Part B Insider (Multispecialty) Coding Alert

Carrier cracks down on LV lead placement claims

When you're reading your carrier's local coverage determinations, sometimes it's not enough to look at the written list of conditions that the carrier will cover for a particular procedure. Take a lesson from the following case study on left ventricular lead insertion for the purpose of biventricular pacing (33224-33226).

Rule: Part B carrier Noridian Administrative Services put out a policy in 2003 stating that it would cover 33224-33226 for patients with "moderate to severe congestive heart failure (CHF)." Patients also must have "an electrical conduction disturbance in the heart that causes the ventricles to contract asynchronously," and not be likely to improve with additional drug therapy, Noridian said.

Roadblock: But the Iowa Heart Center (IHC) ran into trouble when it billed for lead-placement code 33225 with documentation that the patients had moderate to severe CHF. Noridian denied the claims saying that IHC had to document that the patients had Class III or IV heart failure, even though its policy only stated "moderate to severe CHF."

The Noridian reviewer admitted that the carrier's policy didn't specify Class III or IV heart failure, according to Rebecca Caux, senior coding specialist with IHC. But Noridian argued that the term "moderate to severe" meant the same thing as Class III or IV heart failure. In the end, IHC changed its documentation to satisfy Noridian.

The Noridian policy may not specify Class III or IV heart failure, but it does call for ICD-9 Codes 428.0 through 428.9, notes coder Jennifer Kelchen with Cardiologists PC in Cedar Rapids, IA. Those ICD-9 codes should be enough to tell you that the heart failure must be Class III or IV.

Tip: To document Class III or IV heart failure, you should look for items in the patient's heart such as a high QRS level on the patient's electrocardiogram, typically 135 or higher, says Kelchen. Often, an electrophysiologist's report will state "Class III heart failure," or "acute heart failure," and then you simply have to figure out if the heart failure is diastolic or systolic.

Important: Note that Noridian changed its policy to require a "conduction disorder," or a heart block, as a secondary diagnosis for 33224-33226. In its Medicare B News bulletin issue 210, dated Feb. 27, 2004, Noridian says your claim must include a secondary diagnosis code of 426.0, 426.3-426.54 or 426.9, notes Kelchen. If you don't document a heart block, Noridian will deny your claim.

Check other carrier policies

If your local carrier has a tough policy, you should examine other carriers' policies on the same issue to see if they make more sense, advises Cynthia Swanson, a cardiology coding specialist with Seim Johnson Sestak and Quist in Omaha, NE. Often, if another carrier has a more sensible policy, you can write to your carrier medical director and suggest that he or she tweak your carrier's policy to make it more like the other's.