Venefit Targeted Endovenous Therapy

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Venefit

™

Targeted

Endovenous Therapy

Coding, Reimbursement, and Coverage Guidelines

Primer for New Accounts

Trish Dawidczyk

Field Reimbursement Manager, Vascular Therapies

Disclaimer: CMS was the primary source of the information contained in this document. Covidien does not represent or guarantee that this information is complete, accurate, or applicable to any particular patient or third party payer. Covidien disclaims all liability for any consequence resulting from reliance on this document. The final decision of billing for any service must be made by the health care provider considering the medical necessity of the service furnished as well as the requirements of third-party payers and any local, state, or federal laws and regulations that apply. Covidien is providing this information in an educational capacity with the understanding that Covidien is not engaged in rendering accounting, or other professional services. Covidien encourages all health care providers to consult with their own advisors regarding coding and payment

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Disclaimer

Reimbursement information is gathered from the CMS web site and is presented for illustrative

purposes only. This information cannot guarantee coverage or reimbursement, and does not

constitute reimbursement or legal advice. We strongly recommend that you work with a

qualified consultant or attorney to determine the billing practices for your office.

Every effort has been made to ensure that the information provided in this document is accurate.

Reimbursement information changes periodically. Service providers should make sure that they

are reviewing the most recent update to this document and the most recent reimbursement

guidance from their payers. As a result, Covidien can make no representation or warranty

regarding this information or its completeness, accuracy, timeliness, or applicability with respect

to any particular patient or third party payer.

Service providers are responsible for their decisions relating to coding and reimbursement

submissions. This document reflects payment estimates only and is not a guarantee of payment.

AMA CPT Copyright Statement: CPT codes and descriptions are copyright 2013 American

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Part I: Clinical Background

Part II: Coding and Reimbursement

Part III: Claims and Coverage Guidelines

Part IV: Managing Managed Care

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Clinical Need

Venous insufficiency affects more than 30 million people in the US

alone

1,2

• Veins may be symptomatic or asymptomatic

• Asymptomatic may/may not need treatment, generally not covered

by insurance

1 Source: Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: Clinical practice guidelines of the

Society for Vascular Surgery and the American Venous Forum. JVS; May 2011.

2 Source; Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc.

Company),

www.mrg.net

<

http://www.mrg.net/

> , May 2011.

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The Venefit

™

Procedure

The Venefit

™

procedure can be performed:

3, 4

– Outpatient

– Local anesthesia

– Few complications

– Limited pain, bruising, and tenderness

– Faster return to ADL’s & work compared to 980 nm laser

Vein occlusion rates of 92.6% three years post-treatment

3, 4

Reflux-free rate of 95.7% three years post-treatment

3, 4

Can be offered as a stand-alone procedure or

in combination with adjunctive phlebectomy or sclerotherapy

3 Proebstle TM, Alm J, Göckeritz O, Wenzel C et al., “Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities”, J Vasc Surg. 2011 Jul;54(1):146-52.

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Device Indications and Contraindications

5 Indications:

The Venefit™ procedure system is intended for endovascular coagulation of blood

vessels in patients with superficial vein reflux.

The Venefit™ ClosureRFS stylet is intended for use in vessel and tissue coagulation

including treatment of incompetent (i.e. refluxing) perforator and tributary veins.

Contraindications:

Patients with thrombus in the vein segment to be treated.

Caution: The vein wall may be thinner in an aneurysmal segment. To effectively

occlude a vein with an aneurysmal segment, additional tumescent infiltration may be

needed over the aneurysmal segment, and the treatment of the vein should include

segments proximal and distal to the aneurysmal segment.

Caution: No data exists regarding the use of this catheter in patients with

documented peripheral arterial disease. The same care should be taken in the

treatment of patients with significant peripheral arterial disease as would be taken

with a traditional vein ligation and stripping procedure.

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Components

7

Components:

ClosureFast™ catheter

ClosureRFS™ stylet

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The Venefit™ Procedure

7

• Sterile drape and prep

• Anesthetic injected at cut down site

• Needle inserted into GSV

• Guide wire inserted through needle

• Introducer sheath inserted over guide wire

• Tumescent anesthesia instilled in length of

vein to be treated

• Catheter connected to RF generator

• Vein treated in segments

• RF activated and catheter slowly withdrawn

until vein is sealed

• Leg wrapped with compression bandage

• Return for post op scan to rule out DVT

• Entire procedure length 20-30 minutes

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Part II: Coding and Reimbursement

• Coding Guidelines and Frequently Used Codes

• Pre-Certification and Prior-Authorization

• Documentation for Claims Submission

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General Coding Guidelines

Choose the codes that most accurately describe both the

patient’s condition/diagnosis and the procedure(s) you

are doing

Consult with your top payers and review coverage policies

to determine which codes they require, generally listed

at the end of the payer’s medical policy

Follow AMA Coding Guidelines:

“Select the name of the procedure or service that accurately

identifies the service performed. Do not select a CPT code

that merely approximates the service provided.”

8

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Diagnosis Coding

7 Physician must establish the Diagnosis Code, aka the reason why

patient is being treated

Use highest specificity diagnosis code to describe patient’s condition

Common Diagnosis Codes for Endovenous RFA include:

454 Varicose veins of lower extremities

454.0 With ulcer

454.1 With inflammation

454.2 With ulcer and inflammation

454.8 With other complications

454.9 Asymptomatic varicose veins

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Procedural Coding

6 CPT Codes Associated with Diagnosing Venous Disorders

93970: Duplex scan of extremity, complete, bilateral

93971: Duplex scan of extremity, limited, unilateral

CPT Codes for Endovenous Radiofrequency Ablation

36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all

imaging guidance & monitoring, percutaneous, radiofrequency; 1st vein

+36476: Second & subsequent veins treated in a single extremity, each through

separate access sites (Add-On Code)

CPT Codes Associated with Possible Adjunctive Venous Procedures

37765: Stab phlebectomy varicose veins, 1 extremity, 10-20 incisions

37766: Stab phlebectomy varicose veins, 1 extremity, >20 incisions

36470: Injection of sclerosing solution, single vein

36471: Injection of sclerosing solution, multiple veins, same leg

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2013 Overview CMS Codes for Endovenous RF Ablation

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Professional Fee Coding1 Notes

Endovenous RF Ablation

36475 Endovenous ablation incompetent vein, 1st vein .

36476 Endovenous ablation incompetent vein RF 2nd/subsequent veins; Add-On Add-On code; No reduction when done in addition to 1st vein

Stab Phlebectomy

37765 Stab phlebectomy varicose veins, 1 extremity, 10-20 incisions 50% rule applies if done adjunctively to RF; Use Modifier -51 37766 Stab phlebectomy varicose veins, 1 extremity, > 20 incisions 50% rule applies if done adjunctively to RF; Use Modifier -51

Sclerotherapy

36470 Injection of sclerosing solution, single vein 50% rule applies if done adjunctively to RF; Use Modifier -51 36471 Injection of sclerosing solution, multiple veins, same leg 50% rule applies if done adjunctively to RF; Use Modifier -51 76942 US Guidance for needle placement (e.g. localization device) Used in conjunction with Sclerotherapy codes

Duplex Scan

93970 Duplex scan of extremity, complete, bilateral Only pre- or post operative; Intraoperative included in 36475/76 93971 Duplex scan of extremity, limited, unilateral Only pre- or post operative; Intraoperative included in 36475/76

ICD-9 Codes (Diagnosis and Procedure)2

454.0 - 454.8 Varicose veins, lower extremities with symptoms/complications 459.81 Venous insufficiency not otherwise specified

Modifiers 2 Notes

26 Professional Component Used when physician performs U/S in Outpatient Hospital or ASC

TC Technical Component

50 Bilateral 36475-50 (or LT/RT, or units=2), payment based on 150% of the fee schedule for 36475

51 Multiple Procedures For procedures done adjunctively to 36475/36476; Not appended to Add-On Code (36476) 52

53

52: Reduced Procedural Services 53: Discontinued Procedure

Reduction or discontinuation of procedure due to extenuating clinical circumstances, Not for elective cancellation of procedure. Check with insurer.

59 79

59: Distinct procedural service

79: Unrelated procedure, same physician, during post-operative period

Post-procedural ultrasound when RF procedure is done on the same day as another procedure with a 10 or 90 day global (e.g. sclerotherapy or stab phlebectomy). Check with insurer.

Sources: 1.Center for Medicare and Medicaid Services, MPFS 2013 Conversion Factor = $34.0230 effective January 1, 2013, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

3.Centers for Medicare and Medicaid Services, Hospital Outpatient, CMS-1525-FC, Final Changes to the Hospital Outpatient Prospective Payment System and CY 2013 Payment Rates, 01/01/2013,

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/January-2013-addendum-B.html

4Centers for Medicare and Medicaid Services, Ambulatory Surgical Center, CMS-1525-FC, Final Changes to the Ambulatory Surgical Center Payment System and CY 2013 Payment Rates, 01/01/2013,

http://www.cms.gov/apps/ama/license.asp?file=/ascpayment/downloads/CMS-1589-FC-ASC-addenda-FN13.zip

Disclaimer: CMS was the primary source of the information contained in this document. Covidien does not represent or guarantee that this information is complete, accurate, or applicable to any particular patient or third party payer. Covidien disclaims all liability for any consequence resulting from reliance on this document. The final decision of billing for any service must be made by the health care provider considering the medical necessity of the service furnished as well as the requirements of third-party payers and any local, state, or federal laws and regulations that apply. Covidien is providing this information in an educational capacity with the understanding that Covidien is not engaged in rendering accounting, or othe r professional services. Covidien encourages all health care providers to consult with their own advisors regarding coding and payment.

Place of Service Codes

11 Physician Office 22 Outpatient Hospital 24 Ambulatory Surgical Center

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2013 Overview CMS Codes for Endovenous RF Ablation

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Facility Fee Coding

Hospital Outpatient Services (HOPPS) Notes CPT codes "crosswalk" to Ambulatory Payment Classifications (APC)

APC 91 36475- RF 1st vein

APC 92 36476- RF, 2nd/subsequent veins; also Phlebectomy (37765, 37766) Multiple procedure (50% reduction facility payment) applies if done adjunctively to 36475 APC 13 36470, 36471- Sclerotherapy Multiple procedure (50% reduction facility payment) applies if done adjunctively to 36475 APC 267 93970- Duplex scan, bilateral

APC 266 93971- Duplex scan, unilateral

76942- US Guidance for needle placement Packaged service, not separately paid

Catheter Device Code (OPPS Only) Notes

C1888 Endovascular non-cardiac ablative catheter Packaged service, not separately paid

C1894 Introducer/sheath, non-laser Packaged service, not separately paid

Note: Pass-through status expired 12/31/2004. Continue to document in claims for CMS tracking. Claim may be returned without code.

Ambulatory Surgery Center (ASC) Notes Use CPT Codes for ASC reimbursement

36475, 36476 RF 1st vein treated, or 2nd and subsequent veins Surgical procedure with payment based on OPPS relative payment weight

37765, 37766 Stab Phlebecomy Office based surgical procedure with payment based on MPFS non-facility PE RVU's 36470, 36471 Sclerotherapy Office based surgical procedure with payment based on OPPS relative payment weight 76942 US Guidance needle placement Packaged service, not separately paid

93970, 93971 Not approved in ASC setting Done in ASC only intra-procedurally

Other Supplies Notes

A6530-A6541 Pressure gradient compression stockings Generally not paid by Medicare on outpatient claims

A6532 Compression stocking BK40-50 May be paid under fee schedule other than OPPS in Hospital Outpatient setting, check with MAC/FI A4649 Miscellaneous supplies Generally not paid by Medicare on outpatient claims

Sources:

1.Center for Medicare and Medicaid Services, MPFS 2013 Conversion Factor = $34.0230 effective January 1, 2013, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

3.Centers for Medicare and Medicaid Services, Hospital Outpatient, CMS-1525-FC, Final Changes to the Hospital Outpatient Prospective Payment System and CY 2013 Payment Rates, 01/01/2013,

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/January-2013-addendum-B.html

4Centers for Medicare and Medicaid Services, Ambulatory Surgical Center, CMS-1525-FC, Final Changes to the Ambulatory Surgical Center Payment System and CY 2013 Payment Rates, 01/01/2013,

http://www.cms.gov/apps/ama/license.asp?file=/ascpayment/downloads/CMS-1589-FC-ASC-addenda-FN13.zip

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Reimbursement

Medicare fee schedule is publicly available and based on Relative Values (RVU’s)

9

• RVU’s help to define the relative amount of work, expense, and risk involved in delivering a service

or performing a procedure as compared to all other medical services/procedures

Comprised of 3 components:



Physician Work

(abbreviated “Work”, includes Time, Intensity, Expertise, Training)



Practice Expense (Non-Facility & Facility)

(abbreviated “PE”, includes Staff, Supplies, Overhead)

-- Distinguished by Site Of Service



Physician Office is called “Non-Facility”



Hospital Outpatient and/or Ambulatory Surgery Center is called “Facility”



Malpractice Risk

(abbreviated “Risk”, e.g. Allocated Cost of Professional Liability Insurance)

RVU’s are developed for each procedure described by CPT

Medicare localities then “adjust” each RVU component by the Geographic Practice Cost Index (GPCI)

Entire relative value is multiplied by Conversion Factor set annually by Congress to determine payment

Reimbursement Calculation

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (Risk RVU x Risk GPCI)] x Conversion Factor $

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2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

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CPT 2 DESCRIPTION

36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; 1st vein

36476 2nd and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, Laser; 1st vein

36479 2nd and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

37700 Ligation and division of long saphenous vein at saphenofemoral junction

37718 Ligate/strip short leg vein

37722 Ligate/strip long leg vein

37765 Stab phlebectomy of varicose veins, one extremity; 10 to 20 stab incisions

37766 More than 20 incisions

93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral scan

93971 Unilateral or limited study

Sources: 1 Center for Medicare and Medicaid Services, MPFS 2013 Conversion Factor = $34.0230 effective January 1, 2013, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

3 Refers to Duplex Scans done pre- or post-procedurally; Intra-procedural Duplex Scans are included in the code for procedure 36475 and 36476.

4 For Radiology Services: (PC) = Physician Component (TC) Technical Component; Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on the technical component (TC) component of certain diagnostic imaging services. The cap is based on the OPPS payment & the lower amount is used to calculate payment

RVUs as of 1-1-2012 36475 36476 36478 36479

37700 37718 37722

37765 37766 93970 93971

Office Facility Office Facility Office Facility Office Facility

Office Facility Office Facility (P) (T) (P) (T)

WORK 6.72 6.72 3.38 3.38 6.72 6.72 3.38 3.38 3.82 7.13 8.16 7.71 7.71 9.66 9.66 0.70 0.00 0.45 0.00

PRACTICE EXPENSE 45.17 2.46 7.75 1.11 33.71 2.47 8.00 1.15 3.05 4.74 4.74 10.94 4.41 12.37 5.17 0.24 4.63 0.16 2.80

MALPRACTICE 1.42 1.42 0.72 0.72 1.32 1.32 0.65 0.65 0.84 1.57 1.81 1.57 1.57 2.01 2.01 0.07 0.01 0.04 0.01

TOTAL 53.31 10.60 11.85 5.21 41.75 10.51 12.03 5.18 7.71 13.44 14.71 20.22 13.69 24.04 16.84 1.01 4.64 0.65 2.81

2013 MEDICARE FEE SCHEDULE

Medicare Locality 36475 36476 36478 36479 37700 37718 37722 37765 37766 93970 93971 Office Facility Office Facility Office Facility Office Facility Office Facility Office Facility (P) (T) (P) (T)

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 AL Alabama $1,595 $320 $355 $157 $1,251 $318 $362 $157 $232 $404 $442 $608 $413 $723 $508 $32 $138 $20 $84 AK Alaska ** $2,015 $464 $470 $229 $1,596 $462 $478 $229 $325 $571 $629 $826 $589 $987 $726 $46 $168 $30 $102 AZ Arizona $1,775 $354 $395 $174 $1,390 $351 $401 $173 $257 $449 $491 $674 $457 $802 $562 $34 $154 $22 $94 AR _Arkansas $1,572 $315 $350 $155 $1,233 $314 $357 $155 $228 $398 $436 $600 $407 $713 $501 $31 $136 $20 $83 CA Anaheim/Santa Ana, CA $2,143 $373 $458 $183 $1,666 $371 $467 $183 $281 $486 $528 $763 $493 $902 $604 $36 $192 $24 $116 CA Los Angeles, CA $2,041 $364 $439 $178 $1,589 $363 $447 $178 $273 $472 $513 $736 $479 $870 $587 $36 $182 $23 $110

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2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

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Sources:

1 Center for Medicare and Medicaid Services, MPFS 2013 Conversion Factor = $34.0230 effective January 1, 2013, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html 2 AMA CPT Copyright Statement: CPT codes and descriptions are copyright 2013 American Medical Association. All Rights Reserved

2013 MEDICARE FEE SCHEDULE3 ST Medicare

Locality

36475 36476 36478 36479

37700 37718 37722 37765 37766 93970 93971 Office Facility Office Facility Office Facility Office Facility Office Facility Office Facility (P) (T) (P) (T)

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 CA Marin/Napa/Solano , CA $2,180 $367 $461 $179 $1,692 $366 $471 $180 $279 $481 $521 $765 $487 $902 $596 $36 $197 $24 $119 CA Oakland/Berkeley, CA $2,194 $372 $465 $182 $1,703 $370 $474 $182 $282 $486 $528 $772 $493 $911 $604 $37 $198 $24 $120 CA Rest of California $1,928 $351 $417 $172 $1,503 $350 $425 $172 $261 $453 $493 $702 $461 $831 $565 $35 $171 $22 $104 CA Rest of California $1,928 $351 $417 $172 $1,503 $350 $425 $172 $261 $453 $493 $702 $461 $831 $565 $35 $171 $22 $104 CA San Francisco, CA $2,360 $384 $495 $187 $1,828 $383 $505 $188 $295 $507 $549 $815 $513 $960 $627 $38 $214 $25 $130 CA San Mateo, CA $2,351 $383 $493 $187 $1,821 $382 $503 $188 $295 $506 $548 $813 $512 $957 $626 $38 $213 $24 $129 CA Santa Clara, CA $2,326 $383 $489 $187 $1,803 $382 $499 $188 $293 $504 $546 $808 $511 $952 $624 $38 $211 $24 $128 CA Ventura, CA $2,099 $365 $448 $179 $1,632 $364 $457 $179 $275 $476 $517 $748 $483 $883 $591 $36 $188 $23 $114 CO Colorado $1,813 $354 $401 $174 $1,418 $351 $407 $173 $259 $450 $492 $682 $458 $810 $564 $34 $158 $22 $96 CT Connecticut $2,000 $387 $441 $190 $1,563 $383 $447 $189 $284 $493 $539 $748 $501 $888 $616 $36 $175 $23 $106 D.C. DC + MD/VA Suburbs $2,136 $395 $464 $194 $1,665 $391 $472 $192 $293 $508 $554 $781 $515 $926 $633 $37 $189 $24 $115 DE Delaware $1,868 $351 $408 $172 $1,459 $349 $415 $172 $259 $450 $491 $690 $458 $818 $562 $34 $165 $22 $100 FL Fort Lauderdale, FL $1,938 $411 $440 $203 $1,522 $405 $444 $199 $295 $516 $568 $758 $524 $905 $647 $37 $166 $24 $101 FL Miami, FL $1,983 $452 $461 $223 $1,563 $442 $464 $218 $319 $562 $620 $804 $570 $963 $705 $39 $167 $25 $101 FL Rest of Florida $1,787 $381 $406 $188 $1,404 $376 $411 $185 $272 $477 $524 $701 $486 $836 $599 $35 $153 $22 $93 GA Atlanta, GA $1,835 $360 $406 $177 $1,436 $357 $412 $176 $263 $457 $500 $691 $466 $821 $573 $34 $160 $22 $97 GA Rest of Georgia $1,648 $343 $372 $169 $1,295 $341 $377 $168 $247 $431 $473 $640 $441 $763 $543 $33 $142 $21 $86 HA Hawaii/Guam/Ame rican Samoa/Northern Mariana Islands $2,036 $359 $436 $176 $1,584 $357 $445 $176 $270 $466 $507 $729 $473 $862 $580 $35 $182 $23 $110

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2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

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Sources:

Locality

36475 36476 36478 36479

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 ID Idaho $1,627 $328 $363 $161 $1,277 $327 $369 $161 $238 $414 $454 $622 $424 $740 $521 $32 $141 $21 $85 IL Chicago, IL $1,951 $424 $446 $209 $1,534 $417 $450 $206 $302 $530 $583 $772 $539 $923 $665 $38 $166 $24 $101 IL East St. Louis, IL $1,758 $397 $408 $196 $1,386 $391 $411 $193 $281 $494 $544 $711 $503 $851 $621 $36 $148 $23 $90 IL Rest of Illinois $1,685 $364 $385 $179 $1,326 $360 $389 $177 $259 $455 $500 $666 $464 $795 $572 $34 $144 $22 $87 IL Suburban Chicago, IL $1,964 $406 $442 $200 $1,540 $401 $447 $198 $293 $513 $563 $759 $521 $905 $642 $37 $169 $24 $103 IN Indiana $1,670 $328 $370 $161 $1,308 $327 $376 $161 $239 $417 $456 $630 $425 $749 $523 $32 $146 $21 $88 IA Iowa $1,604 $315 $355 $155 $1,257 $314 $362 $155 $230 $400 $437 $606 $409 $719 $502 $31 $140 $20 $85 KS Kansas $1,640 $341 $370 $168 $1,288 $338 $375 $167 $245 $429 $470 $636 $438 $758 $539 $32 $141 $21 $85 KY Kentucky $1,597 $331 $360 $163 $1,255 $329 $365 $162 $238 $416 $456 $619 $426 $737 $524 $32 $137 $21 $83 LA New Orleans, LA $1,769 $351 $393 $172 $1,385 $348 $399 $172 $255 $445 $487 $670 $453 $797 $558 $34 $154 $22 $93 LA Rest of Louisiana $1,605 $330 $361 $163 $1,260 $328 $366 $162 $238 $416 $456 $620 $425 $738 $523 $32 $138 $21 $84 ME Rest of Maine $1,642 $329 $366 $162 $1,288 $327 $372 $161 $238 $416 $455 $625 $425 $744 $522 $32 $143 $21 $86 ME Southern Maine $1,831 $343 $400 $168 $1,430 $341 $407 $168 $253 $440 $480 $675 $448 $801 $550 $33 $162 $22 $98 MD _{Baltimore/Surr.} Cntys, MD $1,979 $385 $437 $189 $1,547 $381 $443 $188 $282 $490 $536 $742 $498 $882 $613 $36 $173 $23 $105 MD Rest of Maryland $1,869 $365 $413 $180 $1,463 $362 $420 $179 $267 $465 $508 $703 $473 $835 $582 $35 $163 $22 $99 MA Metropolitan Boston $2,036 $366 $439 $179 $1,585 $364 $447 $179 $274 $473 $515 $736 $481 $871 $589 $35 $181 $23 $110 MA Rest of Massachusetts $1,902 $359 $416 $176 $1,485 $356 $423 $176 $264 $459 $501 $703 $467 $834 $574 $35 $168 $22 $101

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2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

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Sources:

Locality

36475 36476 36478 36479

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 MI Detroit, MI $1,893 $407 $432 $201 $1,488 $401 $436 $198 $291 $510 $560 $746 $518 $890 $640 $37 $162 $24 $98 MI Rest of Michigan $1,697 $355 $384 $175 $1,333 $352 $389 $174 $255 $446 $490 $661 $456 $787 $561 $34 $146 $22 $88 MN Minnesota $1,797 $326 $388 $160 $1,401 $326 $396 $160 $243 $420 $457 $653 $428 $773 $525 $33 $160 $21 $97 MS Mississippi $1,588 $329 $358 $162 $1,247 $327 $363 $161 $237 $414 $454 $615 $423 $733 $521 $32 $137 $20 $83 MO Metropolitan Kansas City, MO $1,748 $364 $394 $179 $1,373 $360 $399 $177 $262 $458 $502 $678 $466 $808 $574 $34 $151 $22 $91 MO Metropolitan St Louis, MO $1,759 $358 $394 $176 $1,380 $355 $400 $175 $259 $452 $496 $675 $461 $804 $567 $34 $152 $22 $92 MO Rest of Missouri $1,576 $339 $359 $167 $1,241 $336 $364 $166 $242 $424 $466 $622 $433 $742 $534 $32 $134 $21 $81 MT Montana *** $1,806 $353 $399 $173 $1,413 $350 $405 $172 $258 $449 $492 $679 $457 $807 $562 $33 $158 $21 $96 NE Nebraska $1,626 $312 $357 $153 $1,272 $312 $364 $154 $229 $398 $434 $607 $406 $720 $499 $31 $143 $20 $86 NV Nevada *** $1,913 $376 $424 $185 $1,496 $372 $430 $183 $274 $478 $523 $721 $486 $857 $598 $35 $167 $23 $101 NH New Hampshire $1,872 $355 $410 $174 $1,462 $353 $417 $174 $262 $454 $496 $694 $462 $824 $568 $34 $165 $22 $100 NJ Northern NJ $2,112 $388 $458 $190 $1,646 $385 $466 $190 $289 $500 $545 $771 $508 $914 $623 $37 $187 $24 $113 NJ Rest of New Jersey $2,014 $378 $440 $186 $1,572 $375 $447 $185 $279 $485 $529 $743 $493 $881 $605 $36 $178 $23 $108 NM New Mexico $1,682 $351 $380 $173 $1,321 $348 $385 $172 $252 $441 $483 $653 $450 $778 $554 $33 $145 $21 $88 NY Manhattan, NY $2,090 $401 $460 $197 $1,633 $398 $467 $196 $295 $513 $561 $779 $521 $925 $640 $38 $183 $24 $111 NY NYC Suburbs/Long I., NY $2,172 $411 $476 $202 $1,695 $406 $482 $200 $303 $527 $575 $803 $534 $953 $657 $38 $191 $25 $116

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2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

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Sources:

.1 Center for Medicare and Medicaid Services, MPFS 2013 Conversion Factor = $34.0230 effective January 1, 2013, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html 2 AMA CPT Copyright Statement: CPT codes and descriptions are copyright 2013 American Medical Association. All Rights Reserved

3 Refers to Duplex Scans done pre- or post-procedurally; Intra-procedural Duplex Scans are included in the code for procedure 36475 and 36476.

4 For Radiology Services: (PC) = Physician Component (TC) Technical Component; Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on the technical component (TC) component of certain diagnostic imaging services. The cap is based on the OPPS payment & the lower amount is used to calculate payment

Locality

36475 36476 36478 36479

37700 37718 37722

37765 37766 93970 93971 Office Facility Office Facility Office Facility Office Facility Office Facility Office Facility (P) (T) (P) (T)

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 NY Poughkpsie/N NYC Suburbs, NY $1,920 $373 $424 $183 $1,501 $369 $430 $182 $273 $475 $519 $719 $483 $854 $594 $35 $168 $23 $102 NY Queens, NY $2,151 $415 $474 $204 $1,680 $410 $480 $202 $305 $530 $579 $803 $538 $954 $661 $39 $189 $25 $114 NY

Rest of New York

$1,696 $331 $375 $163 $1,328 $330 $382 $163 $242 $421 $460 $638 $430 $758 $528 $33 $148 $21 $90 NC North Carolina $1,680 $333 $373 $164 $1,316 $331 $379 $163 $242 $422 $462 $637 $431 $757 $530 $32 $146 $21 $89 ND North Dakota *** $1,783 $330 $387 $162 $1,391 $328 $395 $162 $244 $423 $461 $653 $431 $774 $529 $32 $158 $21 $95 OH Ohio $1,713 $366 $390 $180 $1,347 $362 $395 $178 $261 $458 $503 $673 $467 $803 $576 $34 $146 $22 $89 OK Oklahoma $1,569 $325 $353 $160 $1,233 $323 $359 $159 $234 $409 $448 $608 $418 $724 $514 $31 $135 $20 $82 OR Portland, OR $1,864 $347 $406 $170 $1,455 $346 $414 $170 $257 $446 $486 $686 $454 $812 $557 $34 $165 $22 $100 OR Rest of Oregon $1,733 $335 $382 $164 $1,355 $333 $388 $164 $245 $426 $466 $649 $435 $770 $534 $33 $152 $21 $92 PA Metropolitan Philadelphia, PA $1,938 $399 $436 $196 $1,519 $394 $441 $194 $288 $504 $552 $747 $512 $890 $631 $37 $167 $23 $101 PA Rest of Pennsylvania $1,683 $356 $382 $175 $1,323 $353 $387 $174 $255 $447 $490 $659 $456 $785 $562 $34 $144 $22 $87 PR Puerto Rico $1,262 $276 $289 $136 $996 $276 $294 $136 $195 $343 $377 $504 $353 $601 $435 $28 $107 $18 $65 RI Rhode Island $1,907 $378 $423 $186 $1,492 $374 $430 $184 $275 $480 $525 $722 $488 $858 $600 $36 $166 $23 $101

(21)

2013 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

1

21 |

Sources:

Locality

36475 36476 36478 36479

37700 37718 37722

NATIONAL $1,814 $361 $403 $177 $1,420 $358 $409 $176 $262 $457 $500 $688 $466 $818 $573 $34 $158 $22 $96 SC South Carolina $1,645 $324 $365 $159 $1,289 $323 $371 $159 $236 $411 $450 $622 $420 $739 $516 $32 $143 $21 $87 SD South Dakota *** $1,775 $322 $383 $157 $1,383 $320 $391 $158 $239 $415 $451 $644 $422 $762 $517 $32 $158 $21 $95 TN Tennessee $1,628 $323 $361 $159 $1,276 $321 $368 $158 $234 $409 $447 $617 $418 $733 $513 $32 $142 $20 $86 TX Austin, TX $1,812 $346 $398 $170 $1,416 $343 $404 $169 $254 $442 $482 $674 $450 $799 $552 $33 $159 $22 $96 TX Beaumont, TX $1,644 $342 $371 $168 $1,291 $339 $376 $167 $246 $429 $471 $638 $438 $759 $540 $33 $141 $21 $86 TX _{Brazoria, TX} $1,792 $358 $399 $176 $1,404 $355 $405 $175 $260 $453 $496 $681 $462 $810 $568 $34 $156 $22 $94 TX Dallas, TX $1,834 $356 $405 $175 $1,435 $354 $411 $174 $261 $453 $495 $688 $462 $817 $568 $34 $160 $22 $97 TX Fort Worth, TX $1,773 $350 $393 $172 $1,388 $348 $400 $171 $255 $444 $486 $671 $453 $797 $557 $34 $154 $22 $94 TX Galveston, TX $1,809 $362 $403 $178 $1,417 $359 $409 $177 $263 $458 $501 $688 $467 $818 $574 $35 $157 $22 $95 TX Houston, TX $1,815 $359 $403 $176 $1,421 $356 $409 $176 $261 $456 $499 $687 $464 $816 $571 $34 $158 $22 $96 TX _{Rest of Texas} $1,664 $339 $373 $167 $1,306 $337 $379 $166 $245 $428 $469 $639 $437 $761 $538 $33 $144 $21 $87 UT Utah $1,683 $352 $380 $173 $1,322 $348 $385 $172 $253 $442 $485 $655 $451 $780 $556 $33 $145 $21 $88 VT Vermont $1,799 $335 $392 $164 $1,404 $333 $399 $164 $247 $429 $468 $661 $437 $783 $536 $33 $159 $21 $96 VA Virgin Islands $1,817 $361 $404 $177 $1,423 $358 $410 $176 $263 $458 $501 $689 $466 $819 $573 $34 $158 $22 $96 VA Virginia $1,764 $344 $390 $169 $1,380 $342 $396 $169 $251 $437 $478 $663 $446 $788 $548 $33 $154 $22 $93 WA Rest of Washington $1,824 $353 $402 $174 $1,426 $351 $409 $173 $259 $450 $492 $683 $458 $811 $563 $34 $160 $22 $97 WA Seattle (King Cnty), WA $2,035 $373 $441 $183 $1,586 $370 $449 $182 $277 $480 $523 $742 $488 $879 $598 $36 $181 $23 $109 WV West Virginia $1,552 $349 $359 $172 $1,225 $345 $363 $170 $246 $433 $477 $626 $442 $749 $546 $33 $131 $21 $79 WI Wisconsin $1,727 $332 $380 $163 $1,351 $331 $387 $163 $244 $423 $463 $645 $432 $766 $531 $33 $151 $21 $92 WY _{Wyoming ***} $1,819 $365 $406 $180 $1,425 $362 $411 $178 $265 $463 $507 $693 $471 $825 $580 $34 $158 $22 $96

(22)

2012 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

1

22 |

Sources:

1 _{Center for Medicare and Medicaid Services, MPFS 2012 Conversion Factor = $34.0376, Effective February, 2012}_{http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4.}

2 _{AMA CPT Copyright Statement: CPT codes and descriptions are copyright 20112American Medical Association. All Rights Reserved} 3_{Refers to Duplex Scans done pre- or post-procedurally; Intra-procedural Duplex Scans are included in the code for procedure 36475 and 36476.}

4_{For Radiology Services: (PC) = Physician Component (TC) Technical Component; Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on the technical component (TC) component of certain diagnostic imaging services.}

The cap is based on the OPPS payment & the lower amount is used to calculate payment.

2012 MEDICARE FEE SCHEDULE ST Medicare

Locality

36475 36476 36478 36479

37700 37718 37722

NATIONAL $1,831 $364 $406 $179 $1,449 $363 $423 $179 $264 $456 $505 $686 $472 $811 $577 $34 $152 $22 $96 SC South Carolina $1,666 $333 $370 $163 $1,320 $333 $386 $164 $241 $416 $461 $626 $433 $740 $528 $32 $138 $21 $87 SD South Dakota $1,803 $336 $392 $165 $1,423 $337 $410 $166 $248 $426 $470 $655 $442 $772 $538 $32 $152 $21 $96 TN Tennessee $1,649 $332 $367 $163 $1,308 $332 $383 $164 $240 $414 $459 $622 $431 $736 $526 $32 $137 $21 $86 TX Austin $1,833 $353 $403 $173 $1,448 $352 $420 $174 $258 $444 $492 $676 $461 $797 $562 $33 $153 $22 $97 TX Beaumont $1,666 $351 $377 $173 $1,323 $350 $391 $173 $251 $435 $483 $643 $452 $762 $553 $33 $136 $21 $86 TX Brazoria $1,809 $361 $402 $177 $1,432 $360 $418 $177 $262 $452 $501 $679 $469 $803 $572 $34 $150 $22 $95 TX Dallas $1,851 $359 $408 $176 $1,464 $359 $425 $177 $262 $452 $501 $685 $469 $809 $572 $34 $155 $22 $98 TX Fort Worth $1,790 $354 $397 $174 $1,416 $353 $413 $174 $257 $443 $491 $668 $460 $790 $561 $33 $149 $22 $94 TX Galveston $1,826 $365 $406 $179 $1,446 $364 $422 $179 $264 $457 $506 $686 $473 $811 $578 $34 $152 $22 $96 TX Houston $1,832 $362 $406 $178 $1,450 $361 $423 $178 $263 $454 $504 $685 $471 $809 $575 $34 $152 $22 $96 TX Rest of Texas $1,685 $347 $378 $171 $1,337 $346 $393 $171 $249 $432 $479 $643 $448 $761 $548 $33 $139 $21 $88 UT Utah $1,705 $362 $386 $178 $1,355 $360 $401 $177 $258 $448 $498 $660 $465 $783 $569 $33 $139 $22 $88 VT Vermont $1,822 $343 $398 $168 $1,438 $343 $415 $169 $252 $434 $479 $665 $450 $784 $548 $33 $153 $22 $97 VA Virginia $1,782 $349 $394 $171 $1,410 $348 $410 $172 $254 $438 $485 $663 $454 $783 $554 $33 $149 $22 $94 VI Virgin Islands $1,834 $365 $407 $179 $1,452 $363 $424 $179 $265 $457 $506 $687 $473 $812 $578 $34 $152 $22 $97 WA Seattle (King Cnty) $2,055 $376 $445 $184 $1,619 $376 $464 $185 $279 $479 $529 $739 $495 $870 $603 $35 $174 $23 $110 WA Rest of WA $1,801 $317 $385 $155 $1,418 $319 $404 $157 $237 $405 $446 $637 $421 $747 $511 $31 $154 $21 $97 WV West Virginia $1,575 $360 $366 $178 $1,257 $358 $379 $177 $253 $441 $491 $634 $458 $755 $562 $33 $126 $21 $80 WI Wisconsin $1,747 $338 $385 $166 $1,382 $339 $401 $167 $247 $425 $471 $647 $442 $763 $539 $32 $146 $21 $92 WY Wyoming $1,842 $375 $412 $184 $1,459 $373 $428 $184 $271 $469 $520 $698 $485 $827 $593 $34 $152 $22 $96

(23)

2012 CMS Physician Reimbursement by State/Locality: Office & Facility Setting

1

23 |

Sources:

1 _{Center for Medicare and Medicaid Services, MPFS 2012 Conversion Factor = $34.0376, Effective February, 2012}_{http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4.}

2 _{AMA CPT Copyright Statement: CPT codes and descriptions are copyright 20112American Medical Association. All Rights Reserved} 3_{Refers to Duplex Scans done pre- or post-procedurally; Intra-procedural Duplex Scans are included in the code for procedure 36475 and 36476.}

4_{For Radiology Services: (PC) = Physician Component (TC) Technical Component; Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on the technical component (TC) component of certain diagnostic imaging services.}

The cap is based on the OPPS payment & the lower amount is used to calculate payment.

2012 MEDICARE FEE SCHEDULE ST Medicare

Locality

36475 36476 36478 36479

37700 37718 37722

NATIONAL $1,831 $364 $406 $179 $1,449 $363 $423 $179 $264 $456 $505 $686 $472 $811 $577 $34 $152 $22 $96 SC South Carolina $1,666 $333 $370 $163 $1,320 $333 $386 $164 $241 $416 $461 $626 $433 $740 $528 $32 $138 $21 $87 SD South Dakota $1,803 $336 $392 $165 $1,423 $337 $410 $166 $248 $426 $470 $655 $442 $772 $538 $32 $152 $21 $96 TN Tennessee $1,649 $332 $367 $163 $1,308 $332 $383 $164 $240 $414 $459 $622 $431 $736 $526 $32 $137 $21 $86 TX Austin $1,833 $353 $403 $173 $1,448 $352 $420 $174 $258 $444 $492 $676 $461 $797 $562 $33 $153 $22 $97 TX Beaumont $1,666 $351 $377 $173 $1,323 $350 $391 $173 $251 $435 $483 $643 $452 $762 $553 $33 $136 $21 $86 TX Brazoria $1,809 $361 $402 $177 $1,432 $360 $418 $177 $262 $452 $501 $679 $469 $803 $572 $34 $150 $22 $95 TX Dallas $1,851 $359 $408 $176 $1,464 $359 $425 $177 $262 $452 $501 $685 $469 $809 $572 $34 $155 $22 $98 TX Fort Worth $1,790 $354 $397 $174 $1,416 $353 $413 $174 $257 $443 $491 $668 $460 $790 $561 $33 $149 $22 $94 TX Galveston $1,826 $365 $406 $179 $1,446 $364 $422 $179 $264 $457 $506 $686 $473 $811 $578 $34 $152 $22 $96 TX Houston $1,832 $362 $406 $178 $1,450 $361 $423 $178 $263 $454 $504 $685 $471 $809 $575 $34 $152 $22 $96 TX Rest of Texas $1,685 $347 $378 $171 $1,337 $346 $393 $171 $249 $432 $479 $643 $448 $761 $548 $33 $139 $21 $88 UT Utah $1,705 $362 $386 $178 $1,355 $360 $401 $177 $258 $448 $498 $660 $465 $783 $569 $33 $139 $22 $88 VT Vermont $1,822 $343 $398 $168 $1,438 $343 $415 $169 $252 $434 $479 $665 $450 $784 $548 $33 $153 $22 $97 VA Virginia $1,782 $349 $394 $171 $1,410 $348 $410 $172 $254 $438 $485 $663 $454 $783 $554 $33 $149 $22 $94 VI Virgin Islands $1,834 $365 $407 $179 $1,452 $363 $424 $179 $265 $457 $506 $687 $473 $812 $578 $34 $152 $22 $97 WA Seattle (King Cnty) $2,055 $376 $445 $184 $1,619 $376 $464 $185 $279 $479 $529 $739 $495 $870 $603 $35 $174 $23 $110 WA Rest of WA $1,801 $317 $385 $155 $1,418 $319 $404 $157 $237 $405 $446 $637 $421 $747 $511 $31 $154 $21 $97 WV West Virginia $1,575 $360 $366 $178 $1,257 $358 $379 $177 $253 $441 $491 $634 $458 $755 $562 $33 $126 $21 $80 WI Wisconsin $1,747 $338 $385 $166 $1,382 $339 $401 $167 $247 $425 $471 $647 $442 $763 $539 $32 $146 $21 $92 WY Wyoming $1,842 $375 $412 $184 $1,459 $373 $428 $184 $271 $469 $520 $698 $485 $827 $593 $34 $152 $22 $96

(24)

Part III: Claims and Coverage Guidelines

Prior Authorization

Pre-Determination

Often used interchangeably…

…but they are not the same!

(25)

Prior Authorization

• Pre-Determination only establishes the patient has valid insurance & their level of benefits

• Prior Authorization establishes Medical Necessity (MN)

• Submit documentation required by payer’s medical policy to meet MN requirements

• Requirements similar, but will differ by payer

• Not required by all insurance companies, but recommend getting on every patient

• For insurances that do require PA, you may get a reference # upon initial submission, and

an authorization # upon final approval (3-4 weeks)

 Check back weekly to ensure all required information has been received

 Provide anticipated date of service for initial request

 Update with actual date of service once final approval is received

• NOT A GUARANTEE OF PAYMENT

(26)

Part IV: Managing Payer Requirements

Recommendations for keeping payer requirements under control:

1. ID practice’s top payers for venous procedures

2. Go to the payer website and print off a copy of each policy

3. Create a Payer Policy Binder and put the policies in the binder

4. Create a Payer Grid that allows you to keep track of:

• Dates of Policy Review (last, next)

• Conservative Therapy Requirements (2 weeks to 6 months)

• Documentation Requirements

• Procedure and Diagnosis Codes

5. Use Grid to identify continuum of least to most restrictive guidelines

(27)

Managing Payer Requirements

• Payer requirements are updated periodically

– Be sure you are looking at the most up to date policy

• Coverage differences may occur in terms of:

– Vein Type (GSV, SSV, Accessory, Tributaries, Perforators)

– Vein Size / Diameter

– Duration of Reflux

• Medical necessity criteria may differ between plans in terms of:

– Documentation of

condition

and required complications (ulcer, bleeding, etc.)

– Confirmatory documentation of condition (type of ultrasound, photos, etc.)

– Conservative therapy (analgesia, leg elevation, compression stockings)

(28)

Managing Payer Requirements

12 This does not represent a comprehensive list of plans. Sources for United, Cigna, and Aetna Policies accurate as of 2/1/2013:

13 http://www.aetna.com/cpb/medical/data/1_99/0050.html http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0234_coveragepositioncriteria_varicose_vein_treatments.pdf https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Varicose_Veins_Surgical_Interventions_Apr_11.pdf Payer (clicking on cell directs to website) Policy Effective Date Next Review Date

Covered Vein Type, Size, Duration of Reflux

GSV SSV Accessory (Posterior, Anterior, Giacomini) P e rfo rat ors Tri but ari e s

Restrictions on: Type, Size, Duration, Staging, Repeat Procedures Aetna ® 5/25/12 3/24/13 >4.5 mm; >500 ms >4.5 mm; >500 ms Investigational/e xperimental for accessories and/or tributaries >3.5mm; >500 ms; located under venous

ulcers Not Covered

GSV/SSV > 4.5mm at junction and documented reflux duration of 500mm or greater. Perforator diameter > 3.5mm and outward flow duration

>500ms Bilateral: 1 tx session of ERFA for GSV of one or

both legs and 1 session for the LSV of one or both legs for a total of 2 tx is considered medically necessary.

Cigna ® 11/15/12 11/15/13 > 3 mm > 3 mm Silent Silent Silent

GSV/SSV Minimum Diameter >3mm, Perforators Silent, not specifically excluded but noted as "limited safety/efficacy data" (p. 9 top);

REMOVED from Prior Policy: Quantity restriction for 1 repeat tx session per year

HealthNet ® 4/1/11 4/1/13 covered covered Silent

covered (see

limitation) Silent

Perforators only Staged: Perforators staged after ablation of saph sys (p. 3 bot); Repeat Px: > twice considered not medically necessary; Other Contraindications p. 4

(29)

Managing Payer Requirements

13

13_{This does not represent a comprehensive list of plans. Sources for United, Cigna, and Aetna Policies accurate as of 2/1/2013:}

http://www.aetna.com/cpb/medical/data/1_99/0050.html

http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0234_coveragepositioncriteria_varicose_vein_treatments.pdf https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Varicose_Veins_Surgical_Interventions_Apr_11.pd

Medical Necessity Documentation Covered Complications/Functional Impairments of CVI

Condition Confirmation Conservative Therapy Notes

Ski n U lce r B le e di ng Thrm oboph le b it is D e rm at it is Ede m a C e llul it is P ai n Notes documented Incompetence at the SF or SP junctions Doppler or Duplex US prior, during, and post-tx

3 month trial (e.g. analgesics and rx gradient Compression stockings), only if the leg has never

undergone prior surgical treatment

CT not required for patients w/ persistent/recurrent VV with prior RFA or stipping/division/ligation in same leg b/c CT is unlikely to be

successful (bottom p 1- top 2). X X X X X

>1 minor or single significant bleeding episode; pain requiring chronic analgesic meds; symptoms other than bleeding refractory to 3 mos. CT

High Risk or Low Risk varicose veins (p. 1-2)

Doppler/Duplex US reports < 12 mos old; and/or standing photos confirming veins > or = 3 mm diameter (p. 3); tx plan w/ procedure codes for planned intervention

documented failure of medically supervised CT; includes Compression Stocking Tx for 3 consecutive months (p. 2)

US no more than 12 mos prior to

px X X X X X X X

leg ulceration refractory to conservative management; recurrent bleeding; hx of bleeding; pain resulting in functional impairment Complications d/t varicosities over at least 3 sequential months (p. 2)

Color photos (if required, p. 2), taken in Provider office, w/ruler; Duplex scan or US (not hand-held Doppler) with pre-tx mapping (p. 3); Patency of deep veins (p. 4 top)

6 weeks compression stockings, leg elevation, walking, AND avoidance of prolonged standing (p. 3 top) Lipodermatosclerosis; Hemorrhage; > or = 2 episodes significant / persistent

thrombophlebitis not responsive to

> 4 wks CT (p. 3) X X X X X X

Document complications over 3 mos sequential OV; symptoms/signs severe enough to impair mobility or ADLs (p. 3)

Payer

(clicking on

cell directs to

website)

Aetna ® Cigna ® HealthNet ® 29

(30)

Additional

Reimbursement Support

You can also access Reimbursement Support by calling 877-278-7482

Speak to live certified coders for coding, coverage and payment inquiries

and ask more complex coding questions

24 hour turn-around for after-hours calls left on voicemail

Email address:

[email protected]

Hours of Operation:

8 AM to 5 PM

Central Standard Time, Monday through Friday

30 COVIDIEN, COVIDIEN with logo and Covidien logo are US and internationally registered trademarks of Covidien AG. All other trademarks are property of their respective owners.

Disclaimer: CMS was the primary source of the information contained in this document. Covidien does not represent or guarantee that this information is complete, accurate, or applicable to any particular patient or third party payer. Covidien disclaims all liability for any consequence resulting from reliance on this document. The final decision of billing for any service must be made by the health care provider considering the medical necessity of the service furnished as well as the requirements of third-party payers and any local, state, or federal laws and regulations that apply. Covidien is providing this information in an educational capacity with the understanding that Covidien is not engaged in rendering accounting or other professional services. Covidien encourages all health care providers to consult with their own advisors regarding coding and payment.

Venefit Targeted Endovenous Therapy

Venefit

™

Targeted

Endovenous Therapy

Coding, Reimbursement, and Coverage Guidelines

Primer for New Accounts

Trish Dawidczyk

Field Reimbursement Manager, Vascular Therapies

Disclaimer

Reimbursement information is gathered from the CMS web site and is presented for illustrative

purposes only. This information cannot guarantee coverage or reimbursement, and does not

constitute reimbursement or legal advice. We strongly recommend that you work with a

qualified consultant or attorney to determine the billing practices for your office.

Every effort has been made to ensure that the information provided in this document is accurate.

Reimbursement information changes periodically. Service providers should make sure that they

are reviewing the most recent update to this document and the most recent reimbursement

guidance from their payers. As a result, Covidien can make no representation or warranty

regarding this information or its completeness, accuracy, timeliness, or applicability with respect

to any particular patient or third party payer.

Service providers are responsible for their decisions relating to coding and reimbursement

submissions. This document reflects payment estimates only and is not a guarantee of payment.

AMA CPT Copyright Statement: CPT codes and descriptions are copyright 2013 American

Contents

Part I: Clinical Background

Part II: Coding and Reimbursement

Part III: Claims and Coverage Guidelines

Part IV: Managing Managed Care

Clinical Need

Venous insufficiency affects more than 30 million people in the US

alone

1,2

• Veins may be symptomatic or asymptomatic

• Asymptomatic may/may not need treatment, generally not covered

by insurance

1

Source: Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: Clinical practice guidelines of the

Society for Vascular Surgery and the American Venous Forum. JVS; May 2011.

2

Source; Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc.

Company),

www.mrg.net

<

http://www.mrg.net/

> , May 2011.

The Venefit

™

Procedure

The Venefit

™

procedure can be performed:

3, 4

– Outpatient

– Local anesthesia

– Few complications

– Limited pain, bruising, and tenderness

– Faster return to ADL’s & work compared to 980 nm laser

Vein occlusion rates of 92.6% three years post-treatment

3, 4

Reflux-free rate of 95.7% three years post-treatment

3, 4

Can be offered as a stand-alone procedure or

in combination with adjunctive phlebectomy or sclerotherapy

Device Indications and Contraindications

5

Indications:

The Venefit™ procedure system is intended for endovascular coagulation of blood

vessels in patients with superficial vein reflux.

The Venefit™ ClosureRFS stylet is intended for use in vessel and tissue coagulation

including treatment of incompetent (i.e. refluxing) perforator and tributary veins.

Contraindications:

Patients with thrombus in the vein segment to be treated.

Caution: The vein wall may be thinner in an aneurysmal segment. To effectively

occlude a vein with an aneurysmal segment, additional tumescent infiltration may be

needed over the aneurysmal segment, and the treatment of the vein should include

segments proximal and distal to the aneurysmal segment.

Caution: No data exists regarding the use of this catheter in patients with

documented peripheral arterial disease. The same care should be taken in the

treatment of patients with significant peripheral arterial disease as would be taken

with a traditional vein ligation and stripping procedure.