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May/June 2011

ACE Accredits First Cardiac Cath Lab! See page 4

The Society for Cardiovascular Angiography and Interventions

Advocacy Victory

RUC Agrees to Oppose Fee Cuts for Diagnostic Cardiac Cath


he committee that advises the Centers for Medicare and Medicaid Services (CMS) on how to value physicians’ work not only has publicly opposed a 10 percent fee cut imposed by CMS for diagnostic cardiac catheterization procedures this year, but also will oppose any future cuts in reimbursement for cardiac catheterization. This decision by the RBRVS Update Committee (or RUC) came after lengthy negotiations with SCAI and ACC representatives, who successfully demonstrated significant changes in the complexity of patients undergoing diagnostic cardiac catheterization procedures over the past two decades. An American Medical Association committee, the RUC evaluates procedures based on time, intensity, and relative risk, and then recommends to CMS how the procedure should be “valued” — a key determinant in how much physicians will be reimbursed for their work. Historically, CMS has accepted the vast majority of the physician work values recommended by the RUC. The

RUC’s tradition of influence with CMS combined with its recent recommendations that led to payment reductions of between 7 and 33 percent for other cardiovascular services, including echocardiography, stress echo, and nuclear stress imaging, set the stage for a significant advocacy challenge. In April, a work group made up of SCAI and ACC members presented to the RUC a report detailing the values and times for diagnostic cardiac catheterization procedures from early 1992 to the present. “We focused on how patients who undergo these services have become increasingly complex over the years and we offered an in-depth examination of the relativity of recommended values for diagnostic caths compared to other services,” explained Cliff Kavinsky, M.D., Ph.D., FSCAI, who is SCAI’s Cliff Kavinsky, M.D., representative to the RUC. “Ultimately, Ph.D., FSCAI

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SCAI’s Emerging Leader Mentorship Program Announces First Fellows Key Points • T en early-career SCAI members have been selected to participate in the new ELM program. • The ELM Fellows will receive two years of intensive training and personalized mentoring. • ELM’s goal is to address the individualized needs of tomorrow’s leaders while providing the interventional cardiology specialty with a robust leadership pipeline.


his spring SCAI announced the selection of 10 earlycareer interventional cardiologists to participate in the Society’s brand-new Emerging Leader Mentorship program. Sponsored by SCAI in partnership with the American College of Cardiology (ACC) and the Cardiovascular Research Foundation, the ELM program identifies early-career interventional cardiologists with great leadership potential and then provides two years of intensive group training and individualized mentoring.

The program fulfills two needs in the field, says Srihari S. Naidu, M.D., FSCAI, ELM chair and director of the cardiac catheterization laboratory at Winthrop University Hospital in Mineola, NY. Dr. Naidu chairs the initiative with Co-chair William O’Neill, M.D., FSCAI. Past SCAI Trustee Mark Turco, M.D., FSCAI, also was Srihari S. Naidu, M.D., instrumental in beginning this program. FSCAI “On one side, there has been a lot of difficulty identifying talented early-career members who are interested in becoming involved at a high level in the multiple facets of cardiology, whether that’s education, clinical care, advocacy or research,” says Dr. Naidu. “On the other side, those who potentially have the talents to do that have historically found it very difficult to enter leadership

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Advocacy Update

Diagnostic Cardiac Cath (cont’d from pg 1) we were able to show the members of the RUC that cardiac catheterization procedures were already fairly valued and did not deserve reductions in reimbursement.” Though Dr. Kavinsky hails the RUC’s decision as a major victory, he is quick to point out that the battle is not yet won. “The ball is now in CMS’s court,” he said. “Now we await the proposed 2012 Medicare Physician Fee Schedule to see if CMS responds favorably to the RUC’s recommendations or it arbitrarily imposes cuts.”

New Challenges Ahead “We’re basically moving the fight to another court,” Dr. Kavinsky said, “because CMS has targeted coronary stenting codes for revaluation.” There’s a good chance this advocacy challenge will be bigger than the one addressed this spring on diagnostic cardiac catheterization, said SCAI Advocacy Committee Chair James B. Blankenship, M.D., FSCAI. “Unlike the diagnostic cardiac cath codes, the current coronary stent codes were valued through the James B. Blankenship, existing RUC process and the valuations, M.D., FSCAI which reflect 120 minutes of intra-service ‘skin-to-skin’ time, will be harder to defend.” SCAI and ACC are approaching the challenge at the level of new code development — meaning the best way to effectively capture the value of more complex coronary stent services that have evolved in the past 15 years is to create new Do you know a woman heart patient who is interested in helping other women by starting a WomenHeart Support Network in your local community? If so, please share the application for the 2011 WomenHeart Science & Leadership Symposium at Mayo Clinic, October 7-10 in Rochester, MN. This year’s Symposium will train women with heart disease to establish and lead patient support groups for women with heart disease in their local communities. WomenHeart’s goal is to have two women from a community attend the training, and return to their community to co-coordinate this new WomenHeart Support Network. Symposium curriculum addresses the science of women’s heart disease and training about the necessary steps and tools for establishing and maintaining a WomenHeart Support Network. Download the application at Application deadline is Friday, July 8, 2011.

codes that reflect the increased time and intensity of many current interventional procedures,” said Dr. Blankenship. “We envision a large family of codes to describe coronary stent services,” he said. “What that means for members is a complex but vitally important RUC survey process.” In other words, interventional cardiologists who receive a survey this fall should make every effort to complete it accurately and return it on time. “There is no room for error in completing these surveys,” Dr. Blankenship said. “SCAI recognizes the surveys can be quite complex, so we will be hosting a webinar to educate members about the process and the surveys themselves.” To learn more about the RUC process and participate in SCAI’s free webinar, contact Dawn Hopkins at n SCAI News & Highlights is published by

The Society for Cardiovascular Angiography and Interventions 2400 N Street, NW, Suite 500, Washington, DC 20037 Phone 800-992-7224; Fax 202-689-7224;;; Christopher J. White, M.D., FSCAI, President J. Jeffrey Marshall, M.D., FSCAI, President-Elect Larry S. Dean, M.D., FSCAI, Immediate Past President Theodore Bass, M.D., FSCAI, Vice President Carl L. Tommaso, M.D., FSCAI, Treasurer Charles Chambers, M.D., FSCAI, Secretary Morton Kern, M.D., FSCAI, Editor-in-Chief L. Van-Thomas Crisco, M.D., FSCAI, Associate Editor Sandeep Nathan, M.D., FSCAI, Associate Editor _______________________________________________________________ Trustees Alexandre Abizaid, M.D., Ph.D., FSCAI Lee N. Benson, M.D., FSCAI Jeffrey Cavendish, M.D., FSCAI Tyrone J. Collins, M.D., FSCAI Anthony Farah, M.D., FSCAI Runlin Gao, M.D., FSCAI James A. Goldstein, M.D., FSCAI James Hermiller, M.D, FSCAI Thomas Jones, M.D., FSCAI Upendra Kaul, M.D., FSCAI Clifford Kavinsky, M.D., Ph.D., FSCAI Ahmed Magdy, M.D., FSCAI Issam D. Moussa, M.D., FSCAI Srihari S. Naidu, M.D., FSCAI Kimberly A. Skelding, M.D., FSCAI Huay-Cheem Tam, MBBS, FSCAI Zoltan G. Turi, M.D., FSCAI Trustees for Life Frank J. Hildner, M.D., FSCAI William C. Sheldon, M.D., FSCAI

Staff Norm Linsky Executive Director Kerry O’Boyle Curtis Senior Director for Education, Meetings, & Communications Wayne Powell Senior Director for Advocacy & Guidelines Terie King, CPA Senior Director of Finance & Accounting Bea Reyes Senior Director of Operations & Administration Kathy Boyd David Communications Director touch three Design and Production Imaging Zone Printing


SCAI Persuades Local Medicare Carrier to Expand Indications for Percutaneous Ventricular Assist Device As a result of SCAI advocacy, the Medicare carrier for several New England states will cover the use of percutaneous ventricular assist devices (pVADs) for most indications. The final policy, issued April 14, 2011, is a dramatic change from what NHIC – the Medicare carrier for Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont – proposed earlier this year. NHIC’s draft local coverage determination would have limited coverage of pVADs only to patients in cardiogenic shock. SCAI became involved in this issue in mid-January, when it sent local interventionalist and Past President Bonnie H. Weiner, M.D., MBA, MSEC, FSCAI, to speak at the carrier’s open meeting, thereby opening dialogue with NHIC’s medical director. NHIC’s final policy completely incorporates the indications recommended by SCAI, as defined in SCAI’s formal comments. In addition to cardiogenic shock, the carrier has revised the policy to additionally cover pVAD for:

• high-risk percutaneous coronary intervention (PCI) with high risk defined as a combination of reduced left ventricular ejection fraction (<35%) in combination with complex coronary artery disease • acute decompensated heart failure • acute myocardial infarction (either with or without cardiogenic shock) • as a bridge to transplant SCAI is pleased the final policy better reflects the body of scientific literature and practical clinical applications for pVAD; however, SCAI remains concerned because the carrier has elected to differentiate coverage between pVAD devices,  a differentiation not asserted by SCAI. The Society’s Advocacy Committee is continuing to assess the need to seek possible further revision to this LCD. Read the final NHIC’s final Local Coverage Determination for Percutaneous Ventricular Devices at n


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Co-Sponsored by: Society for Vascular Medicine

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September 23-25, 2011 • • • • •


Everything you need to know about venous disease in one focused meeting Interact directly with nationally known multidisciplinary faculty members Featured lecturers: Dr. Michael Dake, Dr. Michael Jaff and Dr. Suresh Vedantham Breakout sessions: Hands on imaging, Developing your own Venous Program Tips and tricks, case presentations, review of complications

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4/8/11 10:43 AM


ACE Accredits First Cardiac Cath Lab


he Accreditation for Cardiovascular Excellence (ACE) program awarded its first accreditation to the PCI program at Bon Secours St. Francis Health System in South Carolina. The presentation was made at the SCAI 2011 Scientific Sessions in Baltimore. ACE accreditation recognizes the commitment of clinicians and staff to quality assurance, peer review and use of evidencebased guidelines. “ACE’s goals are to help facilities achieve better patient care in their community and to increase the consistency of superior patient care in cardiovascular procedures throughout the U.S.,” said Bonnie Weiner, M.D., MBA, MSEC, FSCAI, chief medical officer and chair of ACE’s Board of Directors. “Bon Secours St. Francis Health System has achieved ACE’s highest standards for quality and is a model for other cardiovascular programs. We look

ACE’s Five-Step Accreditation Process Step 1: Accredited Hospitals ACE determines your facility’s eligibility for certification or recertification based upon its unique situation and requirements. Step 2: Data Collection ACE collects outcome data. Step 3: Initial Review ACE reviews the application with a focus on quality and outcomes assessment to determine if the facility meets the standards set by the appropriate ACE Standards Committee. Step 4: Onsite Review After ACE has received fees and accepts the application for accreditation, ACE staff schedule an onsite visit. During the visit, a trained review team will validate the application, review patient records, and collect additional data. A tour of the facilities, collection of angiographic studies, and an interview with the key members of the program completes the onsite process. Once the review team has gathered the necessary information, ACE will issue a formal report of the facility’s accreditation status within 30 days. Step 5: Reporting Mechanisms To maintain accreditation, ACE requires that the facility report outcomes at regular intervals. Participation in a national registry is encouraged but not mandatory as long as all required data are submitted according to ACE’s requirements. The facility is also required to report any significant program changes, including changes to equipment or procedures, adding or removing operators, and sentinel events. ACE also requires completion of an online survey each year. To learn more or get your application started, visit www. Or call 202-657-6859.

forward to awarding accreditation to many other deserving programs moving forward.” ACE provides professional review of cardiac and endovascular facilities and accredits those that achieve predetermined benchmarks for quality care. ACE’s accreditation programs currently include diagnostic catheterization, PCI, and carotid stenting programs, and the organization has plans to expand to accreditation programs for other cardiovascular procedures. ACE is currently reviewing other program applications, with additional accreditation awards expected in the coming months. “For St. Francis to earn the very first national accreditation recognizing excellence of cardiac catheterization programs is a distinct honor,” said Mark Nantz, chief executive officer, Bon Secours St. Francis Health System. “Every day, with every patient, we see how our physicians and members of the cardiac cath lab team hold themselves to delivering the highest standards of care. Achieving this level of recognition is a tribute to all those involved with our cardiovascular services. This first rigorous review and outstanding recognition of our cardiac catheterization services reflects to all those we serve how deeply we are committed to a healing ministry and our mission to be ‘Good Help.’” Designed to promote and uphold high-quality patient care and improve patient safety, ACE offers independent evaluation of facilities’ processes and objective peer review of outcomes based on established benchmarks derived from scientific evidence in peer-reviewed medical literature and national practice guidelines. Recent studies have shown accreditation improves patient outcomes and promotes progress toward enhanced patient safety standards. Applicants complete a comprehensive application followed by a site visit from ACE’s team of expert reviewers who assess the facility itself, its personnel, quality assurance and safety protocols, patient indications and outcomes. “Because we employ a standardized, unbiased assessment, patients who are treated at an ACE-accredited cardiovascular center should feel confident the facility has taken the appropriate, evidence-based steps to help ensure the best care for each individual patient,” said Dr. Weiner. Programs that achieve full accreditation are recognized by ACE for two years, at which time their facility must be reviewed again for continued recognition. ACE also provides tools and guidance for quality improvement, assists with peer review activities, and is committed to helping facilities achieve the highest standards of care. Facilities seeking ACE accreditation can obtain more information and complete the application process at n


Emerging Leader Mentorship (cont’d from pg 1) mentorship in two ways. First, the fellows will participate in six group training sessions held at the SCAI, ACC, and TCT meetings each year. This training, which will Future Leaders become more advanced at each session, will teach the The response to ELM’s call for applicants revealed ELM fellows how the different cardiology societies, that there are plenty of potential leaders out there, says industry and government fit together as well as specific Dr. Naidu. “We were very surprised to have so many skills such as public speaking and giving presentations. wonderful applicants,” he says. The ELM committee The first session took place at SCAI’s 2011 Scientific selected 10 winners from 62 applicants. Sessions in Baltimore. To identify the interventionalists with high leadership Between these group sessions, the fellows will get potential over the next 20 to 30 years, the committee individualized support from a mentor they’ve been pored over applicants’ curriculum vitae, personal paired with. “This is very different from other mentorship statements, writing samples and references. programs that select mentors and then assign people to The committee assessed specific skills, such as public them,” says Dr. Naidu. “We did it the other way around: speaking, effective writing, clinical or basic research We looked at where the applicant wanted to go with his and the ability to work as part of a team. They checked or her career and found someone who is on that trajectory whether applicants had already demonstrated leadership, but several years ahead.” Fellows will meet with their such as establishing a new mentors monthly, either in clinical niche or volunteering person or by phone. “This is very different from their services abroad. And they A month or two after other mentorship programs that meeting looked to see if applicants had their mentors select mentors and then assign at the SCAI Scientific already developed a regional reputation. people to them. …We looked at Sessions, the fellows will “If they had made a name for a proposal outlining where the applicant wanted to go submit themselves in their own areas, their goals for the first year, with his or her career and found second year, and five to that was obviously a sign they could do it on a national scale,” someone who is on that trajectory 10 years down the road. says Dr. Naidu. The document will also but several years ahead.” The committee also sought specify how they intend to — Dr. Naidu achieve those objectives to select a group who would represent the breadth of using, among other things, interventional cardiology. Some fellows are focused on the doors opened to them by participation in the ELM clinical work, while others are more intent on research Program. After getting sign-off from the ELM committee, careers and want to launch clinical trials. Others are they’ll get to work. They’ll go through the same process interested in advocacy. at the end of the first year, and then summarize their Subspecialties within interventional cardiologist are accomplishments at the end of the two-year program. also represented. Lynn F. Peng, M.D., for instance, is The fellows will graduate from the program in 2013, a pediatric interventional cardiologist. She thinks the when another 10 fellows will be announced. program will give her a valuable opportunity to meet her ELM fellow Mauricio G. Cohen, M.D., FSCAI, is counterparts in adult interventional cardiology. excited about getting started. “We have been following “Pediatric and adult cardiology don’t always have a lot the lead of interventional cardiology’s pioneers,” says Dr. of interaction,” says Dr. Peng, a clinical assistant professor Cohen, director of the cardiac catheterization laboratories of medicine in the division of pediatric cardiology at the at the University of Miami’s Miller School of Medicine. Lucile Packard Children’s Hospital at Stanford. “But “Now there is a need for a new generation of leaders who as more of our patients are surviving into adulthood can follow their pathway.” with congenital heart disease, it’s really important that Although he hasn’t yet formalized his goals for the pediatric cardiologists get involved with the groups that program, Dr. Cohen already has one item on his agenda: adult cardiologists are involved in.” eventually serving as a mentor himself. “I would love to be on the other side of things,” he says. “I’d like to pass Intensive Mentorship the baton.” The ELM program will go far beyond the informal For more information about SCAI’s ELM program, network of peers. It has been designed to provide intensive contact Dr. Naidu at n positions or get the type of training and mentoring they need to get to that level.”


Introducing the 2011 ELM Fellows J. Dawn Abbott, M.D., FSCAI Director, Interventional Cardiology Fellowship Program, Division of Cardiology, Rhode Island Hospital, Providence, RI

Lynn Peng, M.D. Clinical Assistant Professor of Medicine, Division of Pediatric Cardiology, Lucile Packard Children’s Hospital, Stanford, CA

Mauricio Cohen, M.D., FSCAI Director, Cardiac Catheterization Laboratories, Division of Cardiology, University of Miami - Miller School of Medicine, Miami, FL

Duane Pinto, M.D., M.P.H., FSCAI Director, Cardiovascular Fellowship Program, Division of Cardiology, Beth Israel - Deaconess Medical Center, Boston, MA

Douglas Drachman, M.D., FSCAI Director, Cardiology Fellowship Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA

Paul Sorajja, M.D., FSCAI Associate Professor of Medicine, Division of Cardiology, Mayo Clinic, Rochester, MN

The mentors for the 2011 ELM Fellows are as follows: George Dangas, M.D., Ph.D., FSCAI, Mount Sinai Medical Center, New York, NY Cindy Grines, M.D., FSCAI, William Beaumont Hospital, Royal Oak, MI James B. Hermiller, M.D., FSCAI, The Care Group, Indianapolis, IN Thomas Jones, M.D., FSCAI, Mullins Seattle Children’s Hospital, Seattle, WAWill Lecture Morton J. Kern, M.D., FSCAI, University of California–Irvine, Orange, CA Alexandra Lansky, M.D., FSCAI, Yale University, New Haven, CT Srihari S. Naidu, M.D., FSCAI, Winthrop-University Hospital, New York, NY William O’Neill, M.D., FSCAI, University of Miami, Miami, FL

Allen Jeremias, M.D. Director, Vascular Medicine and Peripheral Intervention, Division of Cardiology, Stony Brook University Medical Center, Stony Brook, NY

Jennifer Tremmel, M.D., FSCAI Clinical Director, Women’s Heart Health, Division of Cardiology, Stanford University Medical Center, Stanford, CA

Navin Kapur, M.D., FSCAI Assistant Director, Cardiac Catheterization Laboratories, Division of Cardiology, Tufts Medical Center, Boston, MA

Thomas Tu, M.D., FSCAI Director, Cardiac Catheterization Laboratory, Louisville Cardiology Medical Group, Louisville, KY

Ramon Quesada, M.D., FSCAI, Baptist Heart & Vascular Institute, Miami, FL Gregg W. Stone, M.D., FSCAI, Cardiovascular Research Foundation, New York, NY

Patient Education

Mended Hearts–SCAI Collaboration

Cath Patient Outreach Program Exceeds Expectations


ore than 4,000 cardiac catheterization patients around the United States have already benefited from a new cath patient outreach program offered by the patient support group Mended Hearts with support from SCAI. And that was just in the program’s first six months. “We’re just getting started,” says long-time Mended Hearts volunteer Steve Stanko of Las Vegas, who co-chairs the initiative with SCAI President-Elect J. Jeffrey Marshall, M.D., FSCAI. Mended Hearts The program sends trained volunteers Volunteer Steve Stanko to visit cath lab patients and offer peerto-peer education and support. “Mended Hearts volunteers do a great job calming patients’ and families’ nerves before a procedure and afterwards stressing the importance of post-care,” says Dr. Marshall. “Having a volunteer there who understands what we’re trying to accomplish gives us another set of J. Jeffrey Marshall, hands to help with education.” M.D., FSCAI

Visiting Cath Patients Mended Hearts has been sending volunteers to visit patients who have undergone bypass surgery for the last five decades. Recognizing that more patients are undergoing interventional procedures, the organization had in recent years begun limited expansion into cath lab visits. In 2009, the organization joined with SCAI to formalize the effort. After a pilot project, the official program kicked off in mid-2010 with 11 Mended Hearts chapters, and others participating on an informal basis. With grant support from AstraZeneca in 2010 (and later in 2011 with a matching grant from the Eli Lilly and Daiichi Sankyo Alliance), Mended Hearts and SCAI have developed a “Cath Pack” that includes a brochure titled “After the Cath Lab: A Guide to Recovery” and other information. Six months into the program, the volunteers had visited and shared that information with 3,313 cath lab patients undergoing stent placements, angiograms, and other procedures plus 720 family members. Recognizing the Power of Data The volunteers are also collecting data from patients, along with permission to follow up later. They’re asking questions focused on adherence to medical regimens after treatment with a stent, such as “Are you following your prescribed medication regimen?” and “Do you understand

the purpose of your medication? If not, what would help you understand its purpose better?” Although the volunteers are still collecting the follow-up data, Mr. Stanko is already seeing trends in the 2,046 reports filed in the program’s first six months. The preliminary data suggest that “patients seem to be complying with their medical regimens,” he says. For those who say they are not, reasons cluster around the cost of the drugs and side effects. Most patients also report understanding the purpose of their medications. Those who didn’t felt that talking with a healthcare professional or visiting a website that explained medications would boost their understanding. The data will provide crucial information on how to boost compliance, says Dr. Marshall. “Especially in today’s costconscious world, the last thing we want is people bouncing back into the hospital for a repeat emergency procedure,” he says. “If patients can understand from another patient’s perspective how important it is to take their medicines, maybe we have an inside track to increasing compliance.” The data also have the potential to validate Mended Hearts’ approach, he adds. “Doctors, pharmacists, nurses and other healthcare professionals have tried for years to impact compliance,” he says. We know that education— especially discharge education—is a very important issue, and who better to talk about that than someone who has actually taken medicines at home themselves?” Mended Hearts is already seeing the impact of the cath patient visiting program on its membership rolls. “I was talking to a chapter yesterday that got six new members from doing the interviews,” says Mr. Stanko.

Planning for Growth Now Mr. Stanko and his colleagues are making plans for the program’s next phase. They’ve already made several improvements. For starters, they have added new materials to the program, including a new brochure on depression. “Depression is one of the major factors a patient has to deal with after a procedure,” explains Mr. Stanko. The Cath Pack, which trained visitors share with patients, will this year include a new brochure about programs to help patients who can’t afford medications they’ve been prescribed get the drugs they need. Mr. Stanko also hopes more Mended Hearts chapters will participate in the initiative. “As time goes by, it will be like a snowball” he predicts. “More and more will pick it up.” To learn more about SCAI’s collaboration with Mended Hearts or to find out about Mended Hearts programs in your area, contact SCAI at 800-992-7224 or or visit n



Education Update SCAI Announces New Online Education Program on High-Risk PCI Key Points • In response to members’ requests, SCAI has developed a new online program, High-Risk Percutaneous Coronary Intervention. • Featuring six modules focused on case selection and management, this new eLearning opportunity is offered at no charge to members.


CAI’s catalog of eLearning opportunities expanded in May with the launch of the High-Risk Percutaneous Coronary Intervention (PCI) online course. Featuring an engaging combination of didactic presentations and case studies, the High-Risk PCI program Mark A. Turco, M.D., fulfills members’ requests for additional FSCAI information about this critical area of interventional cardiology practice. The initial release of the HighRisk PCI online course features six modules developed by some of the field’s thought-leaders. Led by program director Mark A. Turco, M.D., FSCAI, and program codirector Robert Applegate, M.D., Robert Applegate, FSCAI, the initial release includes M.D., FSCAI narrated presentations that offer a solid introductory background to High-Risk PCI. “This online program is designed for physicians at all stages of their careers,” said Dr. Turco. “We have focused on providing an excellent overview of high-risk PCI that will appeal to fellows-in-training as well as seasoned interventionalists looking for a refresher program or additional information. The program is designed to provide core education to physicians regardless of their experience level in high-risk PCI.” Similar to other courses in the SCAI eLearning library, the High-Risk PCI course operates as an online textbook. In addition to presentations developed and narrated by their authors, the website features enhanced navigation and search capabilities. Physicians are able to search for key terms and phrases in the text and audio, decreasing the amount of time necessary to locate pertinent information. The course operates on a Flash system, allowing content to load quickly on high-speed Internet connections within any computer operating system. “It is important to offer this curriculum in an online format,” said Dr. Applegate. “Online education continues

to be an important method of disseminating information, and SCAI members appreciate that this material is available to them 24 hours a day, seven days a week. It isn’t always possible to fit in a full course given busy office hours and demanding schedules, but immediate online access to the curriculum allows physicians to fit in a module when it is most convenient for them.”

“We have focused on providing an excellent overview of high-risk PCI that will appeal to fellowsin-training as well as seasoned interventionalists looking for a refresher program or additional information.”

- Dr. Turco

The program is bolstered by a curriculum focused on case selection and management. Current modules include: • Rationale and Evidence Base Cardiac Assist for High-Risk PCI • Identifying High-Risk Patients • Hemodynamics of Percutaneous Left Ventricular Support Devices During High-Risk Coronary Intervention • Hemodynamic Principles of Acute Percutaneous Circulatory Support • Management Issues (Including Non-Invasive Assessment) While on Support • Case Examples A second release is scheduled for 2012 and will feature an additional seven presentations, including available devices, device selection strategy, and ECHMO. Plans are also underway to offer CME credit for the second release. “This is a growing and changing area of interventional cardiology,” explained Dr. Applegate. “Our aim is to turn this course into a highly comprehensive repository for high-risk PCI information. We will keep the content fresh by continuing to add modules and update with current information.” The High-Risk PCI online course will be a complimentary benefit for SCAI members. The course is provided through an educational grant from Abiomed. For more information about the course or to register, contact SCAI’s online education manager, Stephanie Hubka, at or 800-922-7224. n


Coding Q&A

Transfer of Care Within a Global Period Requires Modifier Use, Impacting Reimbursement


The surgeon at our facility turns follow-up care after CABG over to the cardiology team immediately after surgery – if there is a “global” period associated with the surgical procedure is reimbursement impacted?


Yes. Medicare (and typically many commercial carriers) expect the physician* to provide all applicable care within the assigned global period. There are a few cardiology procedures with extended global periods, including carotid stent (37215), which has a 90day global period with a Medicare reimbursement rate reflecting the inclusion of two follow-up office visits and the endovascular aortic aneurysm repair family of codes, which also typically have a 90-day global period.

Transfer of care from one physician to another during a global period is allowed, requiring modifier use by both providers to communicate to the carrier the portion of services each has provided within the applicable global period. Transfer of care from one physician to another during a global period is allowed, requiring modifier use by both providers to communicate to the carrier the portion of services each has provided within the applicable global period. These modifiers impact the reimbursement rate paid to the respective providers for the procedure/ included post-procedure care. The following are the applicable modifiers used when there is a transfer of care during a service within an assigned global period, • Modifier –54 is appended by the provider performing the surgical care only. • Modifier –55 is appended by the provider performing the postoperative management only. • Modifier –56 is applicable in the rare case when a separate provider performs the pre-operative management only. The Medicare Physician Fee Schedule RVU file details the global period assigned to each CPT code. Copies are available for download from the Centers for Medicare and Medicaid Services website: http://

asp?filterType=none&filterByDID=-99&sortByDID =1&sortOrder=ascending&itemID=CMS1242727& intNumPerPage=10 The Medicare Claims Manual provides reporting requirements for when a transfer of care occurs within the global period for a service. A copy of the complete Medicare Claims Manual can be found at http://www. Both the bill for the surgical care only and the bill for the postoperative care only will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier. Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/ free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he or she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he or she assumes care of the patient. These policies are applicable to ALL Medicare carriers across the nation and local carriers are not allowed to deviate. n * Physicians are permitted to employee nurse practitioners (NP)/physician assistants (PA) to perform postoperative follow-up services. However, the NP/PA must provide these services as the employee of the physician; they CANNOT be hospital employees. In the case of an NP/PA performing postoperative services that is employed by the hospital, the Centers for Medicare and Medicaid Services would consider this to be a transfer of care to another eligible provider and the NP/PA would bill Medicare directly for the services he or she rendered with modifier use as discussed above. Please note: SCAI is committed to making every reasonable effort to provide accurate information regarding the use of CPT®, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. SCAI assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payors or Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors are copyright 2010 by the American Medical Association.


Global Surgical Package The payment for a surgical procedure includes a standard package of preoperative, intraoperative, and postoperative services. The preoperative period included in the global fee for major surgery is 1 day. The postoperative period for major surgery is 90 days. The postoperative period for minor surgery is either 0 or 10 days depending on the procedure. For endoscopic procedures (except procedures requiring an incision), there is no postoperative period. The Medicare-approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performed the surgery. The services included in the global surgical package may be furnished in any setting (e.g., in hospitals, ASCs, physicians’ offices). Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon; however, critical care services (99291 and 99292) are payable separately in some situations. The following services are included in the payment amount for a global surgery: • Preoperative visits — Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures; • Intraoperative services — Intraoperative services that are normally a usual and necessary part of a surgical procedure; • Complications following surgery — All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room; • Postoperative visits — Follow-up visits within the postoperative period of the surgery that are related to recovery from the surgery; • Postsurgical pain management — By the surgeon; • Supplies; and • Miscellaneous services — Items such as dressing changes; local incisional care; removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. The following services are not included in the payment amount for a global surgery: • The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery • Services of other physicians except where the surgeon and the other physician(s) agree on the

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transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complication of the surgery Treatment for the underlying condition or an added course of treatment that is not part of the normal recovery from surgery Diagnostic tests and procedures, including diagnostic radiological procedures Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) that may be performed in succession within 90 days of each other. Treatment for postoperative complications that requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR). If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately For certain services performed in a physician’s office Immunotherapy management for organ transplants Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician

For minor surgeries and endoscopies, the Medicare program will not pay separately for an evaluation and management service on the same day as a minor surgery or endoscopy unless a significant, separately identifiable service is also performed (e.g., an initial consultation or initial new patient visit). As stated, there is no postoperative period for endoscopic procedures (unless an incision is required), and minor surgical procedures have postoperative periods of 0 or 10 days based on the procedure.


See page 4 Key Points May/June2011 (continued on page 5) (continued on page 2) •Tenearly-careerSCAImembers...