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Claims Processing Instructions for Implantable Cardiac Defibrillators

Published on 

Wednesday, April 7, 2021

Reading CMS’s recently released Change Request (CR) 12104  titled Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) made me feel like I had entered the land of Fantasia from The Never Ending Story or as if I was waking up to Sonny and Cher singing I Got You Babe for the umpteenth time in the Bill Murray classic Ground Hog’s Day. Either way, it has been a long road from the release of a Proposed Decision Memo to the transmittal providing claims processing instructions.


The Never Ending Story, Gets It’s Ending

·        May 30, 2017: CMS announced the opening of a National Coverage Analysis (NCA)for Implantable Cardioverter Defibrillators.

·        November 20, 2017: CMS issued a Proposed Decision Memo.

·        February 15, 2018: CMS issued a Final Decision Memo.

·        November 21, 2018: Transmittal 209 (CR 10865) was issued reflecting the reconsideration of an updated version of NCD 20.4. CMS noted that a subsequent CR would be released at a later date containing a Claims Processing Manual update with accompanying instructions. Until that time, CMS instructed that Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.

·        February 15, 2019: Transmittal 211 was rescinded and replaced with Transmittal 213 to change the implementation date from February 26, 2019 to March 26, 2019.

·        March 26, 2019: CMS’ final implementation date for NCD20.4.

·        March 26, 2019: Eleven of the twelve MACs published a Local Coverage Article titled Billing and Coding: Implantable Automatic Defibrillators including:

        o   First Coast Service Options, Inc. (Jurisdiction N) – Article A56341,

       o   National Government Services, Inc. (Jurisdictions 6 and K) – Article A56326,

        o   Noridian Healthcare Solutions, LLC (Jurisdiction E) – Article A56340,

        o   Noridian Healthcare Solutions, LLC (Jurisdiction F) - Article A56342,

        o   Novitas Solutions, Inc. (Jurisdictions H and L) – Article A56355,

        o   Palmetto GBA (Jurisdictions J and M) – Article A56343, and

        o   Wisconsin Physician Service Insurance Corporation (Jurisdictions 5 and 8) – ArticleA56391.

·        March 2, 2020: CMS published MLN SE20006 updating providers on Medicare coverage rules and policies for NCD 20.4. Specifically, this article addresses concerns related to requiring the use of heart failure diagnosis codes. They end this article by stating that “it is incumbent upon the provider to select the proper code(s). We believe the listed covered codes encompass the various clinical scenarios that occur for patients who meet the NCD coverage requirements and are provided, not to write additional parameters into the NCD, but to ensure there is an appropriate code for the covered indications.”

·        March 23, 2021: CMS released CR 12104 and a related MLN MM12104 on March 24, 2021 detailing the claims processing instructions for NCD 20.4.


In Ground Hog’s Day, Bill Murry keeps reliving the same day over and over until he finally turns it around into the perfect day. Almost four years from the opening of the coverage analysis, CMS has provided the final piece to implantable cardiac defibrillators.  


Moving Forward to Your Happy Ending

·        First, now is a good time to review NCD 20.4 to understand the indications for when an ICD implantation is considered medically necessary by CMS.

·        Transmittal 12104 details the codes you “shall” use on your claims when billing for services provided. To assist in understanding the codes, I recommend that you read your MAC’s related coding and billing article as it outlines codes specific to each CMS indication for coverage in the NCD.

·        For patients clinically meeting the indications for a pacemaker and an ICD, all twelve MACs have published billing and coding: single chamber and dual chamber permanent cardiac pacemaker articles related to the single and dual chamber pacemaker NCD 20.8.3.

·        This is also a good time to review a sample of claims at your hospital for documentation supporting medical necessity as well as appropriate coding.

·        Be aware that all Recovery Auditors have been approved to perform audits for medical necessity and documentation requirements for implantable automatic defibrillators in the outpatient (Issue RAC Issue 0093) and inpatient (RAC Issue 0195) setting.  

·        Last, know that the implementation date for Transmittal 12104 is July 6, 2021. However, take note that CMS indicates that MACs will not search their files for claims for ICD services between February 15, 2018, and the implementation date of this transmittal. “However, MACs should adjust those claims that are brought to their attention.”

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.