Cardiology Coding Alert

Question: We have the following puzzling scenarios taking place in our office, and I was wondering if you could give us some advice?

• First, when our physicians place the 3rd lead (+33225) with either a PM or ICD, Medicare is refusing to pay for this code. We were first using the same diagnosis as the device, then we were advised to use the congestive heart failure diagnosis primary instead (when documented). However, none of these diagnoses sequencing are resulting in payment. There are no CCI edits with these codes, and we are using +33225 as an “add on” code as instructed in the CPT^® guidelines.
• A second scenario is when our physicians place a pacemaker prior to an AV node ablation. At the time of the PM implant, the only diagnosis given is a trial fib. This is not a “covered” diagnosis for a Medicare patient. We are not receiving payments in this case for any of the pacemaker code group L. In these cases, we cannot use the required-for-payment “KX” modifier -- indicating we have documentation of either 1) non-reversible symptomatic bradycardia due to sinus node dysfunctionor2) non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.
• A third example is when an “upgrade” is performed (example: 33233, 33234, 33249, +33225). We are not receiving payment for +33225.

Any help or suggestions you can offer would be appreciated. Are there any coding guidelines for these scenarios related to whether the patient is given a hospital status of “in patient” versus “outpatient”?

South Carolina Subscriber

Answer: “We as coders are required to follow the rule ‘If it’s not documented, then it’s not reported,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee. “Therefore, the physician must be held accountable to document all required information needed for medical necessity.”

There are specific coding rules, regulations and guidelines when performing pacemaker and/or ICD/Defibrillator placements, Neighbors continues. When in doubt, always query the physician for clarification.

Please reference the ICD/defibrillator implantation for primary versus secondary prevention (modifier Q0 and/or Q1) and Pacemaker (modifier KX and/or SC) guidelines, Neighbors adds. These guidelines are specific and must be followed or reimbursement will not be received.

Take a look at the following ICD/Defibrillator resources via Neighbors:

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 270.2
• National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4) CMS Change Request (CR) 5805.

And check out these pacemaker resources:

The official instruction, CR8525 (MLN Matters Number MM8525), was issued to your MACs regarding this change via two transmittals, according to Neighbors. The first is the transmittal that updates the “NCD Manual” and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R170NCD.pdf on the CMS website. The second transmittal updated the “Medicare Claims Processing Manual” and it is at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittal/Downloads/R2986CP.pdf on the CMS website

• Local Coverage Article: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker-Coding and Billing (A54929).