Medicare Compliance & Reimbursement

Here's what Medicare says about reimbursement for pacemaker implantation.

If providers weren't clear on when they'd get paid for pacemakers - and when they wouldn't - the Centers for Medicare & Medicaid Services has cleared the fog with its recent national coverage decision (NCD). You can now review a list of what diagnoses justify the implantation procedure.
 
After lengthy review, CMS determined that "pacemaker implantation is no longer considered routinely harmful or an experimental procedure." Pacemakers themselves have been covered as prosthetic devices under the Medicare program, but until this year the only guidance available on medical necessity was the general Medicare rule that "covered services be reasonable and necessary for the treatment of the condition" - which may not be much help.

The single-chamber lowdown:
 
With single-chamber pacemakers, in addition to the usual Medicare rule about "reasonable and necessary," the patient's condition must be "chronic or recurrent." This means providers won't get reimbursed if the pacemaker is for someone whose condition is caused by an isolated event, such as acute myocardial infarction, drug toxicity, or an electrolyte imbalance. If the patient has chronic or recurrent rhythm disturbance, then a seizure or syncope - in most people, an isolated incident - will medically justify the implant.

The double-chamber lowdown:
 
Coverage for these pacemakers is more far-reaching, including all conditions the physician considers the implant medically necessary for, except for these three: ineffective atrial contractions; frequent or persistent supraventricular tachycardias (unless the device is for the control of the tachycardia); and conditions that affect the patient every now and then, and briefly (so the pacemaker use won't be long-term).
 
For the full list of covered and non-covered conditions and guidelines, visit http://www.cms.hhs.gov/manuals/pm_trans/R16NCD.pdf.