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NCD for Transcatheter Mitral Valve Repair (TMVR)


Effective for claims with dates of service furnished on or after August 7, 2014, the Centers for Medicare & Medicaid Services (CMS) will reimburse claims for TMVR for Mitral Regurgitation (MR) when furnished under Coverage with Evidence Development (CED).

TMVR is non-covered for the treatment of MR when not furnished under CED according to the above-noted criteria. TMVR used for the treatment of any non-MR indications are non-covered by Medicare.

Coding Requirements for TMVR for MR Claims Furnished on or After August 7, 2014

The Current Procedural Terminology (CPT) Codes for TMVR for MR Claims are:

• 0343T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis. (Note: 0343T will be replaced by CPT code 33418 effective January 1, 2015.)

• 0344T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure). (Note: 0344T will be replaced by CPT code 33419 effective January 1, 2015.)

• 0345T - Transcatheter mitral valve repair percutaneous approach via the coronary sinus

• 33418 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. (Note: CPT code 33418 is effective January 1, 2015.)

• 33419 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session. (List separately in addition to code for primary procedure.) (Note: CPT code 33419 is effective January 1, 2015.)

ICD-9/ICD-10 Codes for TMVR for MR Claims

• ICD-9 Procedure Code - 35.97 - Percutaneous mitral valve repair with implant - and ICD-10 procedure code is 02UG3JZ – Supplement mitral valve with synthetic substitute, percutaneous approach

• ICD-9 Diagnosis Code for TMVR for MR Claims is - 424.0 – Mitral valve disorder and ICD-10 diagnosis codes are I34.0 – Nonrheumatic mitral (valve) insufficiency or I34.8 – Other nonrheumatic mitral valve disorders

Professional Claims Place of Service (POS) Codes for TMVR for MR Claims

Effective for claims with dates of service on and after August 7, 2014, place of service (POS) code 21 is valid for use for TMVR for MR services. All other POS codes will be denied. MACs will supply the following messages when MACs denying TMVR for MR claims for invalid POS:

• Claim Adjustment Reason Code (CARC) 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed Advance Beneficiary Notice (ABN) is on file.)

Professional Claims Modifiers for TMVR for MR Claims

Effective for claims with dates of service on or after August 7, 2014, MACs will pay TMVR for MR claim lines billed with CPT codes 0343T, 0344T, and 00345T when billed for two surgeons/co-surgeons only when the claim includes modifier -62. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.) Claim lines for two surgeons/co-surgeons billed without modifier -62 shall be returned as unprocessable.

Effective for claims with dates of service on or after August 7, 2014, MACs will pay claim lines for TMVR for MR billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial when billed with modifier -Q0. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.) TMVR for MR claim lines in a clinical trial billed without modifier -Q0 will be returned as unprocessable. 

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9002.pdf

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