TAVR reimbursement: It’s complicated.
As you are probably aware, reimbursement for TAVR procedures is very different than the surgical counterpart. Before 2015, TAVR was assigned to the same diagnosis-related groups (DRGs) as surgical valve replacement and was therefore reimbursed at the same rate. Today, TAVR is assigned to a unique DRG set, exclusive to TAVR procedures, with two possible DRG assignments:
- DRG 266: TAVR procedures with a major complication or comorbidity (MCC), assigned when the medical record includes a secondary diagnosis that is recognized by CMS as an MCC. Examples would include conditions such as acute onset heart failure, hypoxic respiratory failure and end-stage renal disease.
- DRG 267: TAVR procedures without an MCC.
Each DRG has a payment weight assigned to it based on the average resources used to treat Medicare patients within it. DRG 266 has a higher level of reimbursement due to the higher resource requirements associated with treating a patient with MCCs. And while that seems to be pretty straightforward, nothing about TAVR reimbursement is easy.