It appears that the Centers for Medicare & Medicaid Services (CMS) may compromise on reimbursement for MitraClip implantations. If so, you probably have your colleagues and societies to thank for it.
CMS released its proposed coverage decision for transcatheter mitral valve replacement on May 15 with a 30-day period for public comments. The decision took into account a formal request for National Coverage Determination submitted by the Society of Thoracic Surgeons, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and the American Association for Thoracic Surgery. The societies provided a roadmap that CMS largely incorporated into its proposed decision.
One area up for grabs was the diagnosis-related group (DRG), which would affect reimbursement for the procedure. A DRG code for PCIs was used during clinical trials but interventional cardiologists argued the procedure was more akin to surgery.
In an analysis, the Advisory Board cautioned about the discrepancy between the $30,000 cost of the Abbott’s MitraClip device and Medicare reimbursement, which it pegged between $10,000 and $45,000. It added that 80 percent to 90 percent of patients in need of mitral valve replacement were Medicare beneficiaries, making it difficult for hospitals to break even.
The final rule for the hospital inpatient prospective payment system was released Aug. 4 with add-ons but no DRG changes. CMS reportedly will accept an ICD code for MitraClip in addition to the current codes in payments beginning Oct. 1. Providers who submit this way may be reimbursed for part of the cost of the device.
I haven’t seen the specifics on reimbursement from CMS, but the comments and a joint letter from the societies that lay the groundwork for decisions by CMS are posted on its website. You can read them here.
Most likely a lot of behind-the-scenes work by cardiologists who either represented one of the societies or advocated independently helped to persuade federal officials. Check out our cover story, “Physicians as Advocates: On Call in D.C.,” for more on the topic.
Candace Stuart
Cardiovascular Business, editor