TCAR Reimbursement Services
The latest resources and information concerning coding, payment and coverage of TransCarotid Artery Revascularization (TCAR). The information provided herein is for informational purposes only and is intended to explain coverage, coding, and payment policies potentially applicable to TransCarotid Artery Revascularization (TCAR) using Silk Road Medical’s ENROUTE Transcarotid Neuroprotection (NPS) and Transcarotid Stent System (TSS).
Services Overview
TCAR may be described by the same Current Procedural Terminology (CPT®)1 codes and International Classification of Diseases codes (10th revision, clinical modification)2 (ICD-10-CM) as Carotid Artery Stenting (CAS). The ICD-10-CM codes crosswalk to Medicare Severity Diagnosis Related Groups (MS-DRG) for the purposes of hospital inpatient reimbursement. Medicare and most other insurers typically make payment for services based on fee schedules tied to CPT codes or MS-DRGs. Reimbursement policies and rates applicable to TCAR may be similar to those applicable to CAS.
Quick Links to Reimbursement Resources:- TCAR Reimbursement Guide
- C-Codes for TCAR Procedure
- Sample Dictation Report
- Sample Prior Authorization Letter for High Risk or Standard Surgical Risk
For reimbursement questions about Silk Road Medical products, please contact our Health Economics & Reimbursement staff at reimbursement@silkroadmed.com.
TCAR Reimbursement GuideView information on commonly billed hospital and physician codes, Medicare National Average payment rates, and Medicare coverage for patients at high risk and standard surgical risk.
C-Codes for the TCAR ProcedureC-Codes are generally used only for the outpatient setting. TCAR and transfemoral carotid artery stenting procedures only receive CMS coverage when performed on an in-patient basis. The following C-codes are therefore used primarily for internal tracking purposes only.
Carotid Artery Stenting & TCAR Coverage
Medicare (CMS) Coverage
Medicare’s National Coverage Decision (NCD Manual Section 20.7) covers inpatient carotid artery stenting procedures including TCAR in select patient populations:
CMS Definitions of High Surgical Risk
Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection) and would be poor candidates for CEA. The determination that a patient is at high risk for CEA and the patient’s symptoms of carotid artery stenosis shall be available in the patient medical records prior to performing any procedure.
Significant comorbid conditions include but are not limited to:
- Age ≥ 75
- Prior head/neck surgery or irradiation
- Restenosis post CEA
- Surgically inaccessible lesion
- Permanent contralateral cranial nerve injury
- Contralateral occlusion
- Congestive heart failure w/ NYHA class III or IV
- Left ventricular ejection fraction ≥ 30%
- ≥ 2 diseased coronaries with ≥ 70% stenosis
- Unstable angina
- Myocardial infarction > 72 hours and < 6 weeks prior to procedure
- Abnormal stress test
- Need for open heart surgery
- Need for major surgery (including vascular)
- Uncontrolled diabetes
- Severe pulmonary disease
- Cervical spine immobility
- Laryngeal palsy or laryngectomy
- Severe tandem lesions
- Bilateral stenosis requiring treatment
- Chronic renal insufficiency (Creatinine ≥ 2.5 mg/dl)
This is not an exhaustive list of high-risk factors for CEA. Other conditions were used to determine patients at high risk for CEA in carotid artery stenting trials and studies.
Patients that do not meet high risk criteria for CEA are considered standard surgical risk.
CMS Definition of SymptomaticSymptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (Modified Rankin Scale < 3 with symptoms for 24 hours or more), and transient monocular blindness (amaurosis fugax). Patients who have had a disabling stroke (Modified Rankin Scale > 3) shall be excluded from coverage.
CMS Definition of Stenosis MeasurementThe degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or contrast tomography angiography (CTA) or magnetic resonance angiography (MRA) or carotid artery angiography and recorded in the patient’s medical records.
TCAR Surveillance ProjectEffective September 1, 2016, hospitals participating in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) receive CMS coverage for Transcarotid Artery Revascularization (TCAR) procedures entered into the VQI Carotid Artery Stenting module. According to the National Coverage Determination (NCD) 20.7 for Percutaneous Transluminal Angioplasty, the TCAR Surveillance Project is an FDA-approved post-approval carotid stenting study. CMS will reimburse hospitals and physicians for symptomatic and asymptomatic patients at high risk or standard risk for traditional carotid artery surgery who participate in the TCAR Surveillance Project. View the CMS coverage letters detailing approval of the TCAR Surveillance Project for high-risk and standard surgical risk patients.
Under NCD 20.7, the TCAR Surveillance Project does not require the study sites to get approval from the Medicare Administrative Contractors. For billing purposes, facilities and providers will submit claims for the TCAR Surveillance Project using National Clinical Trial (NCT) identifier 02850588.
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