Cardiology Coding Alert

Question: What’s the status of the modifier KX requirement for pacemakers?

Colorado Subscriber

Answer: The national requirement is still on hold, but many local contractors are publishing specific rules.

Example: To see the rules in place for Colorado MAC Novitas, head to www.cms.gov/medicare-coverage-database/ and enter A54982 in the Quick Search/Document ID box.

You’ll see that Novitas article A54982 provides you with the conditions and diagnosis codes that indicate the need to append modifier KX (Requirements specified in the medical policy have been met) to pacemaker insertion/replacement codes 33206-33208.

Example: If the patient has a pacemaker inserted to treat atrioventricular block, coded with I44.2 (Atrioventricular block, complete), the article lets you know that’s a situation in which you should append KX to the CPT^® code for pacemaker insertion.

Caution: You should not append KX based solely on the combination of CPT^® and ICD-10 codes. You should append modifier KX only when your practice has met the descriptor’s requirements. Specifically, you’re saying “that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent pacemaker” for the conditions and situations covered by the national or local payer policy. And Novitas has a long list, so be sure to review the article carefully.

Don’t miss: If the patient has a medically necessary pacemaker insertion for conditions the NCD or article don’t address, Novitas instructs you to append modifier SC (Medically necessary service or supply). Examples include cardiac resynchronization therapy and congenital heart disease.

If you’ve got a pacemaker claim that doesn’t meet the requirements for KX or SC, then Novitas instructs you to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) or GZ (Item or service expected to be denied as not reasonable and necessary).