Procedure coding
Procedure coding for open heart valve replacement and repair is well-established in European countries. Procedure codes may differ depending on the anatomical site (heart valve treated). The type of valve (biological, mechanical, etc.) can be specified in the code description or coded separately. Extracorporeal circulation support during surgery is typically coded separately.
For example, in the Netherlands, open aortic valve replacement with biological valve is described via the combination of procedural code 033079 “Heart valve replacement, open procedure” and material code 190618 “Allograft heart valve prosthesis”. Extracorporeal circulation support is coded separately via the code 032671 “ECC perfusion per operating room session”.
Procedure coding for open heart valve repair in some European countries differs depending on the type of intervention. For example, in Denmark, procedure coding for open mitral valve repair includes code KFKC00 for suture of the mitral valve, code KFKC20 for plasty of the mitral valve, and code KFKC60 for resection and reconstruction of mitral valve leaflets.
Payment mechanism
In most EU countries, DRG is the key reimbursement model for open heart valve replacement and repair procedures. The cases with complications or combined interventions can be allocated to the DRGs with higher reimbursement tariffs. For example, in Norway, open heart valve replacement procedures are allocated to the DRG “Heart valve operation without complications” with a tariff of 253,873 NOK, whereas in the presence of complications or combined heart valve operations are reimbursed via DRG 104B “Multiple heart valve surgery or a heart valve operation with complications” with a tariff of 398,078 NOK.
The devices for open heart valve repair and replacement procedures typically do not attract additional reimbursement in European countries. However, in England, there is a specific category in the High Cost Devices List “Sutureless aortic heart valve / rapid deployment aortic heart valve replacement”.
In some countries, the type of device used for the intervention might impact the DRG allocation. For example, in Switzerland, the use of self-expanding sutureless xenograft for open aortic valve replacement is allocated to the DRG F03C with a higher tariff of 48,840 CHF for an ordinary hospital stay compared to DRG F03E with a tariff of 36,180 CHF for the replacement procedure with conventional biological valve.
Policy considerations
As open heart valve repair and replacement procedures are well-established technologies, they are unlikely to be subject to specific policies from payers or national decision-makers in the countries where such frameworks exist.
Health technology assessment
Due to established reimbursement in European countries, devices for open heart valve repair and replacement procedures rarely become a subject of HTA.
Future challenges
Open heart valve repair and replacement procedures have established reimbursement and funding in most European countries. New health technology assessments are unlikely to be relevant. Open heart valve repair and replacement procedures are unlikely to benefit from the innovative payment schemes.
Novel devices with unique designs, properties, or different cost profiles might need to develop specific procedure codes and adjust payment mechanisms to leverage their unique technology or cost profile fully.
How can MTRC help?
Development of reimbursement analysis (procedure coding, payment mechanism, reimbursement tariffs, and policy considerations)
Development of reimbursement strategy
Development of the value dossier
Performing evidence gap analysis for novel technologies
Development of reimbursement and HTA submission dossiers
Adaptation of the global health economic model to EU settings
MTRC has experience with more than 6 projects related to open heart valve replacement and repair in Europe
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