CPT code 33418 – Transcatheter mitral valve repair

Key takeaways

CPT Code 33418 covers percutaneous transcatheter mitral valve repair with the initial prosthesis, not open surgical repair.

33419 is the add-on code for each additional prosthesis (device) in the same session, reported once per session and never alone.

Medicare covers 33418 under NCD 20.33, with heart team evaluation and TVT Registry participation required for both DMR and FMR cases.

The 2026 national average professional payment is about $1,580.86 for 33418, which carries a 90-day global period.

Pabau, our practice management platform, turns the procedure invoice into an electronic claim through Claim.MD and checks eligibility first.

CPT Code 33418: Definition and official descriptor

CPT Code 33418 is defined by the American Medical Association as transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. It belongs to the cardiovascular surgery section of the CPT code set. Within that section, it sits in the cardiac valves subsection, which covers codes 33361 through 33496. Our CPT guides for coders cover its neighbors there, including the transcatheter aortic valve codes.

The AMA’s CPT code set classifies 33418 as a Category I code. That means many physicians across the US perform the procedure. Its clinical utility is established, and FDA-approved devices are in wide use.

What the procedure involves

Transcatheter mitral valve repair, also called transcatheter edge-to-edge repair (TEER), corrects mitral regurgitation (MR) through a catheter without open-chest surgery. The most widely used device is the MitraClip (Abbott), which clips the mitral valve leaflets together to reduce regurgitant flow. The PASCAL system (Edwards Lifesciences) is another FDA-approved option billed under the same code.

Coders must confirm the procedure used a transcatheter, catheter-based approach before reporting 33418. An open sternotomy or thoracotomy means a different code applies entirely (see the 33427 section below).

• Access route: Transfemoral venous access with transseptal puncture to cross from the right atrium to the left atrium
• Guidance: Continuous fluoroscopy and transesophageal echocardiography (TEE) guidance throughout
• Device deployment: Clip or repair device delivered to the mitral valve via catheter; leaflets grasped and approximated to reduce MR severity
• Setting: Cardiac catheterization laboratory or hybrid operating room, under general anesthesia
• Care team: Multidisciplinary heart team including an interventional cardiologist, cardiothoracic surgeon, cardiac anesthesiologist, and imaging specialist
• Indications: Symptomatic moderate-to-severe or severe degenerative MR (DMR) in patients at prohibitive or high surgical risk; functional MR (FMR) under specific CMS coverage conditions

What CPT Code 33418 includes and excludes

The AMA bundles specific services into 33418 by default. Reporting them separately constitutes unbundling and triggers payer denial or recoupment on audit.

Payers apply National Correct Coding Initiative (NCCI) edits to enforce these bundles. Payers automatically deny or bundle down a claim that pairs 33418 with a transseptal puncture code or fluoroscopy guidance code. Only a modifier that overcomes the edit would prevent that, and generally none applies here.

CPT Code 33418 vs 33419: Primary code and add-on

33419 is an add-on code, so you can only report it alongside 33418, never alone. It covers each additional prosthesis (device) placed in the same session, after the initial prosthesis billed under 33418. Still, 33419 counts once per session, however many extra devices the operator places.

33419 applies only when the operator places one or more devices after the initial prosthesis. When it does, list 33418 first on the claim and 33419 as a secondary line.

How CPT Code 33418 differs from CPT 33427

CPT Code 33418 covers a transcatheter (catheter-based, closed-chest) approach. CPT 33427, by contrast, covers open surgical mitral valve repair requiring sternotomy or thoracotomy with cardiopulmonary bypass. Selecting the wrong code based on the approach is the most common error in structural heart coding.

The operative note is the deciding document. If the surgeon accessed the mitral valve via catheter and transseptal puncture, bill 33418. If the surgeon opened the chest and started bypass, bill 33427. Never infer the approach from the procedure name. Read the operative report, then check the device count and who performed the TEE.

Medicare coverage and CMS policy for CPT Code 33418

Medicare covers transcatheter mitral valve repair under National Coverage Determination (NCD) 20.33. The Centers for Medicare and Medicaid Services (CMS) issued it. The current version comes from decision memo CAG-00438R, effective July 31, 2023. Clinical criteria differ between degenerative and functional mitral regurgitation, but Coverage with Evidence Development (CED) applies to both.

• Degenerative MR (DMR): Medicare covers TEER for symptomatic moderate-to-severe or severe DMR. The patient must have been evaluated by a multidisciplinary heart team and be at high or prohibitive surgical risk. The heart team evaluation and documentation of surgical risk assessment must be in the medical record. Because coverage is under CED, the facility must also take part in an approved registry and submit each case.
• Functional MR (FMR): As with DMR, coverage is under CED. The facility must enroll in an approved registry, specifically the Transcatheter Valve Therapy (TVT) Registry. The Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) maintain it. Missing registry enrollment documentation is an automatic Medicare denial for either indication.
• Facility requirements: The facility must have an established structural heart disease program, on-site cardiac surgery, and documented experience with TEER procedures. In addition, the NCD requires on-site heart valve surgery and interventional cardiology programs. The facility also needs at least two cardiac surgeons with valvular experience and at least 300 PCIs a year. CMS does not reimburse for TEER performed outside these settings.
• Patient eligibility check: Verify Medicare eligibility and coverage type before submission. Insurance eligibility verification at the time of scheduling, not the day of surgery, gives the billing team time to confirm registry enrollment status. As a result, problems surface early.

Commercial payer coverage policies for CPT Code 33418 vary significantly. Some align with the CMS NCD criteria; others impose additional clinical requirements or restrict coverage to specific FDA-approved devices. Verify each payer’s policy before the procedure date.

2026 reimbursement rates and RVUs

CMS publishes the Medicare Physician Fee Schedule (MPFS) annually, and Medicare reimbursement for CPT Code 33418 comes from it. The 2026 national average rates below use the 2026 conversion factor of $33.4009. They reflect facility billing, which applies when the procedure takes place in a hospital outpatient department or inpatient setting.

These figures represent the physician professional fee only. 33418 carries a 90-day global period, so the payment includes related postoperative visits in that window. The facility fee (billed by the hospital under the OPPS) is substantially higher, and CMS determines it separately. The facility payment includes device costs for the MitraClip or PASCAL implant. As a result, the physician does not bill them separately.

Geographic practice cost indices (GPCIs) adjust rates by location. Use the CMS Physician Fee Schedule lookup tool to confirm locality-adjusted amounts for your practice’s zip code. For RVU-level detail, the FastRVU 2026 lookup tool offers free work, practice expense, and malpractice RVU breakdowns by code.

Modifiers used with 33418

Modifier selection for CPT Code 33418 depends on how the practice structured the operative team. Modifiers 26 and TC do not apply, because 33418 is a global surgical code with no professional and technical split.

The co-surgery modifier 62 is common in structural heart programs. There, the interventional cardiologist leads the transcatheter approach and a cardiothoracic surgeon is present for standby or active participation. Both providers bill 33418 with modifier 62, each receiving 62.5% of the standard fee. Document each surgeon’s distinct role in the operative note. Payers often deny claims that describe the second surgeon only as “surgical standby.”

Prior authorization requirements

Medicare does not require prior authorization for CPT Code 33418 under the current CMS rules. However, the procedure must still meet NCD 20.33 criteria before Medicare will pay the claim. Registry enrollment is mandatory for every covered transcatheter edge-to-edge repair (TEER) case, DMR and FMR alike. It functions as a de facto precondition.

Commercial payer prior authorization requirements vary. Most major payers treat TEER as a high-cost cardiovascular procedure requiring pre-procedure approval. The typical PA submission for 33418 includes:

• Letter of medical necessity from the treating cardiologist detailing MR severity and symptom burden
• Echocardiogram report confirming MR grade (moderate-to-severe or severe) and valve anatomy suitable for transcatheter repair
• STS risk score calculation documenting high or prohibitive surgical risk
• Heart team evaluation summary confirming the multidisciplinary decision for TEER over surgical repair
• Documentation of prior medical management (heart failure medications at maximally tolerated doses)
• Facility credentialing confirmation showing the performing center meets the payer’s structural heart program requirements

Submit the PA request well before the scheduled procedure date. TEER is not an urgent procedure in most cases. Payers routinely take 10 to 15 business days to process high-cost cardiac PA requests. Late submission forces rescheduling or creates a retroactive authorization risk.

Documentation that supports a 33418 claim

CMS and commercial payers audit 33418 claims for documentation completeness. The medical record must support both the procedure code and the CED conditions under NCD 20.33. That applies to DMR and FMR cases alike. Missing any of these elements at the time of claim submission is a denial waiting to happen. Coders report nonrheumatic mitral regurgitation with I34.0, and the echocardiogram report must support that diagnosis.

• Operative/procedure note: Must clearly state the transcatheter approach, device used (MitraClip or PASCAL), access site, transseptal puncture confirmation, and number of devices placed
• Pre-procedure echocardiogram: TEE or TTE report documenting MR severity grade, valve anatomy, and eligibility for transcatheter repair
• Heart team meeting note: Summary of the multidisciplinary evaluation confirming the decision to proceed with TEER rather than surgical repair
• STS surgical risk score: Calculated and documented in the medical record for DMR and FMR cases alike. For DMR, it must show high or prohibitive surgical risk.
• TVT Registry enrollment: Confirmation that the facility is enrolled in the TVT Registry and that the specific case has been submitted to it. Without this, Medicare covers neither DMR nor FMR cases.
• Informed consent: Signed consent documenting the risks and alternatives, including surgical repair

A well-constructed superbill for structural heart procedures should capture all six documentation anchors above. It should also link them to the submitted CPT codes. That audit trail supports the initial claim and any later payer review. It is the core of medical billing compliance for high-value procedures.

Common denial reasons for CPT Code 33418 and how to avoid them

Most 33418 denials fall into five categories. Each has a corrective action that your team can build into the pre-submission workflow instead of addressing on appeal.

Denial patterns on high-value cardiac codes like 33418 are worth tracking systematically. A structural heart billing team that logs denial reason codes by category learns which documentation element fails most often. A team handling appeals one by one rarely sees that pattern. Denial management workflows designed for high-acuity codes typically separate the NCD documentation review from the standard coding QA process. Two separate checkpoints reduce the chance that the team skips either one under time pressure.

How claims management software prevents 33418 denials

Many structural heart billing teams assemble a 33418 claim from several places. The heart team note sits in the EHR and the STS score in a spreadsheet. The registry confirmation arrives by email, and the authorization number lives on a payer portal. Each handoff is a chance for one NCD element to go missing.

Pabau’s cardiology claims management software keeps that work next to the procedure record. It turns the invoice into an electronic CMS-1500 claim and submits it through the Claim.MD clearinghouse. It also runs a real-time eligibility check before the procedure date. In addition, it brings electronic remittance advice (ERA) back into the billing workflow.

If you confirm coverage before scheduling the patient, you raise the odds of a clean claim on first submission. Claim statuses and denials show up in one dashboard, so the team can correct a rejected 33418 line quickly.

Get 33418 claims out clean the first time

Pabau attaches 33418 to the procedure invoice, checks the patient’s coverage in real time and submits the claim electronically through Claim.MD. Claim statuses and remittances come back into the same dashboard.

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Conclusion

A 33418 claim is won or lost before anyone opens the billing screen. Build the registry check, the heart team note and the device count into scheduling. Then coding becomes the short step at the end.

The trade-off is front-loaded work on every case, including the ones that would have paid anyway. 33418 is worth about $1,580 to the physician alone, with a 90-day global period behind it. On that code, the extra work pays for itself after one avoided denial.

Book a demo to see how Pabau keeps eligibility, claim submission and remittances for structural heart cases in one place.

Continue your research

Need guidance on denial code patterns for cardiac claims? Denial codes in medical billing covers CARC codes and how to respond to the most common payer rejection reasons.

Submitting 33418 claims electronically for the first time? How the 837 file works explains the EDI claim format that carries CPT codes, modifiers, and diagnosis codes to the clearinghouse.

Looking for a broader revenue cycle overview? What is revenue cycle management walks through the end-to-end process from eligibility through payment posting.

Coding the aortic side of a structural heart program? CPT code 33361 covers transfemoral transcatheter aortic valve replacement and its own NCD conditions.

Building a prior authorization workflow for high-cost procedures? The prior authorization process walks through each step from request to approval.

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