HEART VALVE PROCEDURES
CODING AND REIMBURSEMENT
PHYSICIANS & HOSPITALS
2014 EDITION
NATIONAL MEDICARE
REIMBURSEMENT RATES
EQUIPPED TO PERFORM
PHYSICIAN REIMBURSEMENT – Physician rates effective January 1, 2014 through December 31, 2014
PROCEDUREB
Common Physician Procedure Codes for Heart Valve ProceduresB, C
CODING
REIMBURSEMENTA
CPT® Code
Professional or
Facility
Valvuloplasty, aortic valve; open, with cardiopulmonary bypass
33400
$2,387
Valvuloplasty, aortic valve; open with inflow occlusion
33401
$1,480
Valvuloplasty, aortic valve, using transventricular dilation, with cardiopulmonary bypass
33403
$1,551
Replacement, aortic valve, with cardiopulmonary bypass, with prosthetic valve other than homograft or stentless valve
33405
$2,375
Replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand)
33406
$3,009
Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve
33410
$2,656
Replacement, aortic valve, with aortic annulus enlargement, noncoronary sinus
33411
$3,512
Replacement, aortic valve, with transventricular aortic annulus enlargement (Konno procedure)
33412
$3,330
Replacement, aortic valve, by translocation of autologus pulmonary valve with allograft replacement of pulmonary valve
(Ross procedure)
33413
$3,372
Valvotomy, mitral valve, closed heart
33420
$1,521
Valvotomy, mitral valve, open heart, with cardiopulmonary bypass
33422
$1,762
Valvuloplasty, mitral valve with cardiopulmonary bypass
33425
$2,859
Valvuloplasty, mitral valve, with cardiopulmonary bypass, with prosthetic ring
33426
$2,493
Valvuloplasty, mitral valve, with cardiopulmonary bypass, radical reconstruction, with or without ring
33427
$2,559
Replacement, mitral valve, with cardiopulmonary bypass
33430
$2,928
Valvectomy, tricuspid valve, with cardiopulmonary bypass
33460
$2,550
Valvuloplasty, tricuspid valve, without ring insertion
33463
$3,233
Valvuloplasty, tricuspid valve, with ring insertion
33464
$2,560
Replacement, tricuspid valve, with cardiopulmonary bypass
33465
$2,885
Tricuspid valve repositioning and placation for Ebstein anomaly
33468
$2,565
Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed
33860
$3,361
Ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved conduit and coronary
reconstruction (e.g., Bentall)
33863
$3,296
Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valvesparing aortic root remodeling (e.g., David Procedure, Yacoub Procedure)
33864
$3,362
Unlisted procedure, cardiac surgery
33999
Carrier Priced
HOSPITAL (FACILITY) REIMBURSEMENT – Hospital Inpatient rates effective October 1, 2013 through September 30, 2014.
PROCEDUREB
CODING
ICD-9
Procedure Code
REIMBURSMENT
MS-DRGC
Inpatient (IPPS)
National Average RateD
Closed heart valvotomy, unspecified valve
35.00
237
$29,556
Closed heart valvotomy, aortic valve
35.01
238
$19,473
Closed heart valvotomy, mitral valve
35.02
Closed heart valvotomy, tricuspid valve
35.04
Open heart valvuloplasty without replacement, unspecified valve
35.10
216
$54,981
Open heart valvuloplasty of aortic valve without replacement
35.11
217
$36,442
Open heart valvuloplasty of mitral valve without replacement
35.12
218
$31,470
Open heart valvuloplasty of tricuspid valve without replacement
35.14
219
$45,928
Open and other replacement of unspecified heart valve
35.20
220
$30,690
Open and other replacement of aortic valve with tissue graft
35.21
221
$26,924
228
$39,833
229
$25,758
230
$21,267
Open and other replacement of aortic valve
35.22
Open or other replacement of mitral valve with tissue graft
35.23
Open and other replacement of mitral valve
35.24
Open and other replacement of tricuspid valve with tissue graft
35.27
Open and other replacement of tricuspid valve
35.28
Other operations on valves of heart
35.99
Conversion factor used for this overview is $35.8228, as published in Federal Register Volume 78, Number 237, December 10, 2013.
Abbreviated CPT® code descriptions. See CPT® codebook for complete descriptions.
MS-DRG assignment is determined by the patient ICD-9 diagnoses and procedure code(s). Listed are examples of possible MS-DRGs.
D
Rates per CMS 1599-F.
A
B
C
DEFINITIONS
CC: Complications and Comorbidities. Patient conditions utilized as two of several
factors in MS-DRG groupers.
CMS: Centers for Medicare and Medicad Services. The federal agency that runs the
Medicare program. CMS also works with the states to run the Medicad program.
CPT® Code: Current Procedural Terminology Code. These 5-digit numeric codes are
the property of the American Medical Association and are used to describe physician
services. Additionally, Medicare licenses these codes from the AMA and uses them to
describe physician, hospital outpatient, ASC services, and other outpatient services.
DRG: Diagnosis-Related Group. A numeric classification system used by Medicare
and some commercial payers to reimburse for hospital inpatient services. The DRG
is assigned by software that considers the ICD-9 procedure and diagnosis codes
submitted on a claim.
Facility/Non-Facility: For some physician procedures, the reimbursement is
determined by a site of service. If the fee is designated as Facility, the procedure
is performed in a site of service other than a physician office. If the fee is designated
as “Non-Facility,” the procedure is performed in a physician office.
HCPCS: Healthcare Common Procedure Coding System. The name of a coding
system established by Medicare to describe services and supplies. The base
(Level I) codes are CPT® codes.
ICD-9: International Classification of Diseases. Numeric codes used by essentially
all payers to describe diagnoses and procedures. The combination of procedure and
diagnosis codes determines DRG assignment for inpatient reimbursement.
Inpatient: The status used to describe a patient who has been admitted to the
hospital. Usually involves multi-day stay.
IPPS: Inpatient Prospective Payment System. Medicare (CMS) per case (see “DRG”
and “MS-DRG”) methodology for hospital inpatient services.
MCC: Major Complications and Comorbidities. Patient conditions utilized as
two of several factors in MS-DRG groupers. MCC are typically significant acute
manifestations or advanced stages of chronic conditions that would result in
higher resource utilization in the course of treatment.
MS-DRG: Medicare Severity Diagnosis-Related Group. A numeric classifications
system effective October 1, 2007 used by Medicare to reimburse for hospital
inpatient services. The MS-DRG is assigned by the combination of ICD-9
procedure codes, diagnosis codes and the presence or absence of MCC / CCs
as derived from the medical record documentation. The MS-DRG system was
designed to more accurately pay hospitals based on patient severity of illness.
Modifier: A 2-digit alphanumeric code that is appended to a CPT® code for
further specificity.
Prospective: A predetermined reimbursement rate, regardless of the cost of
that service.
Unadjusted Rate: The prospective reimbursement rate before it is adjusted for
local factors such as the wage index, graduate medical education, outlier cases,
disproportionate share and other factors. This is sometimes called the “national
average” rate. All Medicare reimbursement will have local adjustment factors.
RESOURCES
Product listed may not be available in all markets.
CPT® is a trademark of American Medical Association.
1. American Medical Association, American College of Cardiology Foundation.
CPT® Reference Guide For Cardiovascular Coding. Chicago, IL. American
Medical Association Press; 2012
2. American Medical Association CPT® 2013 Professional Edition. Chicago, IL:
American Medical Association; 2012
Medicare Disclaimer: The payment amounts listed in this guide are national
averages. Actual payment will vary based on several factors including but
not limited to the site of service, geographic location, Medicare and Medicaid
population, and hospital teaching status. References to particular applications and
procedures listed in this overview do not represent the appropriateness or market
availability of any Sorin medical product. The information contained in this overview
is provided for general information purposes only and should NOT be relied on for
claims submission purposes. Consult your professional resources and the patient’s
insurer for situation-specific information.
Providers should follow coding guidelines from the patient’s insurer and should
also review the complete coding authorities (e.g., CPT®,HCPCS,ICD-9-CM) used
by the payer.
The identification of a code in this brochure does not guarantee coverage for
a particular product, procedure, or payment.
Providers are responsible for selecting and reporting the code(s) that most
accurately describe the procedure(s) performed, the products used and the
complete documentation in the medical record, precisely describing the
procedures performed and products used.
3. ICD-9 Provider & Diagnostic Codes Overview. ICD-9-CM. Centers for Medicare
and Medicaid Services Web site.
http://www.cms.gov/ICD9ProviderDiagnosticCodes/ Updated March 8, 2012.
Accessed June 30, 2014.
For additional product information, visit www.sorin.com
Sorin Group USA, Inc.
14401 W. 65th Way, Arvada, CO 80004
800.221.7943 • 303.467.6525 fax
www.sorin.com
© 2014 Sorin Group all rights reserved. Refer to the information for use provided with each product for detailed information, warnings, precautions and possible adverse side effects.
IM-00265/B 092014
Suggested Resources: Coding and reimbursement is complex, specific to case
documentation and variable by geographic location. Always consult current
physician, hospital and
ASC resources.