Bundled Episode Payment and Gainsharing …Page 1 Bundled Episode Payment and Gainsharing...
Transcript of Bundled Episode Payment and Gainsharing …Page 1 Bundled Episode Payment and Gainsharing...
©2016 Integrated Healthcare Association. All Rights Reserved. Page 1
Bundled Episode Payment and Gainsharing Demonstration*
Cardiovascular Episode Definitions
Episode Definitions
1. Angioplasty with Stents
2. Diagnostic Cardiac Catheterization
* This project was supported by grant number R18HS020098 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
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Bundled Episode Payment and Gainsharing Demonstration* Angioplasty with Stents Definition
Component Clinical/Payment
Summary Description
This definition covers a 30-day period of treatment for a qualified patient that begins with a scheduled angioplasty with drug-eluting stent or bare metal stent in one vessel or two vessels as an outcome of the diagnostic catheterization. The episode includes:
Professional and facility charges for angioplasty with drug eluting or bare metal stent(s) in one or two vessels (the index procedure) and for any observation stay.
Routine follow-up care during the episode period provided by the interventional cardiologist (or his cardiology group) during the episode period
Professional and facility charges for outpatient treatment of patient complications arising during the index procedure
Episode price will vary by whether stents are placed in one or two vessels, but not by the type or number of stents per cardiac vessel (Medicare billing definition). The definition excludes patients treated with stents in more than two vessels or who proceed to a coronary artery bypass graft as the recommended treatment following the diagnostic catheterization. This definition requires that an episode rate adjustment be assessed in the event any of a number of defined complications occurs. An episode rate adjustment is an amount that the provider team reimburses the health plan when defined complications occur during the episode period. The amount of the episode rate adjustment is negotiated between the health plan and the primary provider contractor for the episode and may vary by the type of complication; the complications are defined in Attachment B.
Episode Period 0 to 30; Episode begins on date for first index procedure and ends 30 days after the procedure date.
Dx, DRG and procedure codes for standard episodes
See Attachment A
Services
Services expected within the episode period (may not be separately billed), include:
Facility Charges—all services rendered on the same day as the index procedure and during any observational stay following the procedure,
Professional Charges—All services provided by Cardiologists, Interventional Cardiologists, Anesthesiologists, Radiologists, Hospitalists, Other consultants (e.g., internist) on the same day as the index procedure, or during an observational stay following the procedure.
Charges for x-rays or imaging performed on the same day as the index procedure, or during an observational stay following the procedure
Services which, if they occur within the episode period, may not be separately billed:
Professional fees for treatment of complications during episode period
Outpatient facility charges for treatment of complications during episode period
Professional and facility charges for repeat procedure within episode period
Charges for specified cardiac procedures (see Attachment C)
Services excluded from Standard Definition, may be separately billed:
OP Rx
Patient Qualification
For inclusion in the pilot, patient must be:
Covered by participating health plan on date of procedure
Over age 18 and under age 65
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Patients are excluded from the pilot if:
Covered by Medicare as primary payer
Admitted to the cath lab from an inpatient setting
Admitted to the cath lab from an emergency department
Diagnosis in any position equals one of the following:
Description ICD-9-CM Diagnosis
Acute Myocardial Infarction
410, 410.x, 410.xx,
429.5, 429.6, 429.7, 429.71, 429.79
Cardiac Trauma 423.0, 861.0, 861.00-861.03,
861.1, 861.10-861.13
Cardiac Congenital Disorder
425.1, 425.2, 745.0-745.9,
745.10-745.12, 745.19, 745.60, 745.61, 745.69, 746, 746.0-746.9, 746.00-746.02, 746.09, 746.81-746.89, 747, 747.0-747.5, 747.8, 747.9, 747.20-747.22, 747.29, 747.40-747.42, 747.49, 747.83, 747.89
Heart Transplant V42.1
Cancer 140-209, 230-239
HIV 042
BMI>=40 V85.4
Chronic Kidney Disease: Stage III, GFR 30-59
585.3
Chronic Kidney Disease: Stage IV, GFR 15-29
585.4
Chronic Kidney Disease: Stage V, GFR <15
585.5
Acute Congestive Heart Failure
428.21, 428.23, 428.31, 428.33, 428.41, 428.43
Outliers No clinical definition (that is, all patients are inliers).
Inpatient Complications
An episode rate adjustment applies if complications result in a CABG or in a related ED visit or inpatient stay within the episode period. See Attachment B.
Outpatient Complications
The episode includes all professional and facility charges to treat complications if the primary diagnosis code is one of the cardiac complication codes listed in Attachment B.
Other Outpatient Services
The definition includes all charges for services provided by the cardiologist or his cardiology group for follow-up care related to the procedure during the episode period and all charges (professional, facility, imaging center, etc) for the procedures identified in Attachment C.
Repeat Procedures
All charges for repeat procedures that are performed between the 1st and 30th day following the index procedure are included in the episode period (may not be separately billed). A repeat procedure is defined according the criteria in Attachment A.
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Attachment A: Codes: Angioplasty with Stents
Index Procedure Code: One of these procedures must exist to trigger the episode. Angioplasty with Drug-Eluting or Non Drug Eluting Stent Stents in one vessel Drug Eluting : CPT: G0290 - Transcatheter placement of a drug eluting
intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel
ICD-9 Procedure Code:
36.07 - Insertion of drug-eluting coronary artery stent(s)
Non Drug Eluting: CPT: 92980 - Transcatheter placement of an intracoronary
stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel
Stents in two vessels Drug Eluting : CPT: G0291 - Transcatheter placement of a drug eluting
intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel
92981 - Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel
ICD-9 Procedure Code: 36.07 - Insertion of drug-eluting coronary artery stent(s)
Diagnosis Inclusions: Post-procedure diagnosis (any position) for the anchor procedure equals one of the following:
411 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE*
411 POSTMYOCARDIAL INFARCTION SYNDROME
411.1 INTERMEDIATE CORONARY SYNDROME
411.8 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE*
411.81 ACUTE COR OCCLUSION WITHOUT MYOCARDIAL INFARCT
411.89 OTHER ACUTE&SUBACUTE FORM ISCHEMIC HEART DISEASE
412 OLD MYOCARDIAL INFARCTION
413 ANGINA PECTORIS*
413 ANGINA DECUBITUS
413.1 PRINZMETAL ANGINA
413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS
414 OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE*
414.0x-414.07
CORONARY ATHEROSCLEROSIS
414.1 ANEURYSM AND DISSECTION OF HEART*
414.1 ANEURYSM OF HEART
414.11 ANEURYSM OF CORONARY VESSELS
414.12 DISSECTION OF CORONARY ARTERY
414.19 OTHER ANEURYSM OF HEART
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE
414.1 ANEURYSM AND DISSECTION OF HEART*
414.1 ANEURYSM OF HEART
414.11 ANEURYSM OF CORONARY VESSELS
414.12 DISSECTION OF CORONARY ARTERY
414.19 OTHER ANEURYSM OF HEART
414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY
414.3 CORONARY ATHEROSCLEROSIS D/T LIPID RICH PLAQUE
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE
428 HEART FAILURE*
428.1 LEFT HEART FAILURE
428.2 SYSTOLIC HEART FAILURE*
428.2 UNSPECIFIED SYSTOLIC HEART FAILURE
428.22 CHRONIC SYSTOLIC HEART FAILURE
428.3 DIASTOLIC HEART FAILURE*
428.3 UNSPECIFIED DIASTOLIC HEART FAILURE
428.32 CHRONIC DIASTOLIC HEART FAILURE
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428.4 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE*
428.4 UNSPEC COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE
428.42 CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAILURE
428.9 UNSPECIFIED HEART FAILURE
429.5 RUPTURE OF CHORDAE TENDINEAE
429.6 RUPTURE OF PAPILLARY MUSCLE
429.7 CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NEC*
429.71 ACQUIRED CARDIAC SEPTAL DEFECT
429.79 OTHER CERTAIN SEQUELAE MYOCARDIAL INFARCTION NEC
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Attachment B: Complications that result in an episode rate adjustment
Regardless of the provider used, a repeat procedure during the episode period will generate a financial penalty. Regardless of the provider used, if a patient receives angioplasty with stent(s) and subsequently receives CABG between the 1st and the 30th day following the index procedure, CABG is assumed to have resulted from a complication and will generate an episode rate adjustment An acute admission is any admission during the episode period beyond a 23 hour and 59 minute observation stay following the index procedure. Regardless of the provider or site of service, any ED visit or acute admission that begins between the 1st and the 30th day following the index procedure, and carries a diagnosis contained in the table below will result in an episode rate adjustment.
ICD-9 Dx Code Diagnosis Code Description ETG Description
410 ACUTE MYOCARDIAL INFARCTION* Ischemic heart disease
410.0 ACUTE MYOCARDIAL INFARCTION ANTEROLATERAL WALL* Ischemic heart disease
410.00 ACUT MI ANTEROLAT WALL EPIS CARE UNS Ischemic heart disease
410.01 ACUT MI ANTEROLAT WALL INIT EPIS CARE Ischemic heart disease
410.02 ACUT MI ANTEROLAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.1 ACUTE MYOCARDIAL INFARCTION OTHER ANTERIOR WALL* Ischemic heart disease
410.10 ACUT MYOCARD INFARCT OTH ANT WALL EPIS CARE UNS Ischemic heart disease
410.11 ACUT MYOCARD INFARCT OTH ANT WALL INIT EPIS CARE Ischemic heart disease
410.12 ACUT MI OTH ANT WALL SUBSQT EPIS CARE Ischemic heart disease
410.2 ACUTE MYOCARDIAL INFARCTION INFEROLATERAL WALL* Ischemic heart disease
410.20 ACUT MI INFEROLAT WALL EPIS CARE UNS Ischemic heart disease
410.21 ACUT MI INFEROLAT WALL INIT EPIS CARE Ischemic heart disease
410.22 ACUT MI INFEROLAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.3 ACUTE MYOCARDIAL INFARCTION INFEROPOSTERIOR WALL* Ischemic heart disease
410.30 ACUT MI INFEROPOST WALL EPIS CARE UNS Ischemic heart disease
410.31 ACUT MI INFEROPOST WALL INIT EPIS CARE Ischemic heart disease
410.32 ACUT MI INFEROPOST WALL SUBSQT EPIS CARE Ischemic heart disease
410.4 ACUTE MYOCARDIAL INFARCTION OTHER INFERIOR WALL* Ischemic heart disease
410.40 ACUT MYOCARD INFARCT OTH INF WALL EPIS CARE UNS Ischemic heart disease
410.41 ACUT MYOCARD INFARCT OTH INF WALL INIT EPIS CARE Ischemic heart disease
410.42 ACUT MI OTH INF WALL SUBSQT EPIS CARE Ischemic heart disease
410.5 ACUTE MYOCARDIAL INFARCTION OTHER LATERAL WALL* Ischemic heart disease
410.50 ACUT MYOCARD INFARCT OTH LAT WALL EPIS CARE UNS Ischemic heart disease
410.51 ACUT MYOCARD INFARCT OTH LAT WALL INIT EPIS CARE Ischemic heart disease
410.52 ACUT MI OTH LAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.6 ACUTE MYOCARD INFARCT TRUE POST WALL INFARCT* Ischemic heart disease
410.60 ACUT MI TRUE POST WALL INFARCT EPIS CARE UNS Ischemic heart disease
410.61 ACUT MI TRUE POST WALL INFARCT INIT EPIS CARE Ischemic heart disease
410.62 ACUT MI TRUE POST WALL INFARCT SUBSQT EPIS CARE Ischemic heart disease
410.7 ACUTE MYOCARDIAL INFARCT SUBENDOCARDIAL INFARCT* Ischemic heart disease
410.70 ACUT MI SUBENDOCARDIAL INFARCT EPIS CARE UNS Ischemic heart disease
410.71 ACUT MI SUBENDOCARDIAL INFARCT INIT EPIS CARE Ischemic heart disease
410.72 ACUT MI SUBENDOCARDIAL INFARCT SUBSQT EPIS CARE Ischemic heart disease
410.8 ACUTE MYOCARDIAL INFARCTION OTHER SPEC SITES* Ischemic heart disease
410.80 ACUT MYOCARD INFARCT OTH SPEC SITE EPIS CARE UNS Ischemic heart disease
410.81 ACUT MYOCARD INFARCT OTH SITE INIT EPIS CARE Ischemic heart disease
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410.82 ACUT MYOCARD INFARCT OTH SITE SUBSQT EPIS CARE Ischemic heart disease
410.9 ACUTE MYOCARDIAL INFARCTION UNSPECIFIED SITE* Ischemic heart disease
410.90 ACUT MYOCARD INFARCT UNS SITE EPIS CARE UNS Ischemic heart disease
410.91 ACUTE MYOCARD INFARCT UNSPEC SITE INIT EPIS CARE Ischemic heart disease
410.92 ACUT MYOCARD INFARCT UNS SITE SUBSQT EPIS CARE Ischemic heart disease
411 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE* Ischemic heart disease
411.0 POSTMYOCARDIAL INFARCTION SYNDROME Ischemic heart disease
411.1 INTERMEDIATE CORONARY SYNDROME Ischemic heart disease
411.8 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE* Ischemic heart disease
411.81 ACUTE COR OCCLUSION WITHOUT MYOCARDIAL INFARCT Ischemic heart disease
411.89 OTHER ACUTE&SUBACUTE FORM ISCHEMIC HEART DISEASE Ischemic heart disease
412 OLD MYOCARDIAL INFARCTION Ischemic heart disease
413 ANGINA PECTORIS* Ischemic heart disease
413.0 ANGINA DECUBITUS Ischemic heart disease
413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS Ischemic heart disease
414.0 CORONARY ATHEROSCLEROSIS* Ischemic heart disease
414.00 COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT Ischemic heart disease
414.01 CORONARY ATHEROSCLEROSIS NATIVE CORONARY ARTERY Ischemic heart disease
414.02 CORONARY ATHEROSLERO AUTOL VEIN BYPASS GRAFT Ischemic heart disease
414.03 COR ATHEROSLERO NONAUTOL BIOLOGICAL BYPS GRAFT Ischemic heart disease
414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT Ischemic heart disease
414.05 CORONARY ATHEROSLERO UNSPEC TYPE BYPASS GRAFT Ischemic heart disease
414.06 COR ATHEROSLERO COR ART TRANSPLANTED HEART Ischemic heart disease
414.07 COR ATHEROSLERO BYPS GRAFT TRANSPLANTED HEART Ischemic heart disease
414.1 ANEURYSM AND DISSECTION OF HEART* Ischemic heart disease
414.10 ANEURYSM OF HEART Ischemic heart disease
414.11 ANEURYSM OF CORONARY VESSELS Ischemic heart disease
414.12 DISSECTION OF CORONARY ARTERY Ischemic heart disease
414.19 OTHER ANEURYSM OF HEART Ischemic heart disease
414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY Ischemic heart disease
414.3 CORONARY ATHEROSCLEROSIS D/T LIPID RICH PLAQUE Ischemic heart disease
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE Ischemic heart disease
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE Ischemic heart disease
415.1 PULMONARY EMBOLISM AND INFARCTION* Pulmonary embolism
415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION Pulmonary embolism
415.12 SEPTIC PULMONARY EMBOLISM Pulmonary embolism
415.19 OTHER PULMONARY EMBOLISM AND INFARCTION Pulmonary embolism
416.2 CHRONIC PULMONARY EMBOLISM Pulmonary embolism
423.0 HEMOPERICARDIUM Cardiac trauma
423.3 CARDIAC TAMPONADE Cardiovascular diseases signs & symptoms
428 HEART FAILURE* Congestive heart failure
428.0 CONGESTIVE HEART FAILURE UNSPECIFIED Congestive heart failure
428.1 LEFT HEART FAILURE Congestive heart failure
428.2 SYSTOLIC HEART FAILURE* Congestive heart failure
428.20 UNSPECIFIED SYSTOLIC HEART FAILURE Congestive heart failure
428.21 ACUTE SYSTOLIC HEART FAILURE Congestive heart failure
428.22 CHRONIC SYSTOLIC HEART FAILURE Congestive heart failure
428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE Congestive heart failure
428.4 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE* Congestive heart failure
428.40 UNSPEC COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
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428.41 ACUTE COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
428.42 CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
428.43 ACUTE CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAIL Congestive heart failure
428.9 UNSPECIFIED HEART FAILURE Congestive heart failure
444 ARTERIAL EMBOLISM AND THROMBOSIS* Arterial embolism/thrombosis
444.0 EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA Arterial embolism/thrombosis
444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA Arterial embolism/thrombosis
444.2 EMBOLISM&THROMBOSIS ARTERIES THE EXTREMITIES* Arterial embolism/thrombosis
444.21 EMBOLISM&THROMBOSIS ARTERIES UPPER EXTREMITY Arterial embolism/thrombosis
444.22 EMBOLISM&THROMBOSIS ARTERIES LOWER EXTREMITY Arterial embolism/thrombosis
444.8 EMBOLISM&THROMBOSIS OF OTHER SPECIFIED ARTERY* Arterial embolism/thrombosis
444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY Arterial embolism/thrombosis
444.89 EMBOLISM&THROMBOSIS OF OTHER SPECIFIED ARTERY Arterial embolism/thrombosis
444.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY Arterial embolism/thrombosis
445 ATHEROEMBOLISM* Arterial embolism/thrombosis
445.0 ATHEROEMBOLISM OF EXTREMITIES* Arterial embolism/thrombosis
445.01 ATHEROEMBOLISM OF UPPER EXTREMITY Arterial embolism/thrombosis
445.02 ATHEROEMBOLISM OF LOWER EXTREMITY Arterial embolism/thrombosis
445.8 ATHEROEMBOLISM OF OTHER SITES* Arterial embolism/thrombosis
445.81 ATHEROEMBOLISM OF KIDNEY Arterial embolism/thrombosis
445.89 ATHEROEMBOLISM OF OTHER SITE Arterial embolism/thrombosis
447.2 RUPTURE OF ARTERY Arterial embolism/thrombosis
451.0 PHLEBITIS&THROMBOPHLEB SUP VESSELS LOWER EXTREM Phlebitis & thrombophlebitis of veins
451.1 PHLEBITIS&THROMBOPHLEB DEEP VEINS LOWER EXTREM* Phlebitis & thrombophlebitis of veins
451.11 PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN Phlebitis & thrombophlebitis of veins
451.19 PHLEBITIS&THROMBOPHLEB OTH DEEP VES LOWER EXTREM Phlebitis & thrombophlebitis of veins
451.2 PHLEBITIS&THROMBOPHLEBITIS LOWER EXTREM UNSPEC Phlebitis & thrombophlebitis of veins
451.81 PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN Phlebitis & thrombophlebitis of veins
453.4 AC VNUS EMB&THRMB DP VES LWR EXTREM Embolism & thrombosis of veins
453.40 AC VNUS EMB&THRMB UNS DP VES LW EXT Embolism & thrombosis of veins
453.41 AC VNUS EMB&THRMB DP VES PRX LW EXT Embolism & thrombosis of veins
453.42 AC VNUS EMB&THRMB DP VES DST LW EXT Embolism & thrombosis of veins
453.5 CHRON VENOUS EMB & THROMBO DEEP VES LOWR EXTREM Embolism & thrombosis of veins
453.50 CHRON VNUS EMB & THROMB UNSPEC DEEP VES LOWR EXT Embolism & thrombosis of veins
453.51 CHRN VNUS EMB & THROMB DEEP VES PROX LOWR EXTREM Embolism & thrombosis of veins
453.52 CHRN VNUS EMBO & THROMB DP VES DISTL LOWR EXTREM Embolism & thrombosis of veins
453.6 VENOUS EMBO & THROMB SUPERFICIAL VES LOWR EXTREM Embolism & thrombosis of veins
785.51 CARDIOGENIC SHOCK Cardiovascular diseases signs & symptoms
786.5 CHEST PAIN* Cardiovascular diseases signs & symptoms
786.50 CHEST PAIN UNSPECIFIED Cardiovascular diseases signs & symptoms
786.51 PRECORDIAL PAIN Cardiovascular diseases signs & symptoms
786.59 OTHER CHEST PAIN Cardiovascular diseases signs & symptoms
794.3 NONSPECIFIC ABNORMAL RESULTS CV FUNCTION STUDY* Cardiovascular diseases signs & symptoms
794.30 NONSPECIFIC ABNORMAL UNSPEC CV FUNCTION STUDY Cardiovascular diseases signs & symptoms
794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM Cardiovascular diseases signs & symptoms
794.39 OTH NONSPECIFIC ABNORM CV SYSTEM FUNCTION STUDY Cardiovascular diseases signs & symptoms
861.0 HRT INJURY WITHOUT MENTION OPEN WOUND INTO THOR* Cardiac trauma
861.00 UNSPEC INJURY HRT W/O MENTION OPEN WOUND IN THOR Cardiac trauma
861.01 HRT CONTUS WITHOUT MENTION OPEN WOUND INTO THOR Cardiac trauma
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861.03 HEART LACERATION W/PENETRATION OF CHAMBERS Cardiac trauma
902.0 ABDOMINAL AORTA INJURY Arterial trauma
902.53 ILIAC ARTERY INJURY Arterial trauma
904.0 COMMON FEMORAL ARTERY INJURY Arterial trauma
904.1 SUPERFICIAL FEMORAL ARTERY INJURY Arterial trauma
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Attachment C: Cardiac Procedure Codes: Outpatient Services
All services billed by the interventional cardiologist (or others within the cardiology group) within the episode period are included in the episode definition and may not be separately billed. Other Charges All charges associated with the procedures below are included in the episode definition and may not be separately billed when performed with the episode period.
Procedure Group Description Proc Code Procedure Description
CARDIAC COMPUTED TOMOGRAPHY
0144T Computed tomography, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium
CARDIAC COMPUTED TOMOGRAPHY
0145T Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology
CARDIAC COMPUTED TOMOGRAPHY
0146T
Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary
CARDIAC COMPUTED TOMOGRAPHY
0147T
Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary
CARDIAC COMPUTED TOMOGRAPHY
0148T
Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and
CARDIAC COMPUTED TOMOGRAPHY
0149T
Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and
CARDIAC COMPUTED TOMOGRAPHY
0150T Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology in congenital heart disease
CARDIAC COMPUTED TOMOGRAPHY
0151T
Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing, function evaluation (left and right ventricular function, ejection-fraction and segmental wall motion) (List sep
CARDIAC COMPUTED TOMOGRAPHY
75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
CARDIAC COMPUTED TOMOGRAPHY
75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
CARDIAC COMPUTED TOMOGRAPHY
75573
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation
CARDIAC COMPUTED TOMOGRAPHY
75574
Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation
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CARDIAC MAGNETIC RESONANCE IMAGING
75552 Cardiac magnetic resonance imaging for morphology; without contrast material
CARDIAC MAGNETIC RESONANCE IMAGING
75553 Cardiac magnetic resonance imaging for morphology; with contrast material
CARDIAC MAGNETIC RESONANCE IMAGING
75554 Cardiac magnetic resonance imaging for function, with or without morphology; complete study
CARDIAC MAGNETIC RESONANCE IMAGING
75555 Cardiac magnetic resonance imaging for function, with or without morphology; limited study
CARDIAC MAGNETIC RESONANCE IMAGING
75556 Cardiac magnetic resonance imaging for velocity flow mapping
CARDIAC MAGNETIC RESONANCE IMAGING
75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;
CARDIAC MAGNETIC RESONANCE IMAGING
75558 Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification
CARDIAC MAGNETIC RESONANCE IMAGING
75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
CARDIAC MAGNETIC RESONANCE IMAGING
75560 Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification and stress
CARDIAC MAGNETIC RESONANCE IMAGING
75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;
CARDIAC MAGNETIC RESONANCE IMAGING
75562 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification
CARDIAC MAGNETIC RESONANCE IMAGING
75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
CARDIAC MAGNETIC RESONANCE IMAGING
75564 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification and stress
CARDIAC MAGNETIC RESONANCE IMAGING
75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)
ECHOCARDIOGRAPHY 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete
ECHOCARDIOGRAPHY 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study
ECHOCARDIOGRAPHY 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography
ECHOCARDIOGRAPHY 93307 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography
ECHOCARDIOGRAPHY 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study
ECHOCARDIOGRAPHY C8929
Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler
EKG 0178T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report
EKG 0179T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and graphics only, without interpretation and report
EKG 0180T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; interpretation and report only
EKG 0206T Algorithmic analysis, remote, of electrocardiographic-derived data with computer
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probability assessment, including report
EKG 3120F 12-Lead ECG Performed (EM)
EKG 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
EKG 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
EKG 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
EKG 93040 Rhythm ECG, 1-3 leads; with interpretation and report
EKG 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report
EKG 93042 Rhythm ECG, 1-3 leads; interpretation and report only
EKG C8921 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete
EKG C8922 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study
EKG C8923 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D) with or without M-mode recording; complete
EKG C8924 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D) with or without M-mode recording; follow-up or limited study
EKG C8925
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
EKG C8926 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
EKG C8928
Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pha
EKG G0366 Ecg at least 12 leads; i&r cmpnt init prev pe
EKG G0367 Ecg =/>12 leads; tracing only cmpnt init prev pe
EKG G0368 Ecg =/> 12 leads; i&r only cmpnt init prev pe
EKG G8350 Pt doc to have had 12-lead ecg performed
EKG G8356 Pt doc to have had ecg performed
EKG G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy
EXERCISE STRESS TEST 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report
EXERCISE STRESS TEST 93016 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report
EXERCISE STRESS TEST 93017 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report
EXERCISE STRESS TEST 93018 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only
CARDIAC PERFUSION IMAGING AT REST ONLY
78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or
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gated technique, additional quantification, when performed); single study, at rest or stress (
CARDIAC PERFUSION IMAGING AT REST ONLY
78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or
CARDIAC PERFUSION IMAGING AT REST ONLY
78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
CARDIAC PERFUSION IMAGING AT REST ONLY
78454
Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) an
CARDIAC PERFUSION IMAGING AT REST ONLY
78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation
CARDIAC PERFUSION IMAGING AT REST ONLY
78460 Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78461 Myocardial perfusion imaging; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78464 Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78465
Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative
CARDIAC PERFUSION IMAGING AT REST ONLY
78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
CARDIAC PERFUSION IMAGING AT REST ONLY
78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing
CARDIAC PERFUSION IMAGING AT REST ONLY
78478 Myocardial perfusion study with wall motion, qualitative or quantitative study (List separately in addition to code for primary procedure)
CARDIAC PERFUSION IMAGING AT REST ONLY
78480 Myocardial perfusion study with ejection fraction (List separately in addition to code for primary procedure)
CARDIAC PERFUSION IMAGING AT REST ONLY
78481 Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
CARDIAC PERFUSION IMAGING AT REST ONLY
78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress
CARDIAC PERFUSION IMAGING AT REST ONLY
78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress
CARDIAC PERFUSION IMAGING AT REST ONLY
78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing
CARDIAC PERFUSION IMAGING AT REST ONLY
78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure)
CARDIAC PERFUSION IMAGING AT 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine
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REST ONLY
CARDIAC IMAGING WITH EXERCISE
78473 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification
CARDIAC IMAGING WITH EXERCISE
78483 Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
CARDIAC IMAGING WITH EXERCISE
93350
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation
CARDIAC IMAGING WITH EXERCISE
93351
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation
CARDIAC IMAGING WITH EXERCISE
A9500 Technetium tc-99m sestamibi, diagnostic, per study dose
CARDIAC IMAGING WITH EXERCISE
A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie
CARDIAC IMAGING WITH EXERCISE
C8930
Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise
TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY
93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY
93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only
TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY
93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY
93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only
*This project was supported by grant number R18HS020098 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
©2016 Integrated Healthcare Association. All Rights Reserved. Page 1
Bundled Episode Payment and Gainsharing Demonstration* Diagnostic Cardiac Catheterization Definition
Component
Clinical/Payment
Summary Description
This definition covers a 30-day period of treatment for a qualified patient that begins with a scheduled cardiac catheterization. The episode includes:
Professional and facility charges for a diagnostic catheterization (index procedure) and for any observation stay.
Routine follow-up care provided by the interventional cardiologist (or her cardiology group) during the episode period
Professional and facility charges for outpatient treatment of patient complications arising during the index procedure
A separate definition and episode price applies to the patient who is treated with an angioplasty with stents in one or two vessels. The definition excludes patients who are treated with stents in more than two vessels or who proceed to a coronary artery bypass graft as the recommended treatment following the diagnostic catheterization. This definition requires that an episode rate adjustment be assessed in the event a defined complication occurs. An episode rate adjustment is an amount that the provider team reimburses the health plan when defined complications occur. The amount of the episode rate adjustment may vary by the type of complication; the complications are defined in Attachment B.
Episode Period
0 to 30; Episode begins on date for index procedure and ends 30 days after the procedure date.
Dx, DRG and procedure codes for standard episodes
See Attachment A
Services
Services expected within the episode period (may not be separately billed), include:
Facility Charges—all services rendered on the same day as the index procedure, or during an observational stay following the procedure.
Professional Charges: All services provided by Cardiologists, Interventional Cardiologists, Anesthesiologists, Radiologists, Hospitalists, Other consultants (e.g., internist) on the same day as the index procedure, or during an observational stay following the procedure.
Charges for x-rays or imaging performed on the same day as the index procedure, or during an observational stay following the procedure.
Services which, if they occur within the episode period, may not be separately billed:
Charges billed by the treating cardiology group and associated facility for outpatient treatment of complications during episode period
Services excluded from Standard Definition, may be separately billed:
OP Rx
Patient Qualification
For inclusion in the pilot, patient must be:
Covered by participating health plan on date of procedure
Over age 18 and under age 65
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Patients are excluded from the pilot if:
Covered by Medicare as primary payer
Admitted to the cath lab from an inpatient setting
Admitted to the cath lab from an emergency department
Diagnosis in any position equals one of the following:
Description ICD-9-CM Diagnosis
Acute Myocardial Infarction
410, 410.x, 410.xx,
429.5, 429.6, 429.7, 429.71, 429.79
Cardiac Trauma 423.0, 861.0, 861.00-861.03, 861.1, 861.10-861.13
Cardiac Congenital Disorder
425.1, 425.2, 745.0-745.9,
745.10-745.12, 745.19, 745.60, 745.61, 745.69, 746, 746.0-746.9, 746.00-746.02, 746.09,
746.81-746.89, 747, 747.0-747.5, 747.8, 747.9, 747.20-747.22, 747.29, 747.40-747.42,
747.49, 747.83, 747.89
Heart Transplant V42.1
Cancer 140-209, 230-239
HIV 042
BMI>=40 V85.4
Chronic Kidney Disease: Stage III, GFR 30-59
585.3
Chronic Kidney Disease: Stage IV, GFR 15-29
585.4
Chronic Kidney Disease: Stage V, GFR <15
585.5
Acute Congestive Heart Failure
428.21, 428.23, 428.31, 428.33, 428.41, 428.43
Additional Exclusions
CABG: Patients who are scheduled to undergo CABG (codes S2205-S2209, 33510-33516, 33533-33536) as appropriate treatment of their disease are excluded from this definition.
If an intervention of angioplasty with drug or non-drug eluting stent occurs, then this bundle is superseded by the bundle for the intervention:
Outliers
No clinical definition (that is, all patients are inliers).
Inpatient Complications
An episode rate adjustment applies if complications result in a CABG or in a related ED visit or inpatient stay within the episode period. See Attachment B.
Outpatient Complications
All services provided by the cardiologist (or his cardiology group) to treat outpatient complications that begin during the episode period are included in the episode, as well as facility charges from the facility where the index procedure was performed.
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Attachment A:
Procedure and Diagnosis Codes Defining Diagnostic Catheterization Procedure
Index Procedure Code: One of these procedures must exist to trigger the episode. Diagnostic catheterization Note that there were several CPT code modifications for diagnostic catheterization effective 1/1/2011. Therefore the code sets used for the retrospective analyses (for services incurred through 12/31/10) will differ from those used for the prospective definition. CPT (for prospective definition): 93451—Right heart catheterization 93452—Left heart catheterization 93453—Combined right and left heart
catheterization 93454-93461—Catheter placement in
coronary artery(s) 93563-93568—Injection procedure during
cardiac cath CPT (for retrospective analyses): 93508—Catheter placement in coronary
artery(s) 93510-93511—Left heart catheterization 93524—Combined transseptal and
retrograde left heart catheterization 93526-93529; 93531-93533—Combined
right and left heart catheterization 93539, 93540, 93543, 93545—Injection
procedure during cardiac cath 93556--Imaging supervision,
interpretation and report for injection procedure(s) during cardiac catheterization
Diagnosis Inclusions: Post-procedure diagnosis (any position) for the anchor procedure must equal one of the following:
411 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE*
411 POSTMYOCARDIAL INFARCTION SYNDROME
411.1 INTERMEDIATE CORONARY SYNDROME
411.8 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE*
411.81 ACUTE COR OCCLUSION WITHOUT MYOCARDIAL INFARCT
411.89 OTHER ACUTE&SUBACUTE FORM ISCHEMIC HEART DISEASE
412 OLD MYOCARDIAL INFARCTION
413 ANGINA PECTORIS*
413 ANGINA DECUBITUS
413.1 PRINZMETAL ANGINA
413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS
414 OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE*
414.0x-414.07 CORONARY ATHEROSCLEROSIS
414.1 ANEURYSM AND DISSECTION OF HEART*
414.1 ANEURYSM OF HEART
414.11 ANEURYSM OF CORONARY VESSELS
414.12 DISSECTION OF CORONARY ARTERY
414.19 OTHER ANEURYSM OF HEART
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE
414.1 ANEURYSM AND DISSECTION OF HEART*
414.1 ANEURYSM OF HEART
414.11 ANEURYSM OF CORONARY VESSELS
414.12 DISSECTION OF CORONARY ARTERY
414.19 OTHER ANEURYSM OF HEART
414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY
414.3 CORONARY ATHEROSCLEROSIS D/T LIPID RICH PLAQUE
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE
428 HEART FAILURE*
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428.1 LEFT HEART FAILURE
428.2 SYSTOLIC HEART FAILURE*
428.2 UNSPECIFIED SYSTOLIC HEART FAILURE
428.22 CHRONIC SYSTOLIC HEART FAILURE
428.3 DIASTOLIC HEART FAILURE*
428.3 UNSPECIFIED DIASTOLIC HEART FAILURE
428.32 CHRONIC DIASTOLIC HEART FAILURE
428.4 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE*
428.4 UNSPEC COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE
428.42 CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAILURE
428.9 UNSPECIFIED HEART FAILURE
429.5 RUPTURE OF CHORDAE TENDINEAE
429.6 RUPTURE OF PAPILLARY MUSCLE
429.7 CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NEC*
429.71 ACQUIRED CARDIAC SEPTAL DEFECT
429.79 OTHER CERTAIN SEQUELAE MYOCARDIAL INFARCTION NEC
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Attachment B:
Complications that result in an episode rate adjustment A CABG performed as a result of complications from diagnostic cath results in an episode rate adjustment. An acute admission is any admission during the episode period beyond a 23 hour and 59 minute observation stay following the index procedure. Regardless of the provider or site of service, any ED visit or acute admission that begins between the 1st and the 30th day following the index procedure, and carries a diagnosis contained in the table below will result in an episode rate adjustment.
ICD-9 Dx Code Diagnosis Code Description ETG Description
410 ACUTE MYOCARDIAL INFARCTION* Ischemic heart disease
410.0 ACUTE MYOCARDIAL INFARCTION ANTEROLATERAL WALL* Ischemic heart disease
410.00 ACUT MI ANTEROLAT WALL EPIS CARE UNS Ischemic heart disease
410.01 ACUT MI ANTEROLAT WALL INIT EPIS CARE Ischemic heart disease
410.02 ACUT MI ANTEROLAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.1 ACUTE MYOCARDIAL INFARCTION OTHER ANTERIOR WALL* Ischemic heart disease
410.10 ACUT MYOCARD INFARCT OTH ANT WALL EPIS CARE UNS Ischemic heart disease
410.11 ACUT MYOCARD INFARCT OTH ANT WALL INIT EPIS CARE Ischemic heart disease
410.12 ACUT MI OTH ANT WALL SUBSQT EPIS CARE Ischemic heart disease
410.2 ACUTE MYOCARDIAL INFARCTION INFEROLATERAL WALL* Ischemic heart disease
410.20 ACUT MI INFEROLAT WALL EPIS CARE UNS Ischemic heart disease
410.21 ACUT MI INFEROLAT WALL INIT EPIS CARE Ischemic heart disease
410.22 ACUT MI INFEROLAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.3 ACUTE MYOCARDIAL INFARCTION INFEROPOSTERIOR WALL* Ischemic heart disease
410.30 ACUT MI INFEROPOST WALL EPIS CARE UNS Ischemic heart disease
410.31 ACUT MI INFEROPOST WALL INIT EPIS CARE Ischemic heart disease
410.32 ACUT MI INFEROPOST WALL SUBSQT EPIS CARE Ischemic heart disease
410.4 ACUTE MYOCARDIAL INFARCTION OTHER INFERIOR WALL* Ischemic heart disease
410.40 ACUT MYOCARD INFARCT OTH INF WALL EPIS CARE UNS Ischemic heart disease
410.41 ACUT MYOCARD INFARCT OTH INF WALL INIT EPIS CARE Ischemic heart disease
410.42 ACUT MI OTH INF WALL SUBSQT EPIS CARE Ischemic heart disease
410.5 ACUTE MYOCARDIAL INFARCTION OTHER LATERAL WALL* Ischemic heart disease
410.50 ACUT MYOCARD INFARCT OTH LAT WALL EPIS CARE UNS Ischemic heart disease
410.51 ACUT MYOCARD INFARCT OTH LAT WALL INIT EPIS CARE Ischemic heart disease
410.52 ACUT MI OTH LAT WALL SUBSQT EPIS CARE Ischemic heart disease
410.6 ACUTE MYOCARD INFARCT TRUE POST WALL INFARCT* Ischemic heart disease
410.60 ACUT MI TRUE POST WALL INFARCT EPIS CARE UNS Ischemic heart disease
410.61 ACUT MI TRUE POST WALL INFARCT INIT EPIS CARE Ischemic heart disease
410.62 ACUT MI TRUE POST WALL INFARCT SUBSQT EPIS CARE Ischemic heart disease
410.7 ACUTE MYOCARDIAL INFARCT SUBENDOCARDIAL INFARCT* Ischemic heart disease
410.70 ACUT MI SUBENDOCARDIAL INFARCT EPIS CARE UNS Ischemic heart disease
410.71 ACUT MI SUBENDOCARDIAL INFARCT INIT EPIS CARE Ischemic heart disease
410.72 ACUT MI SUBENDOCARDIAL INFARCT SUBSQT EPIS CARE Ischemic heart disease
410.8 ACUTE MYOCARDIAL INFARCTION OTHER SPEC SITES* Ischemic heart disease
410.80 ACUT MYOCARD INFARCT OTH SPEC SITE EPIS CARE UNS Ischemic heart disease
410.81 ACUT MYOCARD INFARCT OTH SITE INIT EPIS CARE Ischemic heart disease
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410.82 ACUT MYOCARD INFARCT OTH SITE SUBSQT EPIS CARE Ischemic heart disease
410.9 ACUTE MYOCARDIAL INFARCTION UNSPECIFIED SITE* Ischemic heart disease
410.90 ACUT MYOCARD INFARCT UNS SITE EPIS CARE UNS Ischemic heart disease
410.91 ACUTE MYOCARD INFARCT UNSPEC SITE INIT EPIS CARE Ischemic heart disease
410.92 ACUT MYOCARD INFARCT UNS SITE SUBSQT EPIS CARE Ischemic heart disease
411 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE* Ischemic heart disease
411.0 POSTMYOCARDIAL INFARCTION SYNDROME Ischemic heart disease
411.1 INTERMEDIATE CORONARY SYNDROME Ischemic heart disease
411.8 OTH ACUTE&SUBACUTE FORMS ISCHEMIC HEART DISEASE* Ischemic heart disease
411.81 ACUTE COR OCCLUSION WITHOUT MYOCARDIAL INFARCT Ischemic heart disease
411.89 OTHER ACUTE&SUBACUTE FORM ISCHEMIC HEART DISEASE Ischemic heart disease
412 OLD MYOCARDIAL INFARCTION Ischemic heart disease
413 ANGINA PECTORIS* Ischemic heart disease
413.0 ANGINA DECUBITUS Ischemic heart disease
413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS Ischemic heart disease
414.0 CORONARY ATHEROSCLEROSIS* Ischemic heart disease
414.00 COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT Ischemic heart disease
414.01 CORONARY ATHEROSCLEROSIS NATIVE CORONARY ARTERY Ischemic heart disease
414.02 CORONARY ATHEROSLERO AUTOL VEIN BYPASS GRAFT Ischemic heart disease
414.03 COR ATHEROSLERO NONAUTOL BIOLOGICAL BYPS GRAFT Ischemic heart disease
414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT Ischemic heart disease
414.05 CORONARY ATHEROSLERO UNSPEC TYPE BYPASS GRAFT Ischemic heart disease
414.06 COR ATHEROSLERO COR ART TRANSPLANTED HEART Ischemic heart disease
414.07 COR ATHEROSLERO BYPS GRAFT TRANSPLANTED HEART Ischemic heart disease
414.1 ANEURYSM AND DISSECTION OF HEART* Ischemic heart disease
414.10 ANEURYSM OF HEART Ischemic heart disease
414.11 ANEURYSM OF CORONARY VESSELS Ischemic heart disease
414.12 DISSECTION OF CORONARY ARTERY Ischemic heart disease
414.19 OTHER ANEURYSM OF HEART Ischemic heart disease
414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY Ischemic heart disease
414.3 CORONARY ATHEROSCLEROSIS D/T LIPID RICH PLAQUE Ischemic heart disease
414.8 OTHER SPEC FORMS CHRONIC ISCHEMIC HEART DISEASE Ischemic heart disease
414.9 UNSPECIFIED CHRONIC ISCHEMIC HEART DISEASE Ischemic heart disease
415.1 PULMONARY EMBOLISM AND INFARCTION* Pulmonary embolism
415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION Pulmonary embolism
415.12 SEPTIC PULMONARY EMBOLISM Pulmonary embolism
415.19 OTHER PULMONARY EMBOLISM AND INFARCTION Pulmonary embolism
416.2 CHRONIC PULMONARY EMBOLISM Pulmonary embolism
423.0 HEMOPERICARDIUM Cardiac trauma
423.3 CARDIAC TAMPONADE Cardiovascular diseases signs & symptoms
428 HEART FAILURE* Congestive heart failure
428.0 CONGESTIVE HEART FAILURE UNSPECIFIED Congestive heart failure
428.1 LEFT HEART FAILURE Congestive heart failure
428.2 SYSTOLIC HEART FAILURE* Congestive heart failure
428.20 UNSPECIFIED SYSTOLIC HEART FAILURE Congestive heart failure
428.21 ACUTE SYSTOLIC HEART FAILURE Congestive heart failure
428.22 CHRONIC SYSTOLIC HEART FAILURE Congestive heart failure
428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE Congestive heart failure
428.4 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE* Congestive heart failure
428.40 UNSPEC COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
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428.41 ACUTE COMBINED SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
428.42 CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAILURE Congestive heart failure
428.43 ACUTE CHRONIC COMB SYSTOLIC&DIASTOLIC HEART FAIL Congestive heart failure
428.9 UNSPECIFIED HEART FAILURE Congestive heart failure
444 ARTERIAL EMBOLISM AND THROMBOSIS* Arterial embolism/thrombosis
444.0 EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA Arterial embolism/thrombosis
444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA Arterial embolism/thrombosis
444.2 EMBOLISM&THROMBOSIS ARTERIES THE EXTREMITIES* Arterial embolism/thrombosis
444.21 EMBOLISM&THROMBOSIS ARTERIES UPPER EXTREMITY Arterial embolism/thrombosis
444.22 EMBOLISM&THROMBOSIS ARTERIES LOWER EXTREMITY Arterial embolism/thrombosis
444.8 EMBOLISM&THROMBOSIS OF OTHER SPECIFIED ARTERY* Arterial embolism/thrombosis
444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY Arterial embolism/thrombosis
444.89 EMBOLISM&THROMBOSIS OF OTHER SPECIFIED ARTERY Arterial embolism/thrombosis
444.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY Arterial embolism/thrombosis
445 ATHEROEMBOLISM* Arterial embolism/thrombosis
445.0 ATHEROEMBOLISM OF EXTREMITIES* Arterial embolism/thrombosis
445.01 ATHEROEMBOLISM OF UPPER EXTREMITY Arterial embolism/thrombosis
445.02 ATHEROEMBOLISM OF LOWER EXTREMITY Arterial embolism/thrombosis
445.8 ATHEROEMBOLISM OF OTHER SITES* Arterial embolism/thrombosis
445.81 ATHEROEMBOLISM OF KIDNEY Arterial embolism/thrombosis
445.89 ATHEROEMBOLISM OF OTHER SITE Arterial embolism/thrombosis
447.2 RUPTURE OF ARTERY Arterial embolism/thrombosis
451.0 PHLEBITIS&THROMBOPHLEB SUP VESSELS LOWER EXTREM Phlebitis & thrombophlebitis of veins
451.1 PHLEBITIS&THROMBOPHLEB DEEP VEINS LOWER EXTREM* Phlebitis & thrombophlebitis of veins
451.11 PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN Phlebitis & thrombophlebitis of veins
451.19 PHLEBITIS&THROMBOPHLEB OTH DEEP VES LOWER EXTREM Phlebitis & thrombophlebitis of veins
451.2 PHLEBITIS&THROMBOPHLEBITIS LOWER EXTREM UNSPEC Phlebitis & thrombophlebitis of veins
451.81 PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN Phlebitis & thrombophlebitis of veins
453.4 AC VNUS EMB&THRMB DP VES LWR EXTREM Embolism & thrombosis of veins
453.40 AC VNUS EMB&THRMB UNS DP VES LW EXT Embolism & thrombosis of veins
453.41 AC VNUS EMB&THRMB DP VES PRX LW EXT Embolism & thrombosis of veins
453.42 AC VNUS EMB&THRMB DP VES DST LW EXT Embolism & thrombosis of veins
453.5 CHRON VENOUS EMB & THROMBO DEEP VES LOWR EXTREM Embolism & thrombosis of veins
453.50 CHRON VNUS EMB & THROMB UNSPEC DEEP VES LOWR EXT Embolism & thrombosis of veins
453.51 CHRN VNUS EMB & THROMB DEEP VES PROX LOWR EXTREM Embolism & thrombosis of veins
453.52 CHRN VNUS EMBO & THROMB DP VES DISTL LOWR EXTREM Embolism & thrombosis of veins
453.6 VENOUS EMBO & THROMB SUPERFICIAL VES LOWR EXTREM Embolism & thrombosis of veins
785.51 CARDIOGENIC SHOCK Cardiovascular diseases signs & symptoms
786.5 CHEST PAIN* Cardiovascular diseases signs & symptoms
786.50 CHEST PAIN UNSPECIFIED Cardiovascular diseases signs & symptoms
786.51 PRECORDIAL PAIN Cardiovascular diseases signs & symptoms
786.59 OTHER CHEST PAIN Cardiovascular diseases signs & symptoms
794.3 NONSPECIFIC ABNORMAL RESULTS CV FUNCTION STUDY* Cardiovascular diseases signs & symptoms
794.30 NONSPECIFIC ABNORMAL UNSPEC CV FUNCTION STUDY Cardiovascular diseases signs & symptoms
794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM Cardiovascular diseases signs & symptoms
794.39 OTH NONSPECIFIC ABNORM CV SYSTEM FUNCTION STUDY Cardiovascular diseases signs & symptoms
861.0 HRT INJURY WITHOUT MENTION OPEN WOUND INTO THOR* Cardiac trauma
861.00 UNSPEC INJURY HRT W/O MENTION OPEN WOUND IN THOR Cardiac trauma
Delivery Case Rate Definition
©2016 Integrated Healthcare Association. All Rights Reserved. Page 8
861.01 HRT CONTUS WITHOUT MENTION OPEN WOUND INTO THOR Cardiac trauma
861.03 HEART LACERATION W/PENETRATION OF CHAMBERS Cardiac trauma
902.0 ABDOMINAL AORTA INJURY Arterial trauma
902.53 ILIAC ARTERY INJURY Arterial trauma
904.0 COMMON FEMORAL ARTERY INJURY Arterial trauma
904.1 SUPERFICIAL FEMORAL ARTERY INJURY Arterial trauma
* This project was supported by grant number R18HS020098 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.