CRHF ECONOMICS & HEALTH POLICY - Medtronic

1 Cardiac Rhythm & Heart Failure ProductsCMS HCPCS (C-Code) List For Hospital Outpatient Device ReportingUpdated April 1, 2017 crhf ECONOMICS & HEALTH POLICY1 of 9 | April 2017 CARDIAC RHYTHM & HEART FAILURE PRODUCTSCMS HCPCS (C-Code) List for Hospital Outpatient Device ReportingUpdated April 1, 2017 Procedure-to-device and device-to-procedure edits for device-intensive hospital outpatient services is not a CMS requirement. For CY 2017, CMS did not create a device code table that would be applicable for device intensive Ambulatory Payment Classifications (APCs). CMS expects hospitals to adhere to the guidelines of correct coding and append the correct device code to the claim when It is important for hospitals to recognize that while the assignment of specific C-codes will not impact payment for device-intensive procedures, the C-codes and charges assigned to each device will be used by CMS in the development of future payment rates for procedures involving devices.

2 The CY 2017 Final Hospital Outpatient Prospective Payment System (OPPS) effective January 1, 2017 continues the Comprehensive APC (C-APC) payment methodology that was implemented in CY 2015. Under C-APCs, the primary service and all adjunctive services provided to support the delivery of the primary service will receive one payment. The UB Editor recommends using revenue code 275 for pacemaker implants (leads, generators), 278 for other implants (leads, generators, implantable loop recorders) and 272 for non-implantable sterile supplies (catheters).2 Disclaimer:These coding suggestions and coverage guidelines do not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures.

3 Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with CMS or other third party payers as to the correct form of billing or the amount that will be paid to providers of which C-Code is applicable is the responsibility of the hospital. All products included in this listing are placed in the appropriate CMS category based on their intended function. For further information, please contact your Medtronic sales representative or send an email to: electronic version of this document is available at of 9 | April 2017 IMPLANTABLE CARDIOVERTER DEFIBRILLATORSC1721 Cardioverter Defibrillator, Dual Chamber (Implantable)DEVICE MODEL NUMBERM aximo DR7278 Marquis DR7274 Jewel AF7250 GEM III AT7276 GEM III DR7275 GEM II DR7273 GEM DR7271 Intrinsic 7287, 7288 EnTrust D153 ATG, D153 DRG, D154 ATG, D154 DRGV irtuoso D154 AWGM aximo II DR ICDD284 DRGS ecura DR ICDD224 DRGV irtuoso II DRD274 DRGP rotecta XT DRD314 DRGP rotecta DRD334 DRGP rotecta XT DRD314 DRMP rotecta DRD334 DRMM aximo II DRD264 DRMS ecura DRD204 DRME vera XT DRDDBB1D4 Evera S DRDDBC3D4 Evera XT DRDDBB1D1 Evera S DRDDBC3D1 Evera MRI XT DR SureScan DDMB1D1, DDMB1D4 Evera MRI S DR SureScan DDMC3D1, DDMC3D4C1722 Cardioverter Defibrillator, Single Chamber (Implantable)

4 DEVICE MODEL NUMBERM aximo VR7232 Marquis VR7230, 7230B, 7230Cx, 7230 EGEM III VR7231 GEM II VR7229 CxGEM 7227, 7227B , 7227Cx, 7227D, 7227 EONYX VR7290 CxMicroJewel 7221B, 7221C, 7221Cx, 7221D, 7221E, 7223 CxEnTrust D153 VRC, D154 VRC Virtuoso D154 VWCM aximo II VR ICDD264 VRM, D284 VRCS ecura VR ICDD204 VRM, D224 VRCV irtuoso II VRD274 VRCP rotecta XT VRD314 VRG, D314 VRMP rotecta VRD334 VRG, D334 VRME vera XT VRDVBB1D4 Evera S VRDVBC3D4 Evera XT VRDVBB1D1 Evera S VRDVBC3D1 Evera MRI XT VR SureScan DVMB1D1, DVMB1D4 Visia AF VRDVAB1D1, DVAB1D4 Visia AF MRI VR SureScan DVFB1D1, DVFB1D4 Visia AF MRI S VR SureScan DVFC3D1, DVFC3D43 of 9 | April 2017 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS, cont. dC1882 Cardioverter Defibrillator, Other than Single or Dual Chamber (Implantable)DEVICE MODEL NUMBERInSync II Marquis 7289 InSync Marquis 7277 InSync ICD 7272 InSync Sentry 7297, 7299 InSync II Protect 7295 InSync Maximo 7303.

5 7304 Concerto C154 DWKC onsulta CRT-DD224 TRKM aximo II CRT-DD284 TRKC oncerto II CRT-DD274 TRKP rotecta XT CRT-DD314 TRGP rotecta CRT-DD334 TRGP rotecta XT CRT-DD314 TRMP rotecta CRT-DD334 TRMC onsulta CRT-DD204 TRMM aximo II CRT-DD264 TRMViva XT CRT-DDTBA1D4 Viva S CRT-DDTBB1D4 Viva XT CRT-DDTBA1D1 Viva S CRT-DDTBB1D1 Viva Quad S CRT-DDTBB1Q1 Viva Quad S CRT-DDTBB1 QQViva Quad XT CRT-DDTBA1Q1 Viva Quad XT CRT-DDTBA1 QQCompia MRI Quad CRT-D SureScan DTMC1 QQAmplia MRI Quad CRT-D SureScan DTMB1 QQAmplia MRI CRT-D SureScan DTMB1D4 Compia MRI CRT-D SureScan DTMC1D1 Amplia MRI Quad CRT-D SureScan DTMB1Q1 Amplia MRI CRT-D SureScan DTMB1D1 Claria MRI CRT-D SureScan DTMA1D1 Claria MRI Quad CRT-D SureScan DTMA1Q1 Claria MRI CRT-D SureScan DTMA1D4 Claria MRI Quad CRT-D SureScan DTMA1QQ4 of 9 | April 2017C1785 Pacemaker, Dual Chamber, Rate-Responsive (Implantable)

6 DEVICE MODEL NUMBEREnPulse E1DR01, E1DR03, E1DR06, E1DR21 EnPulse DRE2DR01, E2DR03, E2DR06, E2DR21 Vitatron C-seriesC60 DRAT500 DDDRPAT5 01 Kappa 900 DRKDR 901, KDR 903, KDR 906, KDR 921, KDR 931, KDR 933 Kappa 800 DRKDR 801, KDR 803, KDR 806 Kappa 700 DRKDR 700, KDR 701, KDR 703, KDR 706, KDR 720, KDR 721, KDR 730, KDR 731, KDR 733 Kappa 400 DRKDR 401, KDR 403 Selection AFm 902902 Diamond 3 DR840 Diamond II DR820E, 822 EKappa 650 DRKDR 651, KDR 653, KDR 656 Kappa 600 DRKDR 600, KDR 601, KDR 603, KDR 606 Vita 2 DR830 Vit a DR810 Sigma 300 DRSDR 303, SDR 306 Sigma 200 DRSDR 203 Legacy II DR826, 828 Clarity DR860, 862, 865 Thera DR7940, 7941, 7942, 7950, 7951, 7952, 7960i, 7961i, 7962i, 7964i, 7965i, 7966i, 7968iPreva DR7088, 7089 Prodigy DR7860, 7861, 7862 Legacy DR850, 851, 852 Vitatron T60 DRT60A1 EnRhythm PI501 DRAdapta ADDR01, ADDR03, ADDR06, ADDRL1, ADDRS1 Sensia SEDR01, SEDRL1 Versa VEDR01 Revo MRI RVDR01 Advisa DRA4DR01 Advisa DR MRI A2DR01C2619 Pacemaker, Dual Chamber, Non-Rate-Responsive (Implantable)

7 DEVICE MODEL NUMBEREnPulse E2 VDD01 EnPulse DE2D01, E2D03, E2 VDD01 Kappa 700 DKD 700, KD 701, KD 703, KD 706 Kappa 900 D KD901, KD903, KD906 Ruby 3 DRuby 3 DRuby II DDD720 Sigma 300 DSD 303 Sigma 200 DSD 203 Legacy II D726, 728 Thera D7944, 7945, 7946, 7964i, 7965i, 7966iPreva D7068 Legacy D750, 751 Vita D710 Prodigy D7864, 7865, 7866 Kappa 900 VDDKVDD 901 Kappa 700 VDDKVDD 700, KVDD 701 Sigma 300 VDDSVDD 303 Thera VDD8948, 8968iProdigy VDD8168 Vita VDD410 Adapta ADD01, ADVDD01 Sensia SED01 PACEMAKERSC1786 Pacemaker, Single Chamber, Rate-Responsive (Implantable)DEVICE MODEL NUMBEREnPulse E2SR01, E2SR03, E2SR06 Vitatron C-seriesC20 SRKappa 900 SRKSR 901, KSR 903, KSR 906 Kappa 700 SRKSR 700, KSR 701, KSR 703, KSR 706 Kappa 400 SRKSR 401, KSR 403 Topaz 3 SR 540 Topaz II SR520, 521, 522 Sigma 300 SRSSR 303, SSR 306 Vita 2 SR530 Vita SR310, 415 Sigma 200 SRSSR 203 Legacy II SR526, 528 Clarity SR560, 562, 565 Prodigy SR8158, 8160, 8161, 8162 Thera SR8940, 8941, 8942, 8960i, 8961i, 8962iPreva SR8088, 8089 Legacy SR550, 551, 552 Vitatron T20 SRT20A1 Adapta ADSR01, ADSR03, ADSR06 Sensia SESR01 Advisa SR MRI A3SR01 Micra Transcatheter Pacing SystemMC1VR015 of 9 | April 2017C2620 Pacemaker, Single Chamber, Non-Rate Responsive (Implantable)

8 DEVICE MODEL NUMBERP remier 8081 Sigma 300 SSS 303 Jade 3 S340 Jade II SSI220 Sigma 200 SSS 203 Legacy II S126, 128 Sigma 100 SSS 103, SS 106 Thera S8944, 8945, 8946, 8964i, 8965i, 8966iPrevail 8484, 8085, 8086 Legacy S150, 151, 152 Prodigy S8464, 8165, 8166 Sensia SES01C1777 Lead, Cardioverter Defibrillator, Endocardial Single Coil (Implantable)DEVICE MODEL NUMBERS print 6932, 6943 Sprint Fidelis 6930, 6931 Sprint Quattro Secure S 6935 Sprint Quattro Secure S MRI SureScan 6935MC1779 Lead, Pacemaker, Transvenous VDD Single PassDEVICE MODEL NUMBERCapSure VDD5038, 5038L, 5038SC1895 Lead, Cardioverter Defibrillator, Endocardial Dual Coil (Implantable)DEVICE MODEL NUMBERS print Quattro Secure 6947 Sprint Quattro Secure MRI SureScan 6947, 6947 MSprint Quattro 6944, 6946 MSprint 6942, 6945 Sprint Fidelis 6948, 6949C1896 Lead, Cardioverter Defibrillator, Other than Endocardial Single or Dual Coil (Implantable)DEVICE MODEL NUMBERS ubcutaneous Lead System6996 SQTransvene 6881, 6884, 6895, 6933, 6934S, 6937, 6937A, 6939, 6963, 6999 Oval Patch Leads6721L, 6721M, 6721S, 6939 PACEMAKERS, cont.

9 DC2621 Pacemaker, Other than Single or Dual Chamber (Implantable)DEVICE MODEL NUMBERInSync III8042 InSync 8040 Syncra CRT-PC2TR01 Consulta CRT-PC4TR01 Viva CRT-PC6TR01 LEADS6 of 9 | April 2017C1764 Event Recorder, Cardiac (Implantable)DEVICE MODEL NUMBERR eveal Reveal Plus Reveal DXReveal XT Reveal LINQ 9525952695289529 LNQ11 INSERTABLE LOOP RECORDERC1900 Lead, Left Ventricular Coronary Venous SystemDEVICE MODEL NUMBERA ttain OTW 4193 Attain LV2187 Attain CS/CV2188 Attain Bipolar OTW4194 Attain StarFix 4195 Attain Ability MRI SureScan 4196 Attain Ability Plus MRI SureScan 4296 Attain Ability Straight MRI SureScan 4396 Attain performa MRI SureScan 4298 Attain performa Straight MRI SureScan 4398 Attain performa S MRI SureScan 4598 LEADS, cont. dC1898 Lead, Pacemaker, Other than Transvenous VDD Single PassDEVICE MODEL NUMBERCapSure Sense MRI SureScan 4074, 4574 CapSure Sense 4073, 4074, 4574 Crystalline ICM 09, ICM 09B, ICM 09 JBCapSure Z Novus5054, 5554 CapSure Z4033, 4034, 4533, 4534, 5033, 5034, 5534 Impulse IIIHP 09B, IHP 09 JBImpulse IMG 49, IMG 49B, IMG 49 JBCapSure SP Novus4092, 4592, 5092, 5592, 5594 CapSure SP4023, 4024, 4523, 4524, 5023, 5023M, 5024, 5024M, 5523, 5523M, 5524, 5524M, 5525 CapSure 4003, 4003M, 4004, 4004M, 4503, 4503M, 4504, 4504M, 4965, 5025, 5026, 5525 CapSure Epi4965, 4968 Excellence +IMD 49, IMD 49B, IMD 49 JBExcellence S+IME 49, IME 49B, IME 49 JBExcellence PS+IMK 49B, IMK 49 JBExcellence SS+IML 49B, IML 49 JBCapSureFix Novus4076 CapSureFix Novus MRI SureScan 4076, 5076 CapSureFix 4067, 4068, 4568, 5058, 5067, 5068.

10 5568 (bipolar), 6940 CapSureFix MRI SureScan 5086 MRISureFix 5072 Pirouet +IMU 49, IMU 49B, IMU 49 JBPirouet S+IMX 49, IMX 49B, IMX 49 JBCrystalline ActFixICF 09, ICQ 094057M, 4058M, 4557M, 4558M, 50584057M, 4058M, 4557M, 4558M, 5058 Epicardial Screw-in4951M, 5071 SelectSecure 38307 of 9 | April 2017C1730 Catheter, Electrophysiology, Diagnostic, Other than 3D Mapping (19 or Fewer Electrodes)DEVICEMODEL NUMBERT orqr CS Diagnostic Catheter041565CS, 041590CS, 041865 CSTorqr , Soloist Diagnostic Catheter041002JM, 041002UM, 041005DM, 041005JM, 041005UM, 04130DS, 04122JM, 04122UM, 04125JM, 04125UM, 441016JF, 441016U, 44216J, 44216JF, 44216U, 44516J, 44516JF, 44516 UMarinr CS043302M, 043325M, 043328 MMarinr 072302, 072322M, 072402 Achieve Mapping Catheter990063-015, 990063-020 Achieve Advance Mapping Catheter2 ACH15, 2 ACH20, 2 ACH25C1731 Catheter, Electrophysiology, Diagnostic, Other than 3D Mapping (20 or More Electrodes)