Pacemaker DX billing question

smerriweather1

Networker
Messages
38
Location
Fort Collins, Colorado
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0
Hello,
I have a pacemaker billing question that I need to run by a fellow cardiology coder:

The following was billed: CPT 33249 with DX I25.5 and I50.9 however Medicare has denied it stating that it does not meet the guidelines of NCD 20.4.

When I look at the NCD I see the DX of I50.9 is on the approved list of DX codes, but when I called the Medicare help line I was just advised the same statement that it was denied. I'm now wondering if the rejection is due to needing to supply a modifier of KX? Any suggestions?
 

Margaret Morgan

Networker
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50
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KX is for pacemakers not ICD's, currently.

There are a number of different acceptable reasons for ICD implantations by Medicare in the NCD. I think the one you are going for is one that follows:
Ischemic dilated cardiomyopathy (IDCM)
documented prior MI
NYHA class II and III heart failure
and measured LVEF equal to or less than 35%.

You are missing dx if that is the reason for the ICD implantation.

I suggest you look up the MCR NCD for ICD's to fully review the policy before reviewing the medical record for documented reasons for the ICD implantation, as my choice might not be your physician reason for implantation. If you are having trouble with the NCD you might want to discuss with fellow coders and/or physician.

Sincerely,
Margaret, CPC CIRCC
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
Hello,
I have a pacemaker billing question that I need to run by a fellow cardiology coder:

The following was billed: CPT 33249 with DX I25.5 and I50.9 however Medicare has denied it stating that it does not meet the guidelines of NCD 20.4.

When I look at the NCD I see the DX of I50.9 is on the approved list of DX codes, but when I called the Medicare help line I was just advised the same statement that it was denied. I'm now wondering if the rejection is due to needing to supply a modifier of KX? Any suggestions?
If the I50.9 is on the list for medical necessity and the I25.5 is not on list, and you linked both codes to the 33249 procedure code, this will cause the denial. Sometimes it is just that simple. But do check the documentation to be certain the diagnosis codes chosen are documented, but link only the medical necessity for that procedure.
 

Casper204

New
Messages
9
Location
Somers, CT
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If VT (I47.2) isn't one of the diagnosis's, with straight federal Medicare, a modifier Q0 is needed. It tells Medicare that the patient is part of the ICD registry and it was put in for primary prevention.
 

smerriweather1

Networker
Messages
38
Location
Fort Collins, Colorado
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0
Thank you all for your suggestions and advice I will certainly look into these and discuss with the provider to have a better understanding of his medical decision making that led to this treatment plan.
 
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