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Denied ICD Claims Worth Another Look

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  • In CMS
  • April 5, 2010
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If your office filed claims for automatic implantable cardiac defibrillator (ICD) services provided in a clinical study on or after Oct. 1, 2007, which Medicare subsequently denied because the diagnosis code lacked the appropriate modifier, you may now be entitled to reimbursement.

Change Request (CR) 6867 instructs contractors to adjust claims brought to their attention that were denied because V12.53 Sudden cardiac arrest lacked the Qo modifier (for dates of service on or after Jan. 1, 2008) or QR modifier (for dates of service prior to Jan. 1, 2008).
Note: Modifier Q0 Investigational service provided in a clinical research study replaced modifier QR effective for dates of service on or after Jan. 1, 2008.
Generally, for new indications, the patient must be enrolled in a data collection system, which is indicated by the Q0 or QR modifier (depending on the date of service). An edit was constructed in 2005 to check for the absence of a secondary prevention diagnosis code—if the diagnosis code is other than one of these secondary diagnosis codes, then the Qo or QR modifier is required for coverage.
The Centers for Medicare & Medicaid Services (CMS) identifies claims through the procedure code for defibrillation implantation and the absence of five specified arrhythmia codes and two codes often used when the device is being replaced. It has come to the attention of CMS, however, that V12.53 should also be included.
The following is an updated list of ICD-9-CM diagnosis codes that do not require the Q0 or QR modifier:

427.1 Paroxysmal ventricular tachycardia
427.41 Ventricular fibrillation
427.42 Ventricular flutter
427.5 Cardiac arrest
427.9 Cardiac dysrhythmia, unspecified
V12.53 Personal history of sudden cardiac arrest
996.04 Mechanical complication of cardiac device, implant, and graft due to automatic implantable cardiac defibrillator
V53.32 Fitting and adjustment of other device, automatic implantable cardiac defibrillator
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