Evolution of Carotid Stenting: Payment Issues

Carotid stent placement received assignment of two Category I Current Procedural Terminology (CPT) codes in 2005, based on the collaborative efforts of 10 medical, surgical, and radiological specialty societies. One code is used to report stent placement with embolic protection, the other without embolic protection. The codes are unusual for interventional procedures because they include all associated catheterizations, diagnostic imaging, angioplasty, and radiologic supervision and interpretation. The Centers for Medicare and Medicaid Services (CMS) issued a coverage policy for carotid stenting in March 2005, imposing major limitations on eligibility. First, the Agency will only pay for carotid stents performed with embolic protection. In addition, each patient must meet three separate criteria to achieve Medicare coverage: (1) lateralizing transient ischemic attack, transient monocular blindness, or minor stroke with Rankin score <3; (2) an angiographically documented stenosis ≥70%, and (3) physiologic or anatomic criteria to indicate the patient is at high risk for carotid endarterectomy. No asymptomatic patients are covered under the current Medicare policy, but coverage criteria are currently under reconsideration. Finally, CMS restricts carotid stent coverage to facilities that meet its certification requirements.