Cardiology Coding Alert

Throw out your old QRS requirements and arm yourself with these new elements

You can master the new 33249 requirements the hard way: submitting and resubmitting claims until you get it right. Or, you can sidestep this hassle by using this breakdown of the new requirements.

The most significant changes are the removal of the wide QRS requirement (>120 ms) and the increase of ejection fraction from less than or equal to 30 percent up to less than or equal to 35 percent.

Translation: "The requirements [to justify 33249] loosened rather than tightened," says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at St. Paul Heart Clinic in Mendota Heights, Minn.

Think of the new criteria as being three-pronged:

1. the SCD-HeFT inspired coverage that throws out the QRS requirement

2. the ischemic changes

3. the class IV heart failure patients who qualify for cardiac resynchronization therapy.
 
1. No Need to Look for QRS Anymore If you have to undergo a medical-necessity review, you won't need to point to a patient's QRS, due to the clinical results from SCD-HeFT. Medicare is throwing out the QRS requirement entirely. "You don't need it anymore," says Eric Prystowski, MD, director of the electrophysiology lab at St. Vincent Hospital in Indianapolis and the editor-in-chief of the Journal of Cardiovascular Electrophysiology.

So that means that among the newly eligible beneficiaries are patients with heart failure, poor function of their left ventricle, and those with a narrow QRS finding on their electrocardiogram.
 
"Trailblazer (Texas Medicare) informed us in the past that we could submit ICD implants with any congestive heart failure (CHF) or cardiomyopathy code as long as the other criteria are met - like the QRS measurement," says Sandy Fuller, CPC, a cardiology coding specialist and compliance officer for a cardiology practice in Tyler, Texas. But that's a criterion you won't have to meet, thanks to the new decision. 2. Abide by These 2 Ischemic Changes

A. Start With Criteria for DCM Medicare has also tweaked the criteria for both ischemic dilated cardiomyopathy patients (DCM) and non-ischemic dilated cardiomyopathy (NDCM) patients. You would report DCM with 414.8 (Other specified forms of chronic ischemic heart disease) and select an ICD-9 code from the 425.x cardiomyopathy category for NDCM.

For example, under the SCD-HeFT portion of the new CMS coverage criteria, your electrophysiologist will still need to make sure that their DCM meet the following three criteria:
  a documented myocardial infarction (MI) greater than 40 days prior to the implant,

  have Class II or III heart failure, and

  a measured left ventricular ejection fraction (LVEF) of less than or equal to 35 percent. Implanting ICDs into these patients can prevent sudden death.

Good news: "The ejection fraction of less than or equal to 35 [...]