Subscribe to eNews Contact us / IVR

Checklist: Endovascular cardiac valve replacement and supplement procedures

This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for endovascular cardiac valve replacement and supplement procedure (DRG 266 and 267). It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.

Check

 Documentation description
  Documentation is for the correct beneficiary and date of service.
  Documentation is complete, legible, signed and dated by the physician or clinician.
  Documentation to support all codes billed.
  Anesthesia record and/or sedation record.
  Certification / recertification by physician.
  Certified plan of care by physician.
  Diagnostic test results / reports, including imaging reports.
  Documentation of minutes billed.
  Evaluation and management / counseling notes.
  History and physical (PCP, other physicians related to treatment to support medical necessity of procedure).
  History and physical.
  Implant log.
  Initial evaluation for therapy services.
  Intra‐operative record.
  Peri‐operative record.
  Medication administration records.
  Nurses' notes.
  Observation orders and progress notes.
  Operative reports and procedure notes, including procedure start and stop times
  Pathology report.
  Physician order for therapy.
  Physician orders or intent to order for the dates of service billed.
  Physician / nonphysician practitioner (NPP) progress notes.
  Plan of care (may be part of evaluation).
  Psychosocial evaluation.
  Recovery room record.
  Reevaluations, when they have been performed.
  For electronic health records, send a copy of the electronic signature policy and procedures that describe how notes and orders are signed and dated.
  Emergency room records.
  Discharge summary / discharge notes.
  Clinic / office visit notes.
  Consultation reports.
 

NCD Transcatheter Aortic Valve Replacement (TAVR) 20.32 DRG 266/267

The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi‐disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient‐centered care.

The heart team includes the following:

  • Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:

    • Independently examined the patient face‐to‐face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy

  • Documented and made available to the other heart team members the rationale for their clinical judgment

  • Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators

The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra‐operative technical aspects of TAVR.
  Advanced Beneficiary Notice (ABN), if applicable

 

Disclaimer 
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.