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Cardiology Coding Alert

Forget Appeals and Forego Denials With New ICD Criteria

Published on Wed Feb 16, 2005

Throw out your old QRS requirements and arm yourself with these new elements

You can master the new 33249 requirements the hard way: submitting and resubmitting claims until you get it right. Or, you can sidestep this hassle by using this breakdown of the new requirements.

The most significant changes are the removal of the wide QRS requirement (>120 ms) and the increase of ejection fraction from less than or equal to 30 percent up to less than or equal to 35 percent.

Translation: "The requirements [to justify 33249] loosened rather than tightened," says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at St. Paul Heart Clinic in Mendota Heights, Minn.

Think of the new criteria as being three-pronged:

1. the SCD-HeFT inspired coverage that throws out the QRS requirement

2. the ischemic changes

3. the class IV heart failure patients who qualify for cardiac resynchronization therapy.
 
1. No Need to Look for QRS Anymore

If you have to undergo a medical-necessity review, you won't need to point to a patient's QRS, due to the clinical results from SCD-HeFT. Medicare is throwing out the QRS requirement entirely. "You don't need it anymore," says Eric Prystowski, MD, director of the electrophysiology lab at St. Vincent Hospital in Indianapolis and the editor-in-chief of the Journal of Cardiovascular Electrophysiology.

So that means that among the newly eligible beneficiaries are patients with heart failure, poor function of their left ventricle, and those with a narrow QRS finding on their electrocardiogram.
 
"Trailblazer (Texas Medicare) informed us in the past that we could submit ICD implants with any congestive heart failure (CHF) or cardiomyopathy code as long as the other criteria are met - like the QRS measurement," says Sandy Fuller, CPC, a cardiology coding specialist and compliance officer for a cardiology practice in Tyler, Texas. But that's a criterion you won't have to meet, thanks to the new decision.

2. Abide by These 2 Ischemic Changes

A. Start With Criteria for DCM

Medicare has also tweaked the criteria for both ischemic dilated cardiomyopathy patients (DCM) and non-ischemic dilated cardiomyopathy (NDCM) patients. You would report DCM with 414.8 (Other specified forms of chronic ischemic heart disease) and select an ICD-9 code from the 425.x cardiomyopathy category for NDCM.

For example, under the SCD-HeFT portion of the new CMS coverage criteria, your electrophysiologist will still need to make sure that their DCM meet the following three criteria:
 

  • a documented myocardial infarction (MI) greater than 40 days prior to the implant,

     
  • have Class II or III heart failure, and

     
  • a measured left ventricular ejection fraction (LVEF) of less than or equal to 35 percent.

    Implanting ICDs into these patients can prevent sudden death.

    Good news: "The ejection fraction of less than or equal to 35 percent is very good news. The old requirement was much lower at less than or equal to 30 percent," Fuller says.

    B. Your NDCM Dx Must Be 9 Months Old

    Also included in the newly covered are those patients who have had NDCM. A study called "Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation study (DEFINITE) and SCD-HeFT" suggested that those with this condition would also benefit from ICD implantation - and that implanting an ICD would be lifesaving, just as it is with patients with coronary disease. These NDCM patients have to meet the following criteria:
     

  • had nonischemic dilated cardiomyopathy for more than 9 months

     
  • have Class II and III heart failure, and

     
  • a measured LVEF of less than or equal to 35 percent.

    Although some commenters (which included associations, patient advocacy groups, manufacturers, etc.) disagreed with the nine-month interval for NDCM, those who supported it agreed that this interval is appropriate to exclude "patients with reversible disease and allow time for evaluating the response to treatment with optimal medical therapy," according to CMS.

    There's a catch. A patient whose NDCM diagnosis is less than three months must meet additional criteria, which include enrollment in a category B IDE trial. Also, the patient must not have had:
     

  • cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm

     
  • a CABG or PTCA within the past three months

     
  • an acute MI within the past 40 days

     
  • clinical symptoms or findings that would make him a candidate for coronary revascularization

     
  • irreversible brain damage from pre-existing cerebral disease

     
  • any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than one year.

    "My guess on this criteria came from the cardiomyopathy trial (CAT) study which focused on patients that had nonischemic cardiomyopathy for less than nine months and turned out to be negative," Prystowski says. CMS has given more requirements to those patients with NIDCM for less than three months (used in the SCD-HeFT study) because they need more data.

    3. Take Note of the CRT-D Change

    Medicare will also cover all patients with Class IV heart failure who meet the current CMS coverage requirements for a cardiac resynchronization therapy device (CRT-D). The rationale for this change is that those patients would likely improve their condition to Class III with this device.
     
    Editor's note: Do terms like "ischemic" and "QRS"  have you wondering what they mean? E-mail me at     suzannel@eliresearch.com for a vocabulary guide.

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