Back Up Dual Chamber Implant with Necessity

by Jackie Stack, AAB, CPC, CPC-I, CFPC, CEMC, CPEDC, CCP-P

Failure to properly document that dual chamber pacemaker implant can arrest reimbursement if medical necessity isn’t proven. Indications differ for the implantation of single and dual chambered pacemakers, and Highmark Medicare Services suggest documentation you will want to include when submitting a pacemaker implant claim:

  1.  Complete History and Physical: An in-depth history and physical is important. Historical information regarding the patient’s medical care, alternative treatments and pertinent lifestyle changes should be included. If single-chamber pacemaker has been previously attempted, note this.
  2. List of Medications: Current medications for this hospital stay, along with information on previous medications that the provider has tried. Include whether the medication was effective, the type of symptoms the patient had, and any adjustments made in medications.
  3. Diagnostic Reports: Include any diagnostic report that may have been performed. The diagnostic tests to support the surgical procedure may have happened on the billed “Date of Service” or prior to it. Include the patient’s prior inpatient/outpatient services that include any diagnostic tests performed supporting why a dual chamber was necessary.
  4. Surgical Report: This will provide an accurate description of the procedure and may include mitigating factors affecting the surgery.
  5. Pertinent Hospital Documentation: Include all pertinent hospital documentation for the requested dates of service such as physician orders, progress notes from all disciplines, surgical reports, anesthesia evaluations and notes, recovery room records, laboratory reports, etc.

By all means, don’t bill for a dual chamber pacemaker when a single chamber pacemaker was implanted. There are specific criteria listed for dual chamber pacemaker implants in the CMS NCD (Pub. 100-03, Chapter1, Part 1, Section 20.8, Cardiac Pacemakers) indicating medical necessity. These include the following:

  1. Patients in whom single-chamber (ventricular pacing) at the time of pacemaker insertion elicits a definite drop in blood pressure, retrograde conduction, or discomfort.
  2. Patients in whom the pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms, has already been experienced with a pacemaker that is being replaced.
  3. Patients for whom even a relatively small increase in cardiac efficiency will importantly improve the quality of life, e.g., patients with congestive heart failure despite adequate other medical measures.
  4. Patients in whom the pacemaker syndrome can be anticipated, e.g., in young and active people, etc.

And remember, the CMS allows the contractor to follow these guidelines when a procedure isn’t medically necessary:

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  • “If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission;
  • If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e. remove from the DRG calculation), but approve the admission. “

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