Summary: The Centers for Medicare & Medicaid Services modified its coverage policy for Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER), effective June 3, 2026. Here's what billing teams need to do.
CMS formally addressed T-TEER coverage under its national policy framework. This is a significant move for cardiovascular and structural heart programs that bill for tricuspid valve interventions. The policy does not list specific CPT or HCPCS codes in the available data — we'll cover what that means for your charge capture below.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS |
| Policy | Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER) |
| Policy Code | N/A |
| Change Type | Modified |
| Effective Date | 2026-06-03 |
| Impact Level | High |
| Specialties Affected | Interventional Cardiology, Structural Heart Programs, Cardiac Surgery, Hospital Outpatient, Inpatient |
| Key Action | Confirm your T-TEER billing guidelines align with updated CMS medical necessity criteria before June 3, 2026 |
CMS T-TEER Coverage Criteria and Medical Necessity Requirements 2026
The CMS T-TEER coverage policy matters because tricuspid valve regurgitation has historically been undertreated. Surgical options carry high mortality risk for many of these patients. T-TEER — using a catheter-delivered clip to reduce regurgitation without open-heart surgery — is now an established structural heart intervention at high-volume centers.
CMS modifying this policy in 2026 signals a formal recalibration of how the Centers for Medicare & Medicaid Services views T-TEER's clinical evidence base. This isn't a minor edit. When CMS issues a policy modification on a structural heart procedure, it typically reflects shifts in coverage criteria, medical necessity thresholds, or facility and operator requirements.
The policy data available does not include the full text of updated coverage criteria. However, based on the CMS policy framework for structural heart interventions and the T-TEER evidence base, billing teams should expect the following areas to be addressed in the updated coverage policy:
Patient selection criteria. CMS coverage for transcatheter structural heart procedures typically requires documented symptomatic disease, anatomic suitability assessed by a heart team, and confirmation that the risk-benefit profile favors the transcatheter approach. For T-TEER specifically, medical necessity documentation should reflect the severity of tricuspid regurgitation (typically grade 3+ or 4+), the patient's surgical risk classification, and prior treatment history.
Heart team and facility requirements. CMS has consistently tied reimbursement for high-complexity structural procedures to facility volume thresholds and multidisciplinary heart team involvement. If your program performs T-TEER, confirm your site meets any updated operator and institutional requirements before June 3, 2026.
Prior authorization status. The updated policy does not explicitly state prior authorization requirements in the available data. That said, Medicare Advantage plans — which follow CMS national coverage determinations as a floor — often layer their own prior authorization requirements on top. Check your Medicare Advantage contracts before the effective date.
If you're billing for T-TEER under fee-for-service Medicare, the national coverage determination framework governs. If you're billing under a Medicare Advantage plan, that plan's prior auth requirements apply. Don't assume they're the same.
CMS T-TEER Exclusions and Non-Covered Indications
The available policy data does not detail specific exclusion criteria for T-TEER. CMS structural heart policies typically exclude coverage in the following situations — and your documentation should proactively address each:
| # | Excluded Procedure |
|---|---|
| 1 | Asymptomatic tricuspid regurgitation without functional impairment |
| 2 | Patients who are deemed anatomically unsuitable after heart team evaluation |
| 3 | Procedures performed at facilities that do not meet the required volume or structural heart program criteria |
| 4 | T-TEER performed outside an approved clinical trial where evidence remains investigational |
The investigational question matters here. T-TEER has FDA device approval (the TRILUMINATE Pivotal trial supported the MitraClip NTR/XTR and PASCAL systems in the tricuspid position), but CMS coverage decisions don't automatically follow FDA clearance. Watch for whether CMS distinguishes between approved device systems in the updated policy text.
If your program is using a device or approach that doesn't have strong clinical trial support specifically in the tricuspid indication, loop in your compliance officer before billing under this modified policy.
Coverage Indications at a Glance
The full indications table cannot be populated from specific policy text, as the detailed criteria are not included in the available data. The table below reflects the general CMS framework for T-TEER coverage as understood from the national policy structure:
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Symptomatic tricuspid regurgitation (grade 3+/4+) in high surgical risk patients | Likely Covered (verify against full policy text) | Not listed in available data | Heart team evaluation and documentation required |
| T-TEER at approved structural heart programs | Likely Covered (verify against full policy text) | Not listed in available data | Facility and operator criteria apply |
| Asymptomatic tricuspid regurgitation | Likely Not Covered | Not listed in available data | Standard CMS exclusion for structural procedures |
| T-TEER under active clinical investigation with separate trial coverage | Conditional | Not listed in available data | May qualify under Coverage with Evidence Development (CED) |
Verify every row in this table against the full policy text at the effective date. These indications reflect standard CMS structural heart policy patterns — not confirmed language from the June 3, 2026 update.
CMS T-TEER Billing Guidelines and Action Items 2026
The T-TEER billing landscape is complex even without a policy modification. A CMS update adds urgency. Take these steps before June 3, 2026.
| # | Action Item |
|---|---|
| 1 | Pull the full policy text from CMS before June 3, 2026. The available data doesn't include detailed criteria. Go to app.payerpolicy.org/p/cms/381-v1 or the CMS website directly. Read the actual modified language — don't rely on summaries, including this one, to make billing decisions. |
| 2 | Audit your current T-TEER charge capture setup. Because the policy does not list specific CPT or HCPCS codes in the available data, confirm with your coding team which codes your program currently uses for T-TEER procedures. Review whether those codes map correctly to the updated coverage criteria once the full policy text is available. |
| 3 | Update your medical necessity documentation templates. Whatever the updated criteria say, your clinical documentation needs to match them precisely. If CMS tightened medical necessity thresholds or added new documentation requirements, claims without updated supporting documentation will generate denials. Do this before the first T-TEER case billed after June 3, 2026. |
| 4 | Check your Medicare Advantage contracts for prior authorization changes. MA plans must follow CMS coverage determinations, but they set their own prior authorization rules. Contact your top three MA payers and confirm whether their T-TEER prior auth requirements changed in response to the CMS modification. |
| 5 | Review facility and operator credentialing documentation. CMS structural heart policies often include facility volume requirements. Confirm your program's credentials are current and on file. A claim denial tied to facility eligibility is avoidable — don't let it happen on a high-dollar structural heart claim. |
| 6 | Talk to your compliance officer if you're uncertain. T-TEER is a high-dollar procedure. Structural heart reimbursement for a single case can run into the tens of thousands of dollars. The combination of high financial exposure, a modified coverage policy, and incomplete published criteria is exactly the situation where a compliance review earns its keep. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for T-TEER Under This CMS Policy
The available policy data does not list specific CPT, HCPCS, or ICD-10 codes. Do not assume codes based on related procedures.
When the full policy text becomes available, expect to find codes in the following categories — but confirm each code against the actual policy language before updating your charge capture:
Procedure Codes — Confirm Against Full Policy Text
T-TEER is a relatively new procedure category. CMS may reference existing transcatheter structural heart repair codes or Category III CPT codes. Your coding team should confirm current code assignments directly from the updated policy or through your coding software's crosswalk to the CMS update.
Diagnosis Codes — Confirm Against Full Policy Text
ICD-10-CM diagnosis codes for tricuspid valve regurgitation will be required to support medical necessity on T-TEER claims. Your coding team should identify the specific codes that document the severity and clinical context required under the updated criteria.
Do not add or remove codes from your charge capture based on this post. Pull the confirmed code list from the full policy text before June 3, 2026, then update your charge capture. Any claim denial tied to a wrong code on a structural heart case is a costly and preventable error.
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