Physician Coding and Payment

0256T: Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach
0257T: Implantation of catheter-delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular)
0258T: Transthoracic cardiac exposure (i.e., sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; without cardiopulmonary bypass
0259T: Transthoracic cardiac exposure (i.e., sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; with cardiopulmonary bypass

Current Procedural Terminology (CPT) codes 0256T – 0259T are Category III codes.  Category III codes are temporary codes for emerging technology, services, and procedures.  These codes are used for tracking purposes. The use of Category III codes allows physicians, insurers, and others to identify emerging technology, services, and procedures for clinical efficacy, utilization and outcomes.  According to CPT rules if a Category III code is available for a procedure, this is the code that must be reported instead of the Category I unlisted code (33999 - unlisted procedure, cardiac surgery). 

Codes 0256T and 0257T include all other catheterization(s), temporary pacing, intraprocedual contrast injections(s), fluoroscopic radiological supervision and interpretation, and imaging guidance.  Please refer to the American Medical Association (AMA) CPT book and the 2012 ACC/AMA CPT Reference Guide for Cardiovascular Coding to review all CPT coding instructions pertaining to these codes.

Category III codes are paid by some payers.  It is best to check with your insurer or local Medicare Administrative Contractor to determine if there is payment associated with the physician work for the TAVR procedure.   With the recent Food and Drug Administration approval, there could be future changes to these codes and ACC will report all changes to members immediately.  Code changes are made on an annual basis so these codes will not change during 2012. 

Hospital Coding and Payment

Hospitals should report one of the following two ICD-9 procedure codes: 
35.05: Endovascular replacement of aortic valve
35.06: Transapical replacement of aortic valve

A balloon valvuloplasty should not be separately reported since it is integral to the procedure. 

Hospitals are paid under the diagnosis-related group (DRG) system which groups procedures with similar patients and resource costs and then pays the average costs for individual cases.  The Centers for Medicare and Medicaid Services (CMS) has placed TAVR cases into the same DRG as open valve replacement procedures.  The payable DRG is dependent on the presence of complicating conditions and whether an additional cardiac catheterization (not part of the TAVR procedure) was reported.  The average payment for patients under the open valve replacement DRG was $38,000 in 2010.  However, hospital payment varies substantially based on location, case mix, and the amount of medical education provided at the facility.  In addition, payment fluctuates on an annual basis due to changes in resources that are reported as part of the procedure.    

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