# HELP!  Pacer and ICD Denials



## crhunt78 (May 7, 2013)

I am working on medical necessity denials for pacemaker and ICD insertions.  I used to code these all the time but haven't since 2009 and at that time there were very specific guidelines and diagnosis codes that Medicare would cover.  Now, Medicare just keeps telling the billers to look at the internet only manual for instructions and I can't seem to find anything from Medicare that is current.  Is the NCD that was created in 2005 still in effect?  Are there any updates for 2012/2013?  Thanks for your help!


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## la_0922 (May 7, 2013)

The NCD would take precedence in any case whether your local carrier had LCD for that pacer/ICD codes. Our local carrier (Novitas-Solutions) denied a code on medical necessity and based it on the NCD, so I would go by the NCD. Are you getting specific denials? Is there a specific CPT code / ICD code combo that you are having problems with? 

Louise


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## crhunt78 (May 8, 2013)

Yes, I am getting denials for 33249 and 33225 when billed with ICD-9 codes: 428.0, 426.3, 414.8, 414.01.  Are these codes even covered for these procedures?  I have to meet with this provider on Monday or Tuesday to go over this information and really need to get some solid documentation together.  Thanks for your help!


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## la_0922 (May 8, 2013)

You may want to check with your hospital's registry to see if it is Q0 modifier exempt... Q0 modifier is for ICD's implanted for primary prevention and that may be why you are getting denials. The hospital's registry is submitted to CMS and it must match your claim...in other words if they are on the registry for Q0 modifier thru the hospital and your claim is without that may be the reason for denial...

here is some documentation on this....


Successfully reporting data for primary prevention ICD implants is a mandatory requirement of Medicare coverage. In order to obtain reimbursement, Medicare national coverage policy requires that providers implanting ICDs for primary prevention clinical indications (i.e., patients without a history of cardiac arrest or spontaneous arrhythmia) report data on each primary prevention ICD procedure

The Centers for Medicare & Medicaid Services (CMS) announced in Transmittal 1403 and Transmittal 1418 that effective January 1, 2008, the â€œQRâ€� modifier has been deleted and replaced with a new â€œQ0â€� (zero) modifier. The â€œQ0â€� modifier must be applied to claims with date of service on or after January 1, 2008:

•Physician practices must enter â€œQ0â€� in the modifier section of the Medicare claim form for CPT code 33249 (full system implant) or 33240 (replacement generator).


Read more: http://www.hrsonline.org/Practice-G...Outpatient-and-Physician-Claims#ixzz2Sjt5pg6j 
Follow us: @hrsonline on Twitter | HeartRhythmSociety on Facebook

Hope this helps 
Louise


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## crhunt78 (May 10, 2013)

What if the patient has had a history of cardiac arrest or had a CABG within the last year?  I have one claim for a person who had a CABG and 9 days later needed an ICD implanted.....this is so confusing!  What do they mean by "primary prevention?"


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## la_0922 (May 10, 2013)

That is basically the indication for primary prevention. The concept is to prevent sudden cardiac death in patients with CAD, ischemic cardiomyopathy with a low ejectin fraction...
here is some more explanation from a very good article on wake forest/baptist health website....

"CMS has determined that patients with coronary artery disease and an ejection fraction of less than or equal to 35% are now indicated for an ICD. This decision increases the lower limit of the qualifying ejection fraction from 30 to 35% and eliminates the need for secondary indicators of risks.. 

CMS has also approved a new diagnosis for primary prevention which includes nonischemic dilated cardiomyopathy with New York Heart Association Class II and III. Therefore, patients with idiopathic dilated cardiomyopathy and other forms of cardiomyopathy with ejection fraction of 35% or less are now indicated for an ICD. The only caveat is that this diagnosis must be in place for at least nine months. If the diagnosis has been in place from three to nine months, the patients can have an ICD but they will need to be entered into a special registry, either an independent registry from each institution approved by the Institutional Review Board (IRB) or a yet to be established ACC/Heart Rhythm Society Registry. 

In addition, New York Heart Association Class IV patients are now indicated for an ICD if they meet the requirements for cardiac resynchronization therapy. 

Essentially all patients with some type of organic heart disease and ejection fraction of 35% are now qualified for an ICD. These patients should be considered for referral to an institution capable of implanting these devices. These institutions should have a low complication rate and high rate of successful ICD implantation and provide a patient registry as required by CMS. This decision by CMS has removed many of the ethical and financial concerns regarding indications for ICD implantation making it easier for physicians to provide the medical care that is proven to be necessary." 

it sounds like this is a Q0 modifier situation...call the hospital's cath lab and ask if they have a nurse in charge of the Primary prevention's Registry. she will be able to tell you if that patient is on the registry if so, then you need to append the Q0 modifier (if medicare) and rebill...

hope this helps 

Louise CPC


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## crhunt78 (May 13, 2013)

Very helpful, thank you!!


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