Cardiology Coding Alert

Learn how your EPs should best document class III or class IV heart failure

When you're reading your carrier's local coverage determinations, looking at the written list of conditions that the carrier will cover for a particular procedure is sometimes not enough.
 
Take a lesson from the following case study on left ventricular lead insertion for the purpose of biventricular pacing (33224-33226).

See How This Scenario Hit a Roadblock

Scenario: Your practice submits a claim for +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [list separately in addition to code for primary procedure]) with documentation that the patient had moderate to severe congestive heart failure (CHF).
 
Part B carrier Noridian Administrative Services released a policy in 2003 stating that it would cover 33224-33226 for patients with "moderate to severe congestive heart failure (CHF)." Patients must also have "an electrical conduction disturbance in the heart that causes the ventricles to contract asynchronously," and not be likely to improve with additional drug therapy, Noridian said.
 
Problem: Noridian denies your claim, saying that you had to document that the patients had class III or IV heart failure, even though its policy only stated "moderate to severe CHF."
 
The Noridian reviewer admitted that the carrier's policy didn't specify class III or IV heart failure, according to Rebecca Caux, senior coding specialist with Iowa Heart Center (IHC) who met with this problem. But Noridian argued that the term "moderate to severe" meant the same thing as class III or IV heart failure. In the end, IHC changed its documentation to satisfy Noridian.

Focus on Your Diagnosis Codes

The Noridian policy may not specify class III or IV heart failure, but it does call for ICD-9 codes 428.0 through 428.9, says Jennifer Kelchen, MA, CCS-P, manager of the coding department for Cardiologists PC in Cedar Rapids, Iowa. Those ICD-9 codes should be enough to tell you that the heart failure must be class III or IV.
 
Tip: To document class III or IV heart failure, you should look for items in the patient's heart such as prolonged QRS duration on the patient's electrocardiogram, typically 135 ms or longer, Kelchen says. Often, an electrophysiologist's report will state "class III heart failure" or "acute heart failure," and then you simply have to determine if the heart failure is diastolic or systolic.
 
Important: Note that Noridian changed its policy to require a "conduction disorder," or a heart block, as a secondary diagnosis for 33224-33226. In its Medicare B News bulletin issue 210, dated Feb. 27, 2004, Noridian says your claim must include a secondary diagnosis code of 426.0, 426.3-426.54 or 426.9, Kelchen says. If you don't document a heart block, Noridian will deny your claim.

Check Other Carrier Policies

If your local carrier has a tough policy, you should examine other carriers' policies on the same issue to see if they make more sense, says Cynthia Swanson, RN, CPC, senior management consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb. Often, if another carrier has a more sensible policy, you can write to your carrier's medical director and suggest that he tweak your carrier's policy to make it more like the other's