Medicare Benefits Schedule - Item 38322

Note: (stable multi-vessel disease - 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.8.4 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 

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $2,286.95 Benefit: 75% = $1,715.25 85% = $2,184.55

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

• Previous - Item 38320
• Next - Item 38323

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

Staging of non-acute (stable) PCI

• Staging of stable PCI is permissible when clinically appropriate. An example of appropriate stable staging could include intervention on the primary target lesion and a decision is made not to intervene on secondary lesions (in triple vessel disease) due to the patient’s deteriorating haemodynamic status (clinically unsafe to continue).

Requirements of subsequent stages of a staged stable PCI

• The qualifying indication for the initial procedure is to be used as the qualifier for the relevant subsequent stages. Subsequent stages are expected to be completed within a reasonable time period following the initial intervention.
• For subsequent stages of a stable PCI it is implied that diagnostic angiography has been completed in the previous 3 months and therefore it is only permissible to claim items 38320, 38322 or 38323 (standalone PCI items) for subsequent stages.
• Note: For patients who meet the criteria in subclause (2)(b) of note TR.8.4 in 3 vascular territories (triple vessel disease), whether treated in an initial procedure (items 38314 or 38323) or in subsequent stages (items 38311, 38313, 38320 or 38322) it is expected that the patient must meet the criteria for (2)(b) of note TR.8.4 for each territory for each subsequent stage. This requirement ensures that the patient who has triple vessel disease must meet the criteria for (2)(b) for each territory when staged or completed in an initial procedure.

The Department will be closely monitoring claiming patterns for staged procedures, particularly where volumes for staged procedures at the same site are not consistent with the broader provider claiming base.

Multiple Providers of one episode of care (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).

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)

Stable patients

It is accepted clinical practice that the following patient pathways for stable PCI service provision (other than a complete service by an accredited PCI cardiologist) may occur when considering the role of the non-interventional cardiologist (non-PCI accredited) as follows:

Ad-hoc PCI:

• Provider 1 completes the selective angiography and hands over to provider 2 to perform the PCI while the patient is still on the cardiac catheterisation table with the arterial access still in place.
• Similar to the acute items, this scenario would likely be rare for e.g. dissection of a coronary artery caused by the angiography catheter that may convert the patient from stable to unstable.
• It is current accepted practice that the selective coronary angiography component of the service can be performed by a non-interventional cardiologist and the PCI component (when required) completed by a PCI accredited provider.
• Ideally ad-hoc stable PCI should be completed by a PCI accredited provider and therefore consideration should be given to current practice site arrangements going forward.

Delayed PCI:

• Provider 1 completes ICA and refers the patient to provider 2, who performs the  PCI later on the same day.
• In the stable patient this scenario presents the opportunity to pause and consider  whether optimal medical therapy, PCI or coronary artery bypass may be the preferred option in consultation with a PCI accredited cardiologist and/or cardiothoracic surgeon; and
• It also allows for a further opportunity to obtain informed consent from the patient for the proposed intervention.
• In most cases this would involve maintaining the arterial access with an indwelling arterial sheath to avoid repuncture.

Elective PCI:

• Provider 1 completes ICA and refers the patient to provider 2, who performs the PCI on the next day, or any subsequent day.
• Similar to delayed PCI, however the PCI accredited cardiologist may not be available on the same day as when the selective coronary angiography was completed; or
• A  short trial of optimal medical therapy is recommended; or
• Further non-invasive functional testing is recommended.

The Department will be closely monitoring claiming patterns, particularly at the same site where selective angiography is completed by a non-accredited cardiologist and the PCI component completed by a PCI accredited provider.

The following  provides guidance for when the  provider can only undertake the selective angiography component of a complete PCI service (PCI non-accredited provider):

Separate hospital/procedural sites (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). 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:

• Stable - example
  Provider 1 – site 1 (diagnostic angiography) claims item 38248 stable – selective angiography). Provider 2 – site 2 (PCI) claims item 38320 (stable – PCI single territory)

Same hospital/procedural site (Stable)

• The first provider undertakes the diagnostic angiography and either makes an independent decision or following discussion with the interventional cardiologist requesting that the secondary provider undertakes the revascularisation component.
• Please note that the underlying intention of a complete PCI service is that the entire service, including diagnostic angiography is completed by a single provider where possible.

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: 38311 38313 38314 38320 38322 38323

Clause 5.10.17C Items 38311, 38313, 38314, 38320, 38322 and 38323—patient eligibility

(1) A patient is eligible for a service to which item 38311, 38313, 38314, 38320, 38322 or 38323 applies if:

(a) subclause (2) applies to the patient; or

(b) the patient is recommended for the service as a result of a heart team conference that meets the requirements of subclause (4).

(2) This subclause applies to a patient if:

(a) the patient has any of the following:

(i) limiting angina or angina equivalent despite an adequate trial of optimal medical therapy;

(ii) myocardial ischaemia demonstrated on functional imaging;

(iii) high risk features such as ST segment elevation, sustained ST depression, hypotension or a Duke treadmill score of minus 11 or less, demonstrated by stress electrocardiogram testing; and

(b) the patient has either of the following in a vascular territory treated:

(i) a stenosis of 70% or more;

(ii) a fractional flow reserve of 0.80 or less, or non-hyperaemic pressure ratios distal to the lesions of 0.89 or less; and

(c) for items 38314 and 38323—either:

(i) the patient does not have diabetes mellitus and the multi-vessel coronary artery disease of the patient meets the criterion in subclause (3); or

(ii) despite a recommendation that surgery is preferable, the patient has expressed a preference for catheter-based intervention.

(3) For the purposes of subparagraph (2)(c)(i), the criterion for the multi-vessel coronary artery disease is that the disease does not involve any of the following:

(a) stenosis of more than 50% in the left main coronary artery;

(b) bifurcation lesions involving side branches with a diameter of more than 2.75 mm; 

(c) chronic vessel occlusions for more than 3 months;

(d) severely angulated or calcified lesions;

(e) a SYNTAX score of more than 23.

(4) For the purposes of paragraph (1)(b), the requirements for a heart team conference are as follows:

(a) the conference must be conducted by a team of specialists or consultant physicians practising in the speciality of cardiology or cardiothoracic surgery, including each of the following:

(i) an interventional cardiologist;

(ii) a specialist or consultant physician;

(iii) for items 38314 and 38323—a cardiothoracic surgeon;

(iv) for items 38311, 38313, 38320 and 38322—a cardiothoracic surgeon or a non-interventional cardiologist; and

(b) the team must:

(i) assess the patient’s risk and technical suitability to receive the service; and

(ii) make a recommendation about whether or not the patient is suitable for percutaneous coronary intervention; and

(c) a record of the conference must be created, and must include the following:

(i) the particulars of the assessment of the patient during the conference;

(ii) the recommendations made as a result of the conference;

(iii) the names of the members of the team making the recommendations.

Related Items: 38311 38313 38314 38320 38322 38323

Clause 5.10.17D Restriction on items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319—reports and clinical notes

Items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319 apply to a service provided to a patient only if a report or clinical note:

(a) is prepared for the service; and

(b) includes documentation that demonstrates how the item applies to the service, including how the patient is eligible for the service.

Related Items: 38244 38247 38248 38249 38251 38252 38307 38308 38310 38311 38313 38314 38316 38317 38319 38320 38322 38323

Definition of a heart team conference: relevant to items 38248, 38249, 38311, 38313, 38320, 38322 and 57364

 (a)   A heart team conference is a team of 3 or more participants who are cardiac specialists; where:

1. the first participant is a specialist or consultant physician who is an interventional cardiologist; and
2. the second participant is a specialist or consultant who is a non-interventional cardiologist; and
3. the third participant is a specialist or consultant physician; and

(b)    the team assesses a patient’s risk and technical suitability to receive the service; and

(c)    the result of the heart team conference’s assessment is that the team makes a recommendation about whether or not the patient is suitable for selective coronary angiography (for items 38248, 38249, 38320) or percutaneous coronary intervention (for items 38311, 38313, 38320, 38322) ; and

(d)    the particulars of the assessment and recommendation/s, and the names of those providers making the recommendation/s are recorded in writing.

Note: For non-complex stable triple vessel disease, providers are encouraged to include a cardiothoracic surgeon in the heart team.

Related Items: 38248 38249 38311 38313 38320 38322 57364