In August 2014, the Centers for Medicare & Medicaid Services issued a National Coverage Determination (NCD) for transcatheter mitral valve repair (TMVR).

This decision memo stated CMS would cover TMVR for mitral regurgitation (MR) under Coverage with Evidence Development (CED) for the treatment of MR when furnished for an FDA-approved indication with an FDA-approved device as follows:

  • Treatment of significant, symptomatic, degenerative MR when furnished according to an FDA-approved indication, and all CMS coverage criteria are met; and
  • TMVR for MR uses not expressly listed as FDA-approved indications but only within the context of an FDA-approved, randomized clinical trial that meets all CMS coverage criteria.

CED requires that each patient be entered into a qualified national registry. In addition, prior to receiving TMVR, face-to-face examinations of the patient are required by a cardiac surgeon and a cardiologist experienced in mitral valve surgery to evaluate the patient’s suitability for TMVR and determination of prohibitive risk, with documentation of their rationale.

Coding and billing for TMVR can be tricky, in part because several of the codes used for TMVR for MR claims were replaced by new codes effective January 1, 2015. If you are struggling to understand how to properly code and bill for TMVR, here are a few resources worth reviewing:

1. MLN Matters article number MM9002 (pdf)

2.Coding, Coverage & Reimbursement for TMVR” Q&A published by the Society for Cardiovascular Angiography and Interventions Foundation (SCAI)

3. “Society Gets to the Bottom of Unfounded Claim Denials of TMVR” column on SCAI website

Coding and billing for cardiology services is very difficult, and just a few small errors can lead to denied claims and significant loss of revenue. To ensure proper compensation is received for services provided, more practices are outsourcing their cardiology billing to PGM Billing, a leader physician billing services provider. Contact PGM today to learn how its team of certified coders and billers can help your organization.