From 3M Health Information Systems
Questions about coding for transcatheter aortic valve replacement?
I recently received some questions from an Inside Angle reader about my blog post on ICD-10 coding for aortic valve disease. The reader asked about transcatheter aortic valve replacement (TAVR) valves: “There is a newer TAVR valve that is going through expedited review with the FDA that can treat Aortic regurgitation and mixed aortic stenosis,” the reader asked. “I was wondering if these ICD-10 codes would apply to this as the diagnosis. Also, what TAVR DRG code would they use? Or would this potentially require a new code?”
First, thanks for the great questions! Below are some tips to help you address TAVR coding. As always, readers should refer to the AHA Coding Clinic for official coding advice and guidelines.
Regarding the correct diagnosis code, look to the documentation in the surgical note. For your example of aortic regurgitation (insufficiency) and aortic stenosis, I would recommend ICD-10 code I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency provided there is no documentation of rheumatic valve disease. You may see the abbreviation of MAVD in your note. This is defined as Mixed Aortic Valve Disease, regurgitation and stenosis combined. Regardless of FDA approval of a new valve, the ICD-10 diagnosis codes would be applied as they always have been.
As to your question about TAVR, we are given direction for procedure coding in the CPT manual. You may also see the abbreviation TAVI which stands for transcatheter aortic valve implantation. Prior to 2005, repair or replacement of any heart valve was done via open chest and cardiopulmonary bypass. The open procedure is still done today. But for patients who are at intermediate or high risk of complications from an open procedure, they may have their valve repaired or replaced via percutaneous methods. This procedure is done for aortic valve stenosis, when the valve thickens and calcifies which prevents the leaflets from opening fully, limiting blood flow from the heart to the rest of the body. Newer studies have been done on patients with MAVD with promising outcomes. TAVR is seldom used for patients with pure aortic insufficiency due to difficulty in anchoring the prosthetic valve properly.
There is a CPT instruction section in advance of the TAVR CPT codes, 33361-33366, that describes how to use these codes. This procedure requires two surgeons and both surgeons will report the same CPT code with the -62 modifier. From the CPT manual:
Codes 33361, 33362, 33363, 33364, 33365, 33366 include the work, when performed, of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system into position, repositioning the valve as needed, deploying the valve, temporary pacemaker insertion for rapid pacing (33210), and closure of the arteriotomy when performed. Codes 33361, 33362, 33363, 33364, 33365, 33366 include open arterial or cardiac approach.
Angiography, radiological supervision, and interpretation performed to guide TAVR/TAVI (eg, guiding valve placement, documenting completion of the intervention, assessing the vascular access site for closure) are included in these codes.
The difference in the CPT codes is based on access (percutaneous femoral artery, open femoral artery, open axillary artery, open iliac artery, transaortic approach or transapical exposure). Add-on codes 33367-33369 are available to report cardiopulmonary bypass support when provided, also based on access. Diagnostic procedures may be reported in addition to the TAVR/TAVI codes when no prior diagnostic catheterization was performed, or the patient’s condition has changed after initial diagnostic testing.
There are a variety of valves approved by the FDA for percutaneous insertion on the market. If insertion of a new valve is performed in a manner described by a current CPT, I would expect the procedure to use an existing code, but that is speculation. Current DRG without MCC for TAVR would be 267, however, I am not sure if the new valve would fit into this DRG or if the current PCS codes would apply. I will update this blog once new information is available.
Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.