic procedures without
cardiac catheterization with MCC
220 – Cardiac valve and other major
cardiothoracic procedures without
cardiac catheterization with CC
221 – Cardiac valve and other major
cardiothoracic procedures without
cardiac catheterization without CC/MCC
$30,851
$45,264
$30,279
$25,541
228 – Other cardiothoracic procedures
with MCC
$40,890
229 – Other cardiothoracic procedures
with CC
$26,723
230 – Other cardiothoracic procedures
without CC/MCC
$22,006
MCC – major complications and comorbidities; CC – complications and comorbidities
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REVENUE CODES AND HCPCS CODES
Revenue codes help hospitals categorize services provided by revenue center. Medicare utilizes revenue codes for cost reporting
purposes. For Medicare, revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. It may be
appropriate for hospitals to capture the cost of products used for the procedures described above within Revenue Code 0278
(Medical/Surgical Supply – Other Implant) or Revenue Code 0360 (Operating Room Services - General). Health Care Common
Procedural Coding System (HCPCS) codes include level I codes (CPT, described above) and level II codes (other products,
supplies, and services not included in CPT). Level II HCPCS codes, including C codes, are not applicable to Valve products utilized
in the procedures described above. C codes are used in conjunction with the Medicare prospective payment system for outpatient
procedures only.
Common CPT Code Modifiers1
22
Increased Procedural Services: When the work required to provide a service is substantially greater
than typically required, it may be identified by adding modifier 22 to the usual procedure code.
Documentation must support the substantial additional work and the reason for the additional work
(i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).
51
Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and
rehabilitation services, or provision of supplies (e.g., vaccines), are performed at the same session
by the same provider, the primary procedure or service may be reported as listed. The additional
procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure
or service code(s). Note: This modifier should not be appended to designated add-on codes.
52
Reduced Services: Under certain circumstances a service or procedure is partially reduced or
eliminated at the physician’s discretion. Under these circumstances the service provided can
be identified by its usual procedure number and the addition of modifier 52, signifying that the
service is reduced.
53
Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a
surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was
started but discontinued. This circumstance may be reported by adding modifier 53 to the code
reported by the physician for the discontinued procedure.
59
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a
procedure or service was distinct or independent from other non-E/M services performed on the
same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not
normally reported together, but are appropriate under the circumstances. Documentation must
support a different session, different procedure or surgery, different site or organ system, separate
incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not
ordinarily encountered or performed on the same day by the same individual. However, when
another already established modifier is appropriate it should be used rather than modifier 59. Only
if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances,
should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report
a separate and distinct E/M service with a non-E/M service performed on the same date, see
modifier 25.
62
Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s)
of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62
to the procedure code and any associated add-on code(s) for that procedure as long as both
surgeons continue to work together as primary surgeons. Each surgeon should report the cosurgery
once using the same procedure code. If additional procedure(s) (including add-on procedure(s)
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are performed during the same surgical session, separate code(s) may also be reported with modifier
62 added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s)
during the same surgical session, those services may be reported using separate procedure code(s)
with modifier 80 or modifier 82 added, as appropriate.
76
Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may
be necessary to indicate that a procedure or service was repeated by the same physician or other
qualified health care professional subsequent to the original procedure or service.
77
Repeat Procedure by Another Physician or Other Qualified Health Care Professional: It may be
necessary to indicate that a basic procedure or service was repeated by another physician or
qualified health care professional subsequent to the original procedure or service.
78
Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified
Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative
Period: It may be necessary to indicate that another procedure was performed during the postoperative
period of the initial procedure (unplanned procedure following initial procedure).
79
Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The
physician may need to indicate that the performance of a procedure or service during the postoperative
period was unrelated to the original procedure.
80
Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the usual
procedure number(s).
81
Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier
81 to the usual procedure number.
82
Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified
resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure
code number(s).
99
Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to
completely delineate a service. In such situations modifier 99 should be added to the basic procedure,
and other applicable modifiers may be listed as part of the description of the service.
References:
1. Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
2. Per CMS-1590-FC determined by multiplying the physician fee schedule conversion factor ($34.0230)
by the total adjusted facility relative value units (RVUs). Payment amount represents national average
with no geographic adjustment. Individual physician reimbursement will vary.
3. ICD-9-CM Code Book - v30 FY2013 (Effective October 1, 2012).
4. Per CMS-1588-F – Assumes payment for a large urban hospital with wage index > 1 and full update.
Medicare payment = MS-DRG relative weight x (labor standardized amount + non-labor standardized
amount + capital rate).
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