Medicare Benefits Schedule - Note TN.8.219

Complex Coronary Artery Disease

Complex coronary artery disease is defined as

1. a stenosis >50% in the left main coronary artery; or
2. >90% in the proximal left anterior coronary artery; or
3. bifurcation lesions involving side branches with a diameter >2.75mm; or
4. chronic vessel occlusions (>3 months); or
5. severely angulated or severely calcified lesions; or
6. SYNTAX score >23.

Such disease should only undergo PCI with a documented recommendation from a Heart Team Conference.

Related Items: 38314 38323

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Multiple Operation Rule

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: $2,627.60 Benefit: 75% = $1,970.70 85% = $2,528.90

(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)

Multiple Operation Rule

Note: (stable multi-vessel disease - 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.8.4 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: $2,590.90 Benefit: 75% = $1,943.20 85% = $2,492.20

(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)