Cardiology Coding Alert

One template trap could cause problems down the road.

If documentation woes are leading to denials for your dual-chamber cardiac pacemaker insertion claims, you’re not alone. Comprehensive Error Rate Testing (CERT) has shown a trend toward denials for this very reason. Here are some tips and tactics, including documentation guidelines from Noridian Medicare, to help you put an end to denials.

Dig In to Diagnosis Criteria

As with any other service or procedure, showing medical necessity is the key element for dual-chamber pacemaker coverage. To brush up on Medicare’s requirements for pacemakers, be sure to review the Medicare National Coverage Determination (NCD) Manual, chapter 1, part 1, section 20.8, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf, advises Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting in Lansdale, Pa.

In section 20.8, the NCD states Medicare considers single-chamber and dual-chamber implanted permanent cardiac pacemakers reasonable and necessary for treating non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block.

Note that the bradycardia must be symptomatic. “Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion),” Falbo adds, quoting the NCD.

Section 20.8 of the NCD also states that nationally covered indications for dual-chamber pacemakers in particular include:

• Single-chamber (ventricular pacing) at the time of pacemaker insertion elicits a definitive drop in blood pressure, retrograde conduction, or discomfort 

• Pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms, has already been experienced with a pacemaker that is being replaced 

• Even a relatively small increase in cardiac efficiency will importantly improve the quality of life, e.g., patients with congestive heart failure despite adequate other medical measures 

• Pacemaker syndrome can be anticipated, e.g., in young and active people, etc.

Example: Suppose a patient with an existing single-chamber pacemaker presents for an upgrade to a dual-chamber pacemaker. The cardiologist indicates the patient has non-reversible symptomatic bradycardia due to sinus node dysfunction with syncope. 

You report 33214 (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system [includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator]). For the diagnosis, you report the bradycardia with ICD-9 code 427.81 (Sinoatrial node dysfunction) or, after ICD-10 implementation, I49.5 (Sick sinus syndrome).

Plan Ahead for Pristine Pacemaker Documentation

Jurisdiction F Part B MAC Noridian sent out guidance to its providers regarding supporting documentation for dual-chamber cardiac pacemaker implantation under CERT review. If you have a payer other than Noridian, and the payer hasn’t provided specific documentation advice, you may find this checklist, based on Noridian’s guidance, helpful in creating your practice’s documentation plan.

EMR idea: Practices may benefit from generating a separate template procedure report in the electronic medical record (EMR) with the applicable documentation requirements, Falbo notes. “The caution in using templates is to educate the physician that there needs to be some level of customization/uniqueness documented about the patient. Avoid massive cloning of this documentation,” she advises.

The template in the EMR will help guide the cardiologist in meeting documentation requirements in an EMR Procedure Report separate from any E/M services, Falbo adds.

Documentation Checklist: Dual-Chamber Cardiac Pacemaker Insertion 

• History and physical: 

• Previous medical care history

• Alternative treatments

• Lifestyle changes

• Single-chamber pacemaker implanted or attempted previously

• Other

• Medical record review:

• Prior year’s services that support choice of dual chamber device

• Diagnostic reports: 

• All relevant testing, regardless of date

• Inpatient

• Outpatient

• Surgical report: 

• Complete description

• Factors affecting surgery

• Hospital documentation: 

• All hospital documentation for dates of service

• Physician orders

• Progress notes

• Consultations

• Anesthesia evaluations and notes

• Recovery room records

• Nursing notes

• Laboratory reports

• Radiology reports

• Medications (document all):

• Current

• Given during the most recent hospital stay

• Previous medications

• Records related to effectiveness

• Any symptoms caused/possibly caused

• Any adjustments 

• Indications (document those that apply):

• Non-reversible symptomatic bradycardia due to:

• Sinus node dysfunction OR second degree and/or third degree atrioventricular block

• WITH symptoms directly attributable to a heart rate less than 60 beats per minute

• Syncope

• Seizures

• Congestive heart failure

• Dizziness

• Confusion

• Other

• Single-chamber ventricular pacing pacemaker insertion caused a definitive blood pressure drop, retrograde conduction, or discomfort

• Pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms experienced with pacemaker being replaced

• Even a small increase in cardiac efficiency will importantly improve the quality of life (e.g., patients with congestive heart failure despite adequate other medical measures)

• Pacemaker syndrome can be anticipated (e.g., in young and active people)

Resources: 

• Medicare National Coverage Determination (NCD) Manual, chapter 1, part 1, section 20.8 at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf

• Dual-Chamber Cardiac Pacemaker Insertion Billing www.noridianmedicare.com/partb/claims/cert/billing_dual-chamber_cardiac_pacemaker.html.