The Sage Group

Peripheral Artery Disease Coding and Reimbursement 2012

Coding and reimbursement are highly specialized and extremely complex topics. This report provides an overview of coding and reimbursement for procedures performed to diagnose and treat lower limb arterial occlusive disease, which we term peripheral artery disease (PAD). PAD is also known as peripheral vascular disease (PVD) or peripheral arterial occlusive disease (PAOD).

In addition to providing an understanding of the general concepts and principles involved, the discussion and analysis demonstrates the relationship between ICD-9 codes, CPT Codes and the inpatient and outpatient reimbursement systems.

The report is designed to assist new entrants into the PAD diagnostic and device markets to understand reimbursement and coding. The analysis is also useful to executives of companies already positioned in other cardiovascular market segments contemplating entry into these PAD markets.

ICD-9 diagnostic and procedure codes are required for reimbursement. All diagnostic and procedure codes that are commonly employed to designate peripheral arterial disease are identified. Case examples, demonstrating the use of ICD-9 diagnostic and procedure codes for treatment of PAD are included.

CPT codes are also required by Medicare as well as private payers for reimbursement. In fiscal 2011, CPT codes relating to PAD procedures were extensively revised. The new PAD CPT codes are identified and discussed in detail.

Beginning October 1, 2013, Medicare will require providers to switch to the ICD-10 diagnosis and procedure code system for reimbursement. The report provides an overview of the new system. Specific ICD-10 codes relevant to PAD are identified and compared with the old ICD-9 codes.

Medicare employs two different reimbursement systems for hospital inpatient and outpatient procedures. Inpatient hospital service reimbursement is based on diagnosis related groups (DRGs) based on severity of illness (MS-DRGs) while outpatient services are reimbursed based on Ambulatory Payment Classification (APC) groups.

The current MS-DRGs for reimbursement of diagnostic, endovascular and surgical PAD procedures are described in detail together with the qualifying conditions known as Major Complications and Comorbidities (MCC) and Complications and Comorbidities (CC). Examples of procedures and related codes are included.

Outpatient reimbursement APC codes employed to diagnose and treat PAD are identified, discussed, analyzed and compared with inpatient codes.

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