End-to-End Revenue Cycle Management

FY 2019 Inpatient Only Procedure List Regulatory Update

Develop and implement a process that involves your cardiac catheterization teams NOW to ensure the placement of the correct admission status order for the inpatient only procedures described by CPT 92941 or HCPCS C9606.

The Inpatient Only Procedure (IPO) List is reviewed annually by CMS and identifies procedures for which the hospital will be paid only when the procedures are provided in the inpatient setting because of “the nature of the procedure, the underlying physical condition of the patient, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged (76 FR 74353).”

New changes have been made to the FY 2019 CMS Inpatient Only Procedure List that will impact hospital cardiac catheterization labs and interventionalists. Previously, CMS added “the procedure described by CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy [sic] and angioplasty, including aspiration thrombectomy when performed, single vessel) to the IPO list because this procedure is performed emergently to treat acute myocardial infarction patients.” (82 FR 52526)

This 2018 change did not have a great deal of practical impact, because the specific referenced CPT code 92941 applies only to the use of bare metal stents which are rarely used in the United States. However, in the OPPS FY 2019 Final Rule (CMS-1695-FC), CMS significantly expands the number of cardiac procedures that will be impacted by including the placement of drug-eluting intracoronary stents in the setting of acute myocardial infarction on the FY 2019 Inpatient Only Procedure List.

“After consideration of the public comments we received, we are adopting as final without modification, our proposal to add the procedure described by HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) to the IPO list for CY 2019.” [Bold added by author.] (83 FR 59001)

“After evaluating the procedure described by HCPCS code C9606 using the criteria described above, we believe that the procedure should be added to the IPO list because this procedure is performed during acute myocardial infarction and it is similar to a procedure already on the IPO list (that is, the procedure described by CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy [sic] and angioplasty, including aspiration thrombectomy when performed, single vessel)), which was added to the IPO list for CY 2018 (82 FR 52526)” [Bold added by author]. (83 FR 59000 – 59001)

Hospital Operational Impact and Imperative:

Develop and implement a process that involves your cardiac catheterization teams NOW to ensure the placement of the correct admission status order for the Inpatient Only Procedures described by CPT 92941 or HCPCS C9606.

It is important to work with your cardiac catheterization laboratory staff, cardiologists, and attending physicians to ensure that all Medicare patients undergoing procedures in the setting of acute myocardial infarction are evaluated for inpatient admission status, based upon the performance of an Inpatient Only Procedure, which is an exception to the two midnight expectation requirement.

Patients who undergo procedures described by CPT code 92941 or HCPCS code C9606 may not be easily identified at admission. Many of these patients may present to the emergency room with chest pain, and, after later being determined to have an acute myocardial infarction, may subsequently be taken to the cardiac catheterization laboratory for cardiac catheterization, stent placement, or other interventions. Since the Inpatient Only Procedures described by CPT code 92941 or HCPCS code C9606 may occur well after the initial admission status order (which may not be inpatient) has been placed, a process should be created to validate the procedure code used by the physician. If the procedure performed is an Inpatient Only Procedure, ensure that an inpatient admission order is placed in the medical record prior to the beneficiary’s disposition from the hospital in compliance with the Medicare Conditions of Participation and Payment. Otherwise, Two-Midnight Rule guidance should be used to ensure correct admission status.

Medical record documentation must support the presence of myocardial infarction and the performance of the procedure defined by either CPT Code 92941 or HCPCS code C9606 in order to support an inpatient admission status order. Remember, the determination as to whether the procedure performed is an Inpatient Only Procedure is based upon the procedure code or codes submitted by the physician who performed the procedure(s). Thus, a formal process of communication between hospital UR admission staff and the physician(s) performing the procedure is necessary to validate the CPT or HCPCS code(s) that will be submitted by the treating physician(s).

Operational Recommendation:

Perform a CM/UM review of all patients leaving the catheterization lab to gather the following information (create a form):

• Did the cardiologist document in the chart an acute myocardial infarction for this patient? Y/N
  • If so, did the cardiologist document in the chart how the myocardial infarction was determined (enzyme markers, EKG, other diagnostic studies)? Y/N
• Did the patient receive a stent? Y/N
• Which code did the cardiologist use to code this procedure? (circle one of the below)
  • CPT Code 92941
  • HCPCS Code C9606
  • Other ______

If based on the above the following are found true:

• Patient received a stent (coded as CPT 92941 or HCPCS C9606) during an acute myocardial infarction
• The presence and method of identification of the myocardial infarction is documented in the medical record

Then, work with the treating/attending physician to ensure an authenticated inpatient admission status order is placed in the medical record prior to the beneficiary’s disposition from the hospital.