Cardiology Coding Alert

Unless local Medicare carriers have their own policies regarding pacemaker checks, the Health Care Financing Administrations (HCFA) guidelines, first formulated in 1984, still apply. These guidelines are endorsed by pacemaker manufacturers such as Medtronics and supported in statements by the American College of Cardiology (ACC), and adhered to by the North American Society of Pacing and Electrophysiology (NASPE).

Many cardiology practices, however, are uncertain how often they can perform and bill for pacemaker evaluations because they are confusing in-clinic visits with transtelephonic monitoring.

The guidelines, which are found in section 50-1 of HCFAs Coverage Issue Manual, detail the appropriate frequency of both in-clinic and telephonic monitoring of pacemakers.

An Understanding of Pacemakers

Pacemaker systems, which consist of two parts a pulse generator and either one or two leads, or wires send electrical signals that regulate the heart when the hearts natural pacemaker, the sino-atrial (SA) node, improperly alters the rate at which it sends electrical signals to the heart, or when there is inadequate conduction of that signal to the ventricular heart chambers.

There are two basic kinds of pacemakers. A single-chamber pacemaker has one lead to carry signals to and from one chamber of the heart either the right atrium or the right ventricle. A dual-chamber pacemaker has two leads, with the tip of one lead positioned in the right atrium and the tip of the other lead located in the right ventricle.

After a pacemaker is implanted, follow-up care usually is performed on a regular basis. Monitoring is performed by telephone (transtelephonic analysis) or in a cardiologists office (in-clinic). Pacemaker checks often are performed by physician assistants, nurses or technicians specially trained in management of pacemakers.

Pacemaker checks performed in the office or clinic are billed using 93731(electronic analysis of dual-chamber pacemaker system [includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response]; without reprogramming), and 93734 (single-chamber system, without reprogramming).

If the pacemaker requires reprogramming, use 93732 (dual chamber, with reprogramming) and 93735 (single chamber, with reprogramming).

CPT provides the following two codes for telephonic analysis: 93733 (telephonic analysis, dual-chamber system) and 93736 (single chamber system).

HCFAs Frequency Guidelines

In October 1984, HCFA published guidelines for pacemaker evaluation services to help its carriers limit excessive claims development to those cases requiring special attention. Accordingly, most Medicare carriers, such as Trailblazer Health Enterprises (Texas, Maryland, Delaware, Virginia and the District of Columbia), Missouri General American Life Insurance and Palmetto Government Benefits Administrators (South Carolina), adhere to the HCFA guidelines and apply them toward routine pacemaker checks, which, according to HCFA, make up the vast majority of pacemaker monitorings.

In-clinic evaluations. Medicare allows payment for two in-clinic pacemaker checks in the first six months after installation of a single-chamber pacemaker and one check every 12 months after that. For dual-chamber pacemakers, one check every six months is allowed after the first six months.

These guidelines apply after the 90-day global period, so the pacer check that typically is performed seven to 10 days after implantation is included in the global package unless there is a mechanical problem.

Note: According to the HCFA guidelines, if a dual-chamber unit is programmed to pace only the ventricles either at the time the pacemaker is implanted or at some time afterward it should be treated as a single-chamber pacemaker.

Transtelephonic monitoring. There are two sets of guidelines for transtelephonic monitoring, depending on the date the device was U.S. Food and Drug Administration (FDA) approved. Guideline I should be used if the pacer was approved less than five years ago. Guideline II is for older pacemakers that were approved by the FDA more than five years ago. The guidelines are further subdivided according to whether the pacemaker is operating as a single- or dual-chamber device. (See box on this page).

Expanded Guidelines

Although HCFA stresses that its guidelines are only recommendations that can be amended by any local carrier using its own data and experience, most Part B carriers follow the guidelines, with some exceptions. For example, because services rendered by a pacemaker clinic are more extensive than those available by telephone (for example, reprogramming of pacemakers), the use of one type of monitoring does not preclude concurrent use of the other. Some Medicare carriers reportedly reject such concurrent claims if they are submitted within the same 30-day period.

In addition, the guidelines are endorsed by the ACC and pacemaker manufacturers such as Medtronics and followed, to a large extent, by NASPE. Medtronics, for example, advises clients to follow HCFA guidelines, says Gregg Deutsch, senior technical consultant with Medtronics, a leading pacemaker manufacturer based in Shoreview, Minn. The company suggests more frequent follow-up care in cases of medical need.

Patient Interviews Needed

NASPE recommendations, issued in 1994, match the HCFA guidelines fairly closely, with some important exceptions. The electrophysiologists organization recommends one direct evaluation or one transtelephonic contact with patient interview in the third through fifth month after the pacemaker is installed, whereas HCFA guidelines allow two in-clinic pacemaker checks in the first six months. Like HCFA, NASPE recommends one direct evaluation per year after the first six months.

One significant difference between NASPE and HCFA in this period is that NASPE also recommends patient contact at three-month intervals, which may consist of telephonic monitoring with patient interview or direct evaluation. HCFA guidelines, while matching or, in the case of guideline II pacers, surpassing NASPEs frequency guidelines regarding telephonic monitoring, make no mention of coverage for patient interview.

Similarly, NASPE, referring to the intensified follow-up period (defined as after 72 months for guideline I pacers and after 48 months for guideline II devices), like HCFA, recommends one in-clinic visit per year. NASPE, however, also says monthly telephonic monitoring with patient interview should be performed, whereas the HCFA guidelines refer only to the monitoring itself.

Medical Necessity Exceeds Guidelines

Although HCFA notes that its guidelines describe the maximum, frequency for pacemaker evaluations (within which, HCFA says, claims are paid without further claims development), Medicare carriers may cover more frequent evaluations when they are medically necessary.

The guidelines note that the decision as to how often any patients pacemaker should be monitored is the responsibility of the patients physician, who is best able to take into account the condition and circumstances of the individual patient. In cases where more frequent evaluations are performed, HCFA advises its carriers to seek written justification (i.e., documentation).

Note: Individual local carriers may vary in the number and type of diagnoses they consider medically necessary. Be sure to check with your local carrier before submitting a claim with these diagnoses.

For example, in a patient with third-degree heart block, there is no intrinsic conduction between the top of the heart and the bottom; therefore, the patient is pacemaker dependent. In such cases, any suspected problem with the pacemaker must be evaluated immediately. Otherwise, should the pacemaker fail, there is a strong possibility the patient will arrest, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in Seattle. In such a situation, Yakovlevitch says, medical necessity for additional evaluation is clearly warranted. If the documentation adequately describes the situation, the carrier should reimburse for the service, which may have saved the patients life.

Note: Carriers should be contacted before a claim is submitted to determine if these services are covered and, if so, what the carriers documentation requirements are.

Evaluation During the Global Period

All pacemaker implantation procedures have a 90-day global period. As a result, any checks performed during that period are part of the surgical package and are not reimbursable separately. This would appear to be straightforward; however, it conflicts with the HCFA guidelines, which state that all pacemakers should be evaluated transtelephonically every two weeks in the first month, and at varying rates, depending on the age and number of chambers, from the second month onward.

Because the HCFA guidelines are in its Coverage Issues Manual, it is assumed that the services described in the guidelines are covered. This contradicts HCFAs surgical package guidelines, under which, for example, a pacemaker check performed four weeks after implantation is included in the services global period.

The same dilemma applies to in-clinic visits. The guidelines in the manual state that two in-clinic evaluations may be performed in the first six months after implantation, but given that the global period is 90 days, that effectively would mean that Medicare recommends (and will cover) two checks in the three months following the end of the global period.

This causes confusion for coders, who assume that the guidelines should be applied only after the end of the global period. In other words, the two covered in-clinic visits would occur in the six months following the end of the global period, and the first month that two telephonic evaluations can be billed is the fourth month after the implantation of the pacemaker.

Although it is conceivable that the two in-clinic visits referred to by HCFA in the first six months could be performed after 90 days and before the end of the six-month period, the same does not hold true for telephonic evaluations. NASPEs recommendations (which are clinical), clearly state that telephonic checks only need to be performed in the first month after implantation. Performing these evaluations every two weeks in the fourth month is clinically unnecessary. NASPE recommends every 12 weeks.

For final clarification, contact your local Medicare carrier to find out how they have resolved this dilemma.

Note: Additional contributors to this story are
Harriet Drucker, MHS, PA-C, who cares for patients at the pacemaker clinic of Summit Cardiology, an
11-cardiologist practice in Seattle; and Rebecca Sanzone, CPC, an assistant billing manager with Mid-Atlantic Cardiology, a 47-cardiologist practice in Baltimore.