EECP/ECP Reimbursement in the United States

Discussion of coverage for EECP/ECP therapy

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EECP/ECP Reimbursement in the United States

Post by ecpforum » Tue May 02, 2017 10:37 am

ECP Therapy Reimbursement in the United States
Patients should contact their primary care physician, cardiologist or local EECP® Therapy center to discuss eligibility for treatment and reimbursement coverage.

CMS-Centers for Medicare and Medicaid Services
Section 20.20 (formerly 35-74) of the Medicare Coverage Issues Manual was revised to provide national Medicare coverage for external counterpulsation (ECP) under code G0166 for physician provided services and under the additional APC Code 5734 for outpatient Hospital p[rovided services (see rates below).

The Centers for Medicare and Medicaid Services currently covers treatment with ECP Therapy/ECP systems for patients who have been diagnosed with disabling stable angina (Class III or IV Canadian Cardiovascular Society or equivalent classification), who in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention because:
1. Their condition is inoperable, or at high risk of operative complications or postoperative failure;
2. Their coronary anatomy is not readily amenable to such procedures; or
3. They have co-morbid states, which create excessive risk.
Though coverage for congestive heart failure is not currently provided under Medicare, patients with stable congestive heart failure of ischemic etiology maybe covered under the aforementioned policy if they present with concomitant angina pectoris or angina equivalent symptoms as the primary diagnosis. The Centers for Medicare and Medicaid Services provide additional information on reimbursement. You can search for both national and local coverage decisions on the CMS website, including information on the national coverage decision (NCD) for external counterpulsation.
Private Insurance

Third party commercial insurance carriers offer reimbursement for ECP Therapy and have established coverage criteria similar to Medicare. Currently over 300 third-party payers cover ECP treatment.

Physician Provided Service Codes and Rates

ECP Therapy Reimbursement in the United States
Patients should contact their primary care physician, cardiologist or local EECP® Therapy center to discuss eligibility for treatment and reimbursement coverage.

CMS-Centers for Medicare and Medicaid Services
Section 20.20 (formerly 35-74) of the Medicare Coverage Issues Manual was revised to provide national Medicare coverage for external counterpulsation (ECP) under code G0166 for physician provided services and under the additional APC Code 5734 for outpatient Hospital p[rovided services (see rates below).

The Centers for Medicare and Medicaid Services currently covers treatment with ECP Therapy/ECP systems for patients who have been diagnosed with disabling stable angina (Class III or IV Canadian Cardiovascular Society or equivalent classification), who in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention because:
1. Their condition is inoperable, or at high risk of operative complications or postoperative failure;
2. Their coronary anatomy is not readily amenable to such procedures; or
3. They have co-morbid states, which create excessive risk.
Though coverage for congestive heart failure is not currently provided under Medicare, patients with stable congestive heart failure of ischemic etiology maybe covered under the aforementioned policy if they present with concomitant angina pectoris or angina equivalent symptoms as the primary diagnosis. The Centers for Medicare and Medicaid Services provide additional information on reimbursement. You can search for both national and local coverage decisions on the CMS website, including information on the national coverage decision (NCD) for external counterpulsation.
Private Insurance
Third party commercial insurance carriers offer reimbursement for ECP Therapy and have established coverage criteria similar to Medicare. Currently over 300 third-party payers cover ECP treatment.

Physician Provided Service Codes and Rates
Code Procedure 2017 National Average Medicare Payment Rate Other Information
G0166 HCPCS Level II Code for external counterpulsation, per treatment session $140.32 G0166 is a Medicare specific code. However, some private payers accept this procedure code and provide reimbursement. Please verify that this code is accepted with private payers before billing it.
G0166-76 Same as above When a patient receives 2 one-hour sessions in one day, then the suffix -76 is typically used for clarification.
93799 CPT Code for unlisted cardiovascular service or procedure Local contractor Some Medicare Carriers require the use of this code with G0166 when two treatments are administered to a patient on the same day of service. Consult local Medicare Carrier guidelines.
92971 CPT Code for Cardioassist-method of circulatory assist - external Local contractor Since an individual CPT code has not yet been assigned for EECP, some private payers that do not accept G0166 allow 92971.

Outpatient Hospital Provided Service Codes and Rates
Code Ambulatory Patient Classification (APC) (Medicare) Status Indicator Procedure 2017 Medicare Payment Rate Other Information
G0166 5734 Q1 Level 4 Minor Procedures $95.66 Q) Packaged Services Subject to Separate Payment Under OPPS Payment Criteria.
1) Separate APC payment based on OPPS payment criteria.

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