Cardiology Coding Alert
Have You Mastered Using Modifier KX on Pacemaker Claims? July 7 Is Implementation Day
Be sure you understand what appending this modifier indicates to your payer.
If your practice reports pacemaker insertion/replacement codes 33206-33208, studying Medicare’s latest instructions for reporting these codes is a must. Here’s a look at the latest list of covered diagnoses and an easy-to-overlook modifier requirement.
Use Transmittal to Comply With National Coverage Determination
In February, CMS issued Transmittal 2872, CR 8525, with the subject, “National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers” (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2872CP.pdf).
The transmittal offers coding advice for complying with the pacemaker NCD released in August, which states:
The following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
The transmittal includes various instructions, but for physician coders, the most important information was that for dates of service on and after Aug. 13, 2013, payers cover single or dual chamber pacemaker claims that combine 33206-33208 with specified diagnosis codes. (Be sure to read the complete document for lists of covered and noncovered indications and codes.)
The CPT® codes involved are as follows:
Including at least one of the ICD-9 codes below supports coverage, notes national healthcare coding and reimbursement consultant Terry A. Fletcher, CPC, CCS-P,CCS, CMSCS, CEMC, CCC, CMC, in her AudioEducator.com webinar, Challenges of Modifier Usage in Cardiology Coding. Medicare also supplies the ICD-10 codes that will support coverage once ICD-10 is implemented:
Don’t miss: Medicare requires contractors to cover the ICD-9 codes above. Medicare gives contractors discretion over whether to cover the diagnosis codes in the list below. But even if the contractor chooses to cover one of the codes below, you must submit it with one of the diagnosis codes above.
In other words, whether or not your contractor covers the codes below, you still must have one of the codes in the previous list on your claim, too. The optional codes are:
Make Room for Modifier KX or Face Denials
In the same transmittal, Medicare instructs contractors to return as unprocessable claims lines for 33206, 33207, or 33208 if the line does not include modifier KX (Requirements specified in the medical policy have been met).
But take heed. Including modifier KX indicates that “documentation is on file verifying the patient has non-reversible symptomatic bradycardia (symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion)),” notes Fletcher, quoting Medicare.
Be sure to let your providers know that you need the documentation to reference non-reversible symptomatic bradycardia due to sinus node dysfunction or due to second or third degree atrioventricular block to support Medicare coverage.
Dig Through the List of Dates
One possible area for confusion with the transmittal is the array of dates listed:
Translation: The issued date is when CMS published the transmittal. The effective date is when the rule is effective, but payers don’t have to have systems in place to apply the rule until the implementation date of July 7, 2014.
In practical terms, that means that you absolutely must start using modifier KX on your claims to avoid denials by July 7, 2014. Unless your payer instructs you otherwise, you shouldn’t need to resubmit claims you’ve sent in without KX since the Aug. 13, 2013, effective date. But if you have a denied 33206-33208 claim that includes one of the covered ICD-9 codes, and it took place on or after Aug. 13, 2013, consider resubmitting that claim for reconsideration after July 7, 2014, implementation.
Resources: To review the transmittal and related MLN Matters article, go to these Web addresses:
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.
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