Can I Bill for Daily Management of Impella®?
Question: Are there billable services after Impella® insertion in the cath lab, such as ICU monitoring?
Answer: Yes, with medical documentation and specific requirements we will discuss below. The most common are critical care E&M codes (CPT 99291-2), repositioning after leaving the cath lab (CPT 33993), and removal in a separate session (CPT 33992).
When a patient is being cared for in the ICU (post-Impella insertion, CPT Code 33990), the critical care Evaluation and Management Codes can be used. These codes are "time based codes": CPT Codes 99291-99292 are used to report the total duration of time spent in provision of critical care services to a critically ill patient, even if the time spent on that date is not continuous. CPT Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the individual is not continuous on that date. CPT Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes.
Time spent with the individual patient should be recorded in the patient's record (usually in the progress note). The time that can be reported as critical care is the time spent engaged in work related to the individual patient's care whether that time was spent at the bedside, or in conversation with family or other consultants related to patient management. While these are not only for Impella® procedures, the criteria for use of hemodynamic support are of the complexity required for this higher level daily care fee.
Any repositioning of the Impella® device that occurs in the ICU (with documentation of imaging guidance) can also be coded and billed using CPT 33993. Cardiogenic Shock patients with ongoing Impella® support require close monitoring and frequently benefit from decision making regarding mechanical circulatory support evaluation, weaning, escalation, and drip management.
If a patient remains on support beyond the original cath lab procedure, the removal of the device can also be coded and billed using CPT 33992. This is only in the case removal in a separate session and is not available if done during the same session as the device is inserted.
Impella® Device — Indication & Safety Information
INDICATIONS FOR USE
The Impella 2.5® and Impella CP® Systems are temporary (≤ 6 hours) ventricular support devices indicated for use during high-risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease, when a heart team, including a cardiac surgeon, has determined high-risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 and Impella CP Systems in these patients may prevent hemodynamic instability, which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.
The Impella 2.5®, Impella CP®, Impella 5.0®, and Impella LD® Catheters, in conjunction with the Automated Impella Controller (collectively, “Impella® System Therapy”), are temporary ventricular support devices intended for short term use (≤ 4 days for the Impella 2.5 and Impella CP, and ≤ 6 days for the Impella 5.0, and Impella LD) and indicated for the treatment of ongoing cardiogenic shock that occurs immediately (< 48 hours) following acute myocardial infarction or open heart surgery or in the setting of cardiomyopathy, including peripartum cardiomyopathy, or myocarditis as a result of isolated left ventricular failure that is not responsive to optimal medical management and conventional treatment measures (including volume loading and use of pressors and inotropes, with or without IABP). The intent of Impella System Therapy is to reduce ventricular work and to provide the circulatory support necessary to allow heart recovery and early assessment of residual myocardial function.
Important Risk Information for Impella devices
The Impella 2.5, Impella CP, Impella 5.0 and Impella LD are contraindicated for use with patients experiencing any of the following conditions: Mural thrombus in the left ventricle; Presence of a mechanical aortic valve or heart constrictive device; Aortic valve stenosis/calcification (equivalent to an orifice area of 0.6 cm2 or less); Moderate to severe aortic insufficiency (echocardiographic assessment graded as ≥ +2); Severe peripheral arterial disease precluding placement of the Impella System; Significant right heart failure*; Combined cardiorespiratory failure*; Presence of an Atrial or Ventricular Septal Defect (including post-infarct VSD)*; Left ventricular rupture*; Cardiac tamponade*
* This condition is a contraindication for the cardiogenic shock indication only.
POTENTIAL ADVERSE EVENTS
Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury
In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices. Visit http://www.abiomed.com/important-safety-information to learn more.
General Indication and Safety Information
To learn more about the Impella platform of heart pumps, including important risk and safety information associated with the use of the devices, please visit: www.protectedpci.com/indications-use-safety-information/