Wiki 33249- ICD implant help!

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charityelaine

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Hope y'all can follow me here....
(There is not a specific LCD (payable dx) for the 33249, however, the NCD (rules) lists some payable dx IF all the requirements have been met.)
Here's my question/issue: I was under the impression that the physician only had to meet 3 of the requirements listed in the NCD (ie. EF of <35, 40 days after MI, etc) in order for the device to be implanted, but now I'm being told that the physician has to meet ALL requirements listed in the NCD before he can perform the procedure!
I have opened up a whole new can of worms & want some help from my fellow EP coders.
On the CMS website, I have found the NCD 20.4, but that's the only documentation I can find and nowhere does it specify how many requirements have to be met.
Any help, ideas or facts?! :eek:

Thanks in advance!
 
I don't think there is a standard number of requirements the physician has to meet. We have billed and been paid after meeting only 2 requirements but we also attach documentation to show it was medically necessary.

HTH,
Dawn CPC, CCC
 
Thanks, Dawn! I appreciate your input. We are under scrutiny right now for the billing of ICD implants and are being heavily monitored on why our EP docs have implanted the device. They are only looking at the dual chamber, not the single. Go figure.
I still haven't gotten a clear cut answer on whether we have to meet ALL criteria, but I have a meeting about it on Friday. Hopefully, I'll learn more then. In the meantime, if you hear of or know of anything else to add, please do so. :)
Thanks again, Charity
 
charityelaine said:
Thanks, Dawn! I appreciate your input. We are under scrutiny right now for the billing of ICD implants and are being heavily monitored on why our EP docs have implanted the device. They are only looking at the dual chamber, not the single. Go figure.
I still haven't gotten a clear cut answer on whether we have to meet ALL criteria, but I have a meeting about it on Friday. Hopefully, I'll learn more then. In the meantime, if you hear of or know of anything else to add, please do so. :)
Thanks again, Charity
Click to expand...

Hi Charity - if you find out anything helpful at your meeting Friday, would you mind sharing? I am new to a cardiology group and have run into a lot of 33249 denials!
Thank you :)
 
Our group has been pouring over the NCD and what I understand is that all requirements for that indication must be met to be considered medically necessary.

For example:
Indication #6
Ischemic dilated cardiomyopathy > 9 months with
a. A prior MI occurring more than 40 days ago
b. EF Less than or equal to 35% (measured by angiography, nuclear scanning, or echo)
c. NYHA class II & III heart failure
d. And none of the following apply to the patient
i. CABG or PTCA with the past 3 months
ii. Is a candidate for CABG or PTCA
iii. Current cardiogenic shock or symptomatic hypotension while in a stable
baseline rhythm.
iv.Has any disease, other than cardiac disease (e.g., cancer, uremia, liver failure)
associated with a likelihood of survival less than 1 year.

We are currently working on a worksheet for the physician/staff to follow and sign prior to an ICD implant. I would be happy to share if you want to PM me with your email address.
 
If the ICD is for the primary prevention of sudden cardiac arrest and does not have a history of induced or spontaneous arrhythmias, does not have one of the following Dx's 427.1, 427.41, 427.42, 427.9, 427.5, 427.9, 996.04, V12.53, or V53.32 and is enrolled in a data collection system.....you can use modifier -Q0.

We enroll our patients into the ACCNCDR ICD Data Registry, therefore we can append the -Q0 modifier to our claims when appropriate.
 
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