Cardiology Coding Alert

You can add one more ICD-9 code to the short list that supports implantablecardioverter defibrillator services for Medicare patients outside of a clinical trial and not enrolled in a CMS-specified data registry. Here's the scoop on applying the change and perhaps recouping payment for past services rendered.

Background: An automatic implantable cardioverter defibrillator (AICD) has a pulse generator (battery) and electrodes that detect and treat life-threatening tachyarrhythmias (fast heart rhythms). Medicare covers AICD services in very specific cases, described in the National Coverage Determinations Manual (NCD Manual), Chapter 1, Part 1, Section 20.4.

Through various transmittals, CMS has posted a handful of ICD-9 codes that support coverage without the patient needing to be enrolled in a clinical trial or CMSspecified data registry. But there are numerous other indications that Medicare covers only if the patient is in a trial, and you signify enrollment by appending modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) to the AICD service's CPT code. (Note that the modifier is Q-zero.)

What's new: CMS announced you should add V12.53 (Personal history of sudden cardiac arrest) to the short list of diagnoses that don't require modifier Q0 for AICD procedure coverage (Transmittal 663, CR 6867).

The news about not needing modifier Q0 on claims that include V12.53 makes sense, says Sandy Fuller, CPC, MCS-P, HIS supervisor and compliance officer for Cardiovascular Associates of East Texas. You use modifier Q0 to indicate that the cardiologist implanted the device for the primary preventative reasons studied in the trials (MADIT I, MADIT II, and SCD-HeFT), she explains. You can't assume a personal history of sudden cardiac arrest moves the patient into the "primary prevention" category.In fact, the NCD Manual indicates that one of the covered indications not considered "primary prevention of sudden cardiac death" is a documented episode of cardiac arrest caused "by ventricular fibrillation (VF), not due to a transient or reversible cause."

Term tip: Primary prevention means the patient has "no history of induced or spontaneous arrhythmias," according to Transmittal 819, CR 4273. Look specifically for no spontaneous sustained ventricular arrhythmias, experts say.

Now that V12.53 is on CMS's list of codes that support AICD service coverage without the use of modifier Q0, be sure to update your job aids. The current list includes the following codes:

427.1 -- Paroxysmal ventricular tachycardia

427.41 -- Ventricular fibrillation

427.42 -- Ventricular flutter

427.5 -- Cardiac arrest

427.9 -- Cardiac dysrhythmia, unspecified

V12.53 -- Personal history of sudden cardiac arrest

996.04 -- Mechanical complication of cardiac device, implant, and graft; due to automatic implantable cardiac defibrillator

V53.32 -- Fitting and adjustment of other device;automatic implantable cardiac defibrillator.

Application: Based on the list, if a patient has v-tach (427.1), for example, you haven't had to -- and still don't have to -- append Q0 to the AICD procedure code, such as 33249 (Insertion or repositioning of electrode  lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator), to receive payment, explains Sarah Tupper, CMC, billing manager for Central New York Cardiology in Utica, N.Y. And this rule now applies for V12.53.

For those indications that the NCD Manual lists under "primary prevention," such as heart failure and cardiomyopathy (see the manual for specific clinical indications), you must append modifier Q0 for payment, she warns. And the facility must enroll the patient in the American College  of Cardiology data registry.

Helpful history: In Transmittal 819, retroactive to April 1, 2005, CMS added the last two codes on the list, 996.04 and V53.32, to allow payment for services such as replacing the AICD due to a recall, a complication, or the end of battery-life.

The V12.53 change is retroactive, so check your files for AICD claims with dates of service on or after Oct. 1, 2007, that Medicare denied because the diagnosis code was V12.53 and the claim did not include the clinical trial modifier. Transmittal 663 refers to modifier Q0 for dates on or after Jan. 1, 2008, and modifier QR (Item or service provided in a Medicare specified study) for dates before Jan. 1, 2008. This is because modifier Q0 essentially replaced now deleted modifier QR in 2008.

Action plan: If any of these claims remain unpaid, you can bring them to your contractor's attention for payment, Transmittal 663 reveals. The implementation date for this transmittal is July 6, 2010, so payers have until that date to change their systems to recognize the new rule.

Round Up the AICD Resources

If you want to learn more about AICD coding, CMS has various resources available:

• The NCD Manual, Chapter 1, Part 1, Section 20.4,explains coverage requirements in detail: www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf.
• Transmittal 819, CR 4273 (2006), explains the appropriate use of 996.04 and V53.32: www.cms.gov/Transmittals/downloads/R819CP.pdf
• The recent V12.53 update is in Transmittal 663, CR 6867: www.cms.gov/transmittals/downloads/R663OTN.pdf.