Knowledge Base Article

I love making lists – all sorts of lists: daily to-do’s, grocery lists, my favorite songs/books, long-term goals, etc. There is something satisfying about organizing things into a list format. For those fellow list-lovers out there, the long-awaited instructions on billing of pacemakers to Medicare should be right up your alley. There are lists of covered conditions, non-covered conditions, HCPCS codes, CPT codes, ICD-9 procedure codes, covered diagnosis codes, and sometimes allowed diagnosis codes.

Medicare has finally issued the manual guidance concerning the new guidelines for coverage of single chamber and dual chamber permanent cardiac pacemakers. Under the new guidelines, effective for dates of service on and after August 13, 2013, Medicare covers implanted permanent single chamber or dual chamber cardiac pacemakers for:

1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example, syncope, seizures, congestive heart failure, dizziness, or confusion).

The list of conditions for which implanted cardiac pacemakers are not covered is much longer than the list of covered indications. Diagnosis codes for a few of the non-covered indications (exceptions) may be accepted on claims that also contain a covered diagnosis for the bradycardia. The non-covered conditions include:

1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia.
2. Asymptomatic first degree atrioventricular block. *(exception)
3. Asymptomatic sinus bradycardia.
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest. *(exception)
5. Ineffective atrial contractions (for example, chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia. *(exception)
6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart).
7. Syncope of undetermined cause. *(exception)
8. Bradycardia during sleep.
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block. *(exception)
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy.
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia. *(exception)
12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

Hospital Claim Requirements

For outpatient claims, implantable cardiac pacemakers are reported with the following -

Pacemaker device HCPCS Codes

• C1785 – Pacemaker, dual chamber, rate-responsive (implantable);
• C1786 – Pacemaker, single chamber, rate-responsive (implantable);
• C2619 – Pacemaker, dual chamber, nonrate-responsive (implantable);
• C2620 – Pacemaker, single chamber, nonrate-responsive (implantable);

CPT Procedure Codes

• 33206 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial
• 33207 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) –ventricular
• 33208 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial and ventricular

A –KX modifier must be appended to the procedure claim line(s) to attest that documentation is on file verifying the patient has non-reversible symptomatic bradycardia, with symptoms such as syncope, seizures, congestive heart failure, dizziness, or confusion. Claims with one of the above listed pacemaker insertion CPT codes without the KX modifier will be returned to the provider.

Report pacemaker insertion procedures on a hospital inpatient claim with one of the following procedure codes:

• 37.81 Initial insertion of single chamber device, not specified as rate responsive
• 37.82 Initial insertion of single chamber device, rate responsive
• 37.83 Initial insertion of single chamber device

Both inpatient and outpatient claims require one of the following diagnosis codes for the services to be covered by Medicare:

• 426.0 Atrioventricular block, complete (I44.2)
• 426.12 Mobitz (type) II atrioventricular block (I44.1)
• 426.13 Other second degree atrioventricular block (I44.1)
• 427.81 Sinoatrial node dysfunction (I49.5)
• 746.86 Congenital heart block (Q24.6)

There are diagnoses from the “non-covered” indications (exceptions) that the Medicare Administrative Contractors may decide to accept on claims, but only when reported with one of the above “covered” diagnosis codes. The claim must contain one of the covered diagnosis codes in addition to one of the following diagnosis codes. Also note, this coverage is at the discretion of the MAC. One more note - after ICD-10 implementation, the presence of code R55 (syncope and collapse) will result in denial. These codes are:

• 426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block;
• 426.11 First degree atrioventricular block/ I44.0 Atrioventricular block first degree;
• 426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block/ I45.19 Other right bundle-branch block;
• 427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia;
• 427.31 Atrial fibrillation/ I48.1 Persistent atrial fibrillation/ I48.91, Unspecified atrial fibrillation;
• 427.32 Atrial flutter/ I48.3 Typical atrial flutter/ I48.4 Atypical atrial flutter or I48.91 Unspecified atrial fibrillation; or
• 780.2 Syncope and collapse/R55 Syncope and collapse (R55 is the ICD-10 dx code but is not payable upon implementation of ICD-10 and is only included here for information purposes). 

For additional information, please refer to the MLN Matters Article MM9078, Transmittal R3204CP, and Transmittal R179NCD. This includes instructions on professional billing, listing of I-10 procedure codes, and coverage not addressed by the NCD that is left to the discretion of the Medicare Administrative Contractors.

Now you have Medicare’s lists… When hospitals implement these instructions, they will want to have a checklist of their own to make sure they have addressed all the requirements for coverage.

Other recent coverage updates include: