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Cardiology Coding Alert

Coding Dilemma for Treatment of Atrial Fibrillation

Published on Sat Sep 01, 2001

The use of internal cardioverter defibrillators (ICDs) to treat atrial fibrillation (AF) is relatively new. Medicare has not issued national coverage guidelines on the subject, and local Medicare and private carriers have yet to publish local medical review policies (LMRPs) governing the use of these devices for atrial fibrillation, which until now has been treated using drugs (e.g., anticoagulants and beta-blockers). As a result, coding for AF using ICDs has not yet been clearly defined.
 
On May 25, 2001, Minneapolis-based Medtronics received approval for its GEM III AT internal cardioverter-defibrillator, which, among its many functions, treats and controls atrial fibrillation. The AT is the second device approved to treat atrial and ventricular arrhythmias. Until May 2001, the Jewel-AF, also manufac-tured by Medtronics, was the only ICD that could treat AF and ventricular fibrillation (VF).
 
Until now, atrial fibrillation (427.31, irregular, rapid atrial contractions) has not been considered an indication for the implantation of an ICD-device, which is usually associated with ventricular tachycardia (VT) or VF, conditions that affect cardiac output more directly and often require immediate treatment. AF's major potential complication is thrombosis, and it is typically managed pharmacologically (e.g., with anticoagulation drugs). In some cases (for instance, if the patient also has ventricular tachycardia), cardiologists may implant the combined ventricular/atrial arrhythmia ICD. Carriers may cover the AF/VF ICD, even though AF on its own is not yet a recognized diagnosis for ICD implantation. As is often the case with new technologies, coverage and payment decisions for ICDs that control atrial arrhythmias have been left to local carriers, many of whom are likely to pay for the device and its implantation, says Linda Laghab, CPC, a practice coder with Foothill Cardiology and California Heart, a 26-physician practice with offices throughout the Los Angeles area.
 
"Medicare national coverage policy for ICDs does not address A-fib. I don't expect that there are other local payment policy guidelines out there, because the FDA has just recently approved the device," she says. "Coverage seems to be determined on a carrier-by-carrier basis." This applies both to Medicare and private payers, Laghab says, noting that her first attempt at preauthorization for the implantation of the GEM III AT was with Blue Cross Blue Shield and was successful.

ICD Implantation and Evaluation Coding
 
The same codes that are used to report the implantation and follow-up evaluation (including reprogram-ming) of any dual-chamber ICD apply to this device as well.
 
For implantation only, use 33249 (insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator), says Diane Elvidge, CPC, a coding specialist with Princeton Reimbursement Group in Minneapolis, which runs a Medtronics' reimbursement hotline. If the GEM III AT is replacing a previous ICD, the procedure should be coded with 33241 (subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator) and 33249.
 
If the cardiologist removes the old leads as well, use  33244 (removal of single or dual chamber pacing cardioverter-defibrillator electrode[s]; by transvenous extraction). Additionally, 71090 (insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) may be billed separately.
 
Follow-up evaluation, electronic analysis and/or reprogramming should be reported using the appropriate codes in the medicine section of the CPT manual. For electrophysiologic evaluation, the correct code from 93640-93642 should be selected. For electronic analysis, with or without reprogramming, use the appropriate code from among 93724-93738 or 93741-93744.

Carrier Discretion Determines Coverage
 
There is no national policy governing coverage for the implantation of an ICD that treats and controls atrial and ventricular arrhythmias. The Medicare Coverage Issues Manual addresses only briefly the question of ICDs, as stated in section 35-85: "Effective for services performed on or after July 8, 1991, the implantation of an automatic defibrillator is a covered service for patients who have had a documented episode of life-threatening ventricular tachyarrhythmia or cardiac arrest not associated with myocardial infarction."
 
The American College of Cardiology guidelines on ICD use broaden the list of Class I indications (i.e., conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful and effective) for ICD use to include:
 
1. cardiac arrest due to VF or VT not due to a  transient or reversible cause;
 
2. spontaneous sustained VT;
 
3. syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study when drug therapy is ineffective, not tolerated or not preferred; and
 
4. nonsustained VT with coronary disease, prior MI LV dysfunction, and inducible VF or sustained VT  at electrophysiological study that is not suppressible by a Class I antiarrhythmic drug.
 
The guidelines also state, "the fact that the use of a device for treatment of a particular condition is & beneficial, useful and effective does not preclude the use of other therapeutic modalities that may be equally effective." Both Medicare and commercial carriers have yet to issue any policies on ICDs that manage both ventricular and atrial arrhythmias, so coverage is determined on a case-by-case basis, Elvidge says.
 
The only current indications and contraindications for use of the GEM III AT ICD come from Medtronics, its manufacturer. The AT is intended for patients "who are at risk of sudden death due to ventricular tachyarrhythmia." The AT should not be implanted on patients "with transient or reversible tachyarrhythmias."
 
The AT is also intended for patients with atrial fibrillation, in addition to either VF or VT. But even here the device is meant to supplement other therapy and should not be "the sole treatment of atrial arrhythmias," according to Medtronics.
 
Carriers tend to cover most ICD placements because of the condition of the patient, but they are more likely to deny implantations of newer devices with additional features, such as GEM III AT.
 
"Be prepared for a denial the first time around," Elvidge cautions. "The carrier may accept the patient's VF or VT diagnosis but, at the same time, may not recognize AF as a covered diagnosis for ICD implantation and, as a result, may not understand why such a top-of-the-line ICD is required."
 
Practices should appeal such initial denials, Elvidge says, and she recommends strongly that AT implantations be documented well. It is especially important, she says, to include a sentence or paragraph explaining that the patient has both VF (or VT) and AF and that this ICD can treat and control both. Ultimately, the claim will most likely be paid, Elvidge adds, noting that to date, few coverage problems have been reported.

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