Medicare Benefits Schedule - Note TN.8.218

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.218

Percutaneous Coronary Intervention (PCI) for stable patients

Stable Angina or Angina Equivalent

  • Stable angina or angina equivalent includes chest pain, chest discomfort and/or shortness of breath due to myocardial ischaemia.
  • Limiting angina includes patients with symptoms that are Canadian Cardiovascular Society (CCS) class II, III or IV.

Staging

  • If a staged procedure is appropriately performed over multiple days, items 38320, 38322 or 38323 should be used for subsequent stages.
  • For subsequent stages of a stable percutaneous coronary intervention completed up to 3 months after the initial procedure, it is expected that the patient would receive the subsequent stage/s of the intervention based on the qualifying indication for the initial procedure

Coronary Vascular Territories

  • The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are treated during the procedure, not the total number of treated territories the patient has received to date.
  • The number of coronary vascular  territory refers to any of the 3 major arteries (Left Anterior Descending, Circumflex or Right Coronary Artery) or their branches. The item number claimed should reflect the number of coronary vascular territories that are treated during the procedure, not the total number of diseased territories.
  • For isolated Left Main (no involvement of the bifurcation), a single territory should be claimed but if the treated segment involves the bifurcation then 2 territories should be claimed.
  • The intermediate artery when treated in isolation is considered a single territory, however when treated with the Left Anterior Descending or Circumflex or both, it can be claimed as two territories.
  • A single lesion in a bypass graft should be claimed as a single territory regardless of how many vascular territories are supplied by that graft. If the graft has multiple lesions and those lesions are in separate skip portions to a different territory, then an additional territory may be claimed.

Related Items: 38311 38313 38314 38320 38322 38323


Related Items

Category 3 - THERAPEUTIC PROCEDURES

38311

38311 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 1 coronary territory with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible under clause 5.10.17C for the service and a service to which item 38314 applies; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on one coronary vascular territory; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,874.10 Benefit: 75% = $1,405.60 85% = $1,786.20

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38313

38313 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 2 coronary territories with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible under clause 5.10.17C for the service and a service to which item 38314 applies; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 2 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,156.20 Benefit: 75% = $1,617.15 85% = $2,068.30

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38314

38314 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 3 coronary territory with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17C; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 3 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38316, 38317, 38319, 38320, 38322 or 38323 applies

(Anaes.) (Assist.)

Fee: $2,438.30 Benefit: 75% = $1,828.75 85% = $2,350.40

(See para TN.8.218, TN.8.219, TN.8.226, TR.8.4, TR.8.5, TR.8.7 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38320

38320 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 1 coronary territory without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible under clause 5.10.17C for the service and a service to which item 38323 applies; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on one coronary vascular territory; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,675.35 Benefit: 75% = $1,256.55 85% = $1,587.45

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38322

38322 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 2 coronary territories with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible under clause 5.10.17C for the service and a service to which item 38323 applies; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 2 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,122.20 Benefit: 75% = $1,591.65 85% = $2,034.30

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38323

38323 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 3 coronary territories with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17C; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 3 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320 or 38322 applies 

(Anaes.) (Assist.)

Fee: $2,404.30 Benefit: 75% = $1,803.25 85% = $2,316.40

(See para TN.8.218, TN.8.219, TN.8.226, TR.8.4, TR.8.5, TR.8.7 of explanatory notes to this Category)


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change