Medicare Benefits Schedule - Note TN.8.225

Staging of acute/unstable PCI

• Staging of acute PCI is permissible when clinically appropriate.
• An example of appropriate Acute Coronary Syndrome (ACS) staging could include intervention on an occluded proximal lesion in the context of an ST elevation myocardial infarction (STEMI) and a decision is made not to intervene on a distal lesion as it is difficult to determine whether it is a real lesion (possibly a thrombus) or the patient’s haemodynamic status remains compromised (clinically unsafe to continue).

Requirements of subsequent stages of a staged acute/unstable PCI

• The qualifying indication for the initial procedure is to be used as the qualifier for the relevant subsequent stages.
• Subsequent stages are required to be completed within 3 months of the initial procedure otherwise the patient will need to requalify under the appropriate indication (if applicable).
• It would generally be expected that subsequent stages would be completed as soon as is practicable proceeding the initial intervention.
• For subsequent stages of an acute/unstable PCI it is implied that diagnostic angiography has been completed in the previous 3 months and therefore it is only permissible to claim items 38316, 38317 or 38319 for subsequent stages.

Multiple Providers of one episode of care (acute/unstable or stable) PCI – Separate interventional sites or Same interventional site

One of  the primary intentions of the changes to selective coronary angiography and PCI items, is to encourage the provision of the entire intervention in a single episode of care. Therefore, the provider should consider that there will be a reasonable need to intervene (revascularise), noting that in some cases intervention is not required (e.g. pressure testing – FFR result does not support the need for stenting).

However, it is recognised that some providers of interventional cardiology services only provide selective coronary angiography (diagnostic) and require a secondary provider to undertake angioplasty, stenting and/or atherectomy.
 

Non-interventional – selective angiography providers (clinical assessment suggests intervention required)

Acute/Unstable patients

• Acute/Unstable patients should undergo both selective coronary angiography and PCI by an accredited PCI provider in a single episode of care, unless staging is clinically required.
• Rare exceptions might include rural or remote sites that offer diagnostic angiography as a triage service prior to limited availability PCI.
• It would be expected that the non-interventional cardiologist (non-PCI accredited) has a limited role in the management of acute/unstable patients.

Separate hospital/procedural sites (Acute/Unstable or Stable)

• The first provider undertakes the diagnostic angiography and either makes an independent decision or following discussion with the interventional cardiologist  refers to the secondary provider at another site  for the purposes of revascularisation (e.g. referral from a rural or regional hospital to a metropolitan hospital); therefore 
• In this scenario there is a clear delineation between the angiography and revascularisation services due to the different geographical locations (separate episodes of care). Example claiming is as follows:

Acute (ACS) - claiming example

• Provider 1 – site 1 (diagnostic angiography) claims item 38244 (ACS – selective angiography). Provider 2 – site 2 (PCI) claims item 38316 (ACS – PCI single territory)

Abandoned T8 Surgical Procedures and Acute or Stable Percutaneous Coronary Intervention (PCI) – Excluding appropriate staging

The new acute PCI items have time restrictions applied whether claimed by the same or different providers. It is important for the patient that if a provider cannot complete (abandoned) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

The new stable PCI items do not have time restrictions. However, it is important for the patient that if a provider cannot complete (abandoned) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

Related Items: 38307 38308 38310 38316 38317 38319

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Multiple Operation Rule

Note: (acute coronary syndrome - 1 coronary territory with selective coronary angiography)  the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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;

(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, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,951.25 Benefit: 75% = $1,463.45 85% = $1,852.55

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 2 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies

(Anaes.) (Assist.)

Fee: $2,244.95 Benefit: 75% = $1,683.75 85% = $2,146.25

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 3 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,538.75 Benefit: 75% = $1,904.10 85% = $2,440.05

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 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.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,744.35 Benefit: 75% = $1,308.30 85% = $1,645.65

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 2 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 3808, 38310, 38311, 38313, 38314, 38316, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,209.60 Benefit: 75% = $1,657.20 85% = $2,110.90

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 3 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,503.30 Benefit: 75% = $1,877.50 85% = $2,404.60

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)