On March 18, 2005, the Centers for Medicare and Medicaid Services (CMS) will determine whether to cover carotid stenting. 1 Under the terms of a proposal that CMS issued on December 17, 2004, 2 carotid stenting would be covered for symptomatic patients with stenosis of 70% or more who are high-risk candidates for carotid endarterectomy. Only stenting systems with embolic protection devices could be used in procedures eligible for reimbursement. Reimbursement rates will vary based on the usual CMS adjustments, but the national average might be roughly $1,100 for physicians and $5,200 to $8,200 for facilities. 3

In order to obtain reimbursement, providers will have to demonstrate competence in performing the procedure, evaluating patients, and providing follow-up care. The mechanisms that would be used to determine competence for physicians and facilities have not been specified, so medical specialty societies are expected to propose guidelines and/or plans for the necessary programs.

CODING AND BILLING

Katharine L. Krol, MD, is director of vascular and interventional radiology, CorVasc MDs, PC, Indianapolis. On March 25, 2004, she presented Coding and Reimbursement for Carotid Stenting 2004 at the Society of Interventional Radiology’s 29th annual meeting in Phoenix. There are, she explained, two components of reimbursement: coding and coverage. For carotid stenting, neither element is yet clear. There are no level-I Current Procedural Terminology (CPT) codes assigned to the procedure, and the CMS policy is not to pay for the procedure unless it is part of a covered clinical trial or postapproval study.

Lack of coverage has greatly decreased the availability of carotid stenting in many areas, Krol said, especially since many clinical trials that formerly enrolled Medicare patients for covered carotid stenting have now ended.

At present, there are three options for CPT coding for carotid stenting: level-III codes, unlisted-procedure codes, or a combination of level-I codes. Level-III codes are also called T codes because they end with that letter. They have been used, over the past few years, for emerging technologies. There are three level-III codes in use for carotid stenting, but there are no relative value units (RVUs) associated with them because they have not been reviewed by the RVU Update Committee. In some areas, a local carrier has assigned a value to these codes. Some carriers reject them entirely; some consider them bundled codes, but others treat them as component codes, since what they include has not been defined. It is imperative to communicate directly with the carrier if these codes are used.

Using an unlisted-procedure code (for example, 37799 for an unlisted vascular procedure) can cause similar problems, since there are, likewise, neither RVUs assigned nor a universal definition accepted. It may be preferable to use existing level-I codes in certain combinations, but the carrier must be contacted directly to clarify these. Krol issued a warning: it is unwise to assume that using particular codes together (and being paid as a result) means that the coding was correct. Providers may later be accused of accepting payment in error.

Because carotid stenting is not yet covered for Medicare patients, providers must be certain to have patients sign Advance Beneficiary Notices for both the professional and technical components of the procedure. Unless the physician has explained to the patient that Medicare does not cover the procedure and that the patient will be required to pay out of pocket, it is illegal for either the facility or the physician to bill the patient.

PROVIDER COMPETENCE

Minimum Training Requirements for Carotid Stenting was presented by John J. “Buddy” Connors III, MD, medical director of neurointerventional radiology, Cardiac and Vascular Institute, Miami. Connors reported that while industry, medical societies, physicians, and patients share a common interest in quality of care, opinions on how carotid stenting supports that goal vary widely. Likewise, there are disagreements concerning who should provide the procedure. It seems probable, however, that CMS will make reimbursement contingent upon expertise at some measurable level.

As Connors pointed out, the seriousness of the potential complications of carotid stenting can be a rude awakening for those unused to such dramatic changes in the patient’s status. Cerebrovascular accident (CVA) is the worst complication that can occur in all of medicine, Connors said. CVA following a stenting procedure that goes badly may leave the patient paralyzed and unable to speak. Clearly, the stenting team must excel at its task because carotid stenting is a predictable cause of CVA. Some CVAs have no relationship to the skills of the stenting team, but it is imperative to eliminate the potential CVAs that could occur due to inexperience or lack of training.

Because current training standards for interventional neuroradiology are stringent, Connors noted, those with experience in this field are more likely to perform carotid stenting well. It makes sense, he said, to become competent at diagnostic angiography before attempting carotid stenting. A neurosurgeon may have performed a thousand carotid endarterectomies, but that has no bearing on readiness to begin carotid stenting. All radiologists who have attained board certification have already been trained in neurodiagnosis and neuroradiology, so they have a good start toward further training for carotid stenting.

Standards for training, competency, and credentialing were recently published by a multispecialty coalition. 4 Beginners from all specialties will have gaps in the knowledge needed for carotid stenting, and will also have to invest considerable time acquiring the necessary amount of experience to achieve respectable outcomes.

Kris Kyes is technical editor of Decisions in Axis Imaging News.

References:

  1. Centers for Medicare & Medicaid Services. Medicare coverage database. NCA tracking sheet for carotid artery stenting (CAG-0085R). Available at: www.cms.hhs.gov. Accessed February 13, 2005.
  2. Centers for Medicare & Medicaid Services. Medicare coverage database. Draft decision memo for carotid artery stenting (CAG-0085R). Available at: www.cms.hhs.gov. Accessed February 15, 2005.
  3. Carotid artery stenting. Available at: www.bostonscientific.com (PDF). Accessed February 14, 2005.
  4. Connors JJ III, Sacks D, Furlan AJ, et al. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention: a joint statement from the American Academy of Neurology, American Association of Neurological Surgeons, American Society of Interventional and Therapeutic Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, AANS/CNS Cerebrovascular Section, and Society of Interventional Radiology. Radiology. 2005; 234:26-34.