Part B Insider (Multispecialty) Coding Alert

Medicare HMO patients get defibrillators on fee-for-service basis

Patients should be able to receive an implantable defibrillator on a fee-for-service basis even if they're enrolled in a Medicare Advantage Plan, according to Transmittal 488, issued March 4.

Defibrillators won't be part of the capitated rates the plans receive. Also, Medicare will require that all patients receiving defibrillators to prevent cardiac arrest must be enrolled in a data-collection program. For these patients, you should append the -QR modifier starting April 4.

As of Jan. 25, Medicare has expanded coverage for implantable defibrillators to include four new indications (coverage will extend through Dec. 31):

1) Patients with ischemic dilated cardiomyopathy, documented prior myocardial infarction, New York Heart Association Class II and III heart failure, and measured left ventricular ejection fraction of less than or equal to 35 percent.

2) Patients with nonischemic dilated cardiomyopathy for longer than nine months, Class II and III heart failure, and measured left ventricular ejection fraction of less than or equal to 35 percent.

3) Patients who meet all current CMS coverage requirements for a cardiac resynchronization therapy device and have Class IV heart failure.

4) Patients with nonischemic dilated cardiomyopathy for longer than three months, Class II or III heart failure, and measured left ventricular ejection fraction of less than or equal to 35 percent.

Also: New Coverage for IADs 

Separately, in Transmittal 29 issued March 4, CMS says it will now cover implantable automatic defibrillators (IADs) for patients with a documented former myocardial infarction and a measured left ventricular ejection fraction of less than or equal to 30 percent.

More qualifiers: Those IAD patients must not have Class IV heart failure; cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; a coronary artery bypass graft or percutaneous transluminal coronary angioplasty within the past three months; an acute MI within the past 40 days; symptoms or findings that would make them a candidate for coronary revascularization; or any disease associated with a life-expectancy of less than one year.

New coverage: Also, after Jan. 25, CMS will cover IADs for some new indications:

1) Patients with ischemic dilated cardiomyopathy, prior myocardial infarction, Class II and III heart failure, and left ventricular ejection fraction of less than or equal to 35 percent.

2) Patients with non-ischemic dilated cardiomyopathy for longer than nine months, Class II and III heart failure, and measured left ventricular ejection fraction of less than or equal to 35 percent.

3) Patients who meet all current CMS coverage requirements for a cardiac resynchronization therapy device and have Class IV heart failure.