Traditionally, carotid endarterectomy has been the primary method of treating high-grade asymptomatic and symptomatic carotid artery stenosis. However, a minimally invasive technique known as carotid artery stenting (“CAS”) has evolved over the years. This technique offers reduced postoperative pain, reduced potential for postoperative wound complications, and shorter hospital stays.
On July 13, 2023, The Centers for Medicare and Medicaid Services (CMS) released a draft decision memorandum regarding carotid artery stenting that would expand coverage of the procedure and remove certain requirements for CAS facilities and operators.
The proposal is a result of a national coverage analysis for carotid artery stenting initiated by request of the Multispecialty Carotid Alliance (MSCA). The request was to make existing guidelines less restrictive and was initiated in January 2023. This proposal was considered and following release to public comments, 193 immediately followed.
- The decision proposal will expand coverage for CAS “to standard surgical risk patients” by removing the limitation of coverage to only “high-surgical risk patients.”
- Expanding coverage to individuals previously only eligible for coverage in clinical trials. Limit the coverage to patients for whom CAS is considered “reasonable and necessary” and who are either symptomatic with carotid stenosis of 50% or greater or asymptomatic with carotid stenosis of at least 70%.
- Would require practitioners to “engage in a formal shared decision-making interaction with the beneficiary” that involves use of a “validated decision-making tool.” The conversation with the beneficiary must include discussion of all treatment options and their risks and benefits and cover information from the clinical guidelines, as well as “incorporate the patient’s personal preferences and priorities.”
- Removing facility standards and approval requirements.
- Allowing Medicare Administrator Contractor (MAC) discretion for all other coverage of Percutaneous Transluminal Atherectomy (PTA) of the carotid artery concurrent with stenting not otherwise addressed in National Coverage Determination (NCD) 20.7.
The proposed changes drastically differ from the original coverage criteria and are highly anticipated. For more information regarding this proposed rule, contact Pinnacle Enterprise Risk Consulting Services, Robin Peterson, Manager of Professional Coding and Compliance Reviews, CPC, CPMA at RPeterson@AskPHC.com or Amy Pritchett, Manager HCC Coding/Audit & Education Services, CCS, CRC, CPA-RA,CPC, CPMA, CPCO, CDEI, CDEO, CDEC, CANPC, CASCC, CMPM, AAPC Approved Instructor, Approved ICD-10-CM/PCS Trainer at APritchett@AskPHC.com