Advanced Search

Cardiology Coding Alert

Understand MADIT II Coverage

Published on Thu Jan 01, 2004

You could be coding a lot more ICD implant procedures soon. New guidelines for ICD implants could dramatically increase the number of Medicare patients who are eligible for this service. So you'll need to know about the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) coverage criteria to bill ICD implant reports accurately.
 
Background: MADIT II was a clinical study in which patients who did not meet the traditional coverage criteria for an ICD (prior history of ventricular tachycardia or ventricular fibrillation) had ICD implants. These patients each had a prior myocardial infarction (MI) and an ejection fraction (EF) of less than or equal to 30 percent (normal EFs are in the range of 55-60 percent.)  
 
(See "Be on the Lookout for ICD Report Boost" in the July 2003 Cardiology Coding Alert for more information on the MADIT II study.)
 
Added criteria: When MADIT II coverage criteria went into effect on Oct. 1, 2003, Medicare added new requirements to the MADIT II indications and listed several exclusions from coverage that have received relatively little attention. The bottom line: If you fail to heed the following additional criteria and the exclusionary conditions, you could be subject to refunds and penalties, coding experts say. 
 
Wide QRS complex. In addition to the MADIT II criteria of a prior MI and an EF of less than or equal to 30 percent, Medicare now requires patients to have a wide QRS complex (measured at greater than or equal to 120
milliseconds). QRS is one of the measurements evaluated by an EKG and an EP study. Although the MADIT II data suggest that patients with a wide QRS may benefit more from ICD implant, many view the additional requirement as a way to reduce the number of patients who qualify for these implants. There are efforts under way to have this additional criteria repealed.
 
More exclusions. In addition to the wide QRS criteria, Medicare listed several conditions that would exclude patients from the MADIT II coverage in its Oct. 1 national coverage decision (NCD).
 The NCD specifically says that patients must not have:
 (a) New York Heart Association classification IV
 (b) cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
 (c) had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within the past three months
 (d) had an enzyme-positive MI within the past month
 (e) clinical symptoms or findings that would make them a candidate for coronary revascularization or
 (f) any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than one year. 
 
Providers are encouraged not to submit claims for services provided on or after Oct. 1, 2003, until January 2004, because Medicare will not be able to process the claims until Jan. 5, 2004, according to a NASPE bulletin.
 
Note: To see the NCD list online, go to http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=35-85&ncd_version=5&show=all.

Other Articles in this issue of

Cardiology Coding Alert

View All