Clinical symptoms or findings that would indicate the member is a. Automatic implantable cardioverter defibrillators aicd why is the doctor performing this procedure. For example, a diagnosis of fatigue, bone pain or weakness is not specific a diagnosis. Reimbursement policy implantable automatic defibrillators. Both aicd and pacemakers are medical devices that are implanted inside the bodies of heart patients, yet there are some key differences.
This is according to a recent issue of medicare quarterly provider compliance newsletter pdf. National coverage determination ncd for implantable. The medical policies do not constitute medical advice or medical care. This final rule implements section 212 of the protecting access to medicare. Nothing contained in these pages is intended to be for medical diagnosis or treatment. Medicare provides guidance on billing for implantable. The material provided on this website is for informational purposes only and is not provided as medical advice.
Medical record documentation should be relevant to the members medical. Implantable automatic cardiac defibrillators icds 3 5. Medicare provides guidance on billing for implantable automatic defibrillators. Diagnostic cardiology procedures and medical necessity. Wearable cardio defibrillator and automatic external defibrillator description. Primary prevention indicators are listed as numbers 38 in ncd 20.
Anthem blue cross members should discuss the information in the medical policies with their treating health care professionals. Does anyone else have an abnormally high amount of denials for cpt codes 9328293284, 93289, and 93295 for diagnosis codes due to medical necessity. The plan may request medical records for determination of medical necessity. Automatic implantable cardioverter defibrillators aicd. It seems like every time i turn around theres a new one to deal with. The aicd is capable of correcting most lifethreatening cardiac arrhythmias, while also storing information on the event. Had a cabg or pci with angioplasty andor stenting, within the past three 3 months.
Establish medical necessity for implantable cardioverter. Credentialing and accreditation standards the accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Please note that pacemaker clinic also includes physician practice, place of service pos and hospital device monitorin g departments. Medicare cd medical coverage policy implantable automatic. Serum iron studies coverage indications, limitations, andor medical necessity serum iron studies are useful in the evaluation of disorders of iron metabolism, particularly iron deficiency and iron excess. Aicd device check denials medical billing and coding. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. If you use nonstandard abbreviations in your medical record entries, we strongly recommend you include definitions with any records you submit. Automatic implantable cardioverter defibrillator aicd. Hmsas determination as to medical necessity in a given case, the physician may request that hmsa reconsider the application of the medical necessity criteria to the case at issue in light of any. Iron studies are best performed when the patient is fasting in the morning and has abstained from medications that may influence iron balance. The indicators require one of the following combinations of conditions and corresponding icd10cm codes be documented to demonstrate medical necessity for icd placements for primary prevention of sudden cardiac death. Subcutaneous implantable cardioverter defibrillator icd. Patients with nidcm 3 months, nyha class ii or iii heart failure, and measured lvef.
The need for documentation to support medical necessity has always been required by cms. In all cases, clinical judgment consistent with the. It is the ordering practitioners responsibility to choose the appropriate, active diagnosis code that best meets the condition of the patient. The above medical necessity criteria must be met for the following codes to be covered for commercial members. Role of medical therapy in the prevention of sudden cardiac death with and without aicd implantation. Medicare national and local coverage determination policy. Insufficient documentation and medical necessity errors. The volume of documentation cant compensate for a lack of medical necessity, but neither can medical necessity compensate for a lack of documentation. Illegible notes will not be used in determining medical necessity of a claim. Medical policy medical records documentation guidelines medical record documentation is frequently required to determine the medical necessity for services described in blue cross blue shield of texas bcbstx medical policies. Medical necessity indicators for primary prevention. Wearable cardioverter defibrillator and automatic external. If the previous icd9cm diagnosis cannot be crosswalked to an icd10cm diagnosis to meet coverage requirements, consider asking the physician for a new narrative diagnosis that can.
Implantable cardioverter defibrillator icd colorado. Wearable cardio defibrillator and automatic external. Providers must be able to justify the medical necessity of devices other than single lead devices. Medical policy biventricular pacemakers cardiac resynchronization therapy for. The biggest trend we have seen is with the ultrasound vascular. These lists do not necessarily reflect all options, but payers include this reference in their policy guidelines. Billing and coding guidelines centers for medicare and. To monitor an abnormally beating heart, either one that beats too fast tachycardia, too slow bradycardia or irregularly atrial fibrillation. Icd10 is here and we wish to thank all of you who have been sending icd10 codes that meet medical necessity. Automated implantable cardioverter defibrillator aicd an implantable cardioverter defibrillator icd or aicd is a permanent device in which a lead wire inserts into the right ventricle and. Implantable automatic cardiac defibrillators icds origination. Procedures and the reasons for performing them are at the heart of medical necessity and its the medical coder and billers job to properly explain them in a claim by selecting the correct codes. Automatic implantable cardioverter defibrillators aicd external stimuli from a strong magnet, arc welding devices and some strong electric feilds can affect the unit but these are rare. Automated implantable cardioverter defibrillator aicd or.
This justification should be available in the patients medical record. Managed care hmo and pos, ppo, indemnity, medicare. This lesson describes what an aicd is and how it can be helpful for patients at risk of cardiac events. Arrhythmia and the automatic implantable cardioverter defibrillator. Any individual should consult with his or her own physician before. These updates do not expand, restrict, or alter existing coverage policy. The major clinical restriction is inability to have a mri scan. Medical necessity guidelines for conventional and intensive outpatient cardiac rehabilitation programs. Ohio medicaid is accepting icd10 test claims from trading partners indefinitely, but encourages your organization to test as soon as possible. When an existing pacing cardioverterdefibrillator pulse generator is replaced with a system that is different from the existing system, code selection should be based on the final lead system inserted if a pacing cardioverterdefibrillator pulse generator duallead system is. Learn more about this lifesaving device, including just how safe and easy it is to insert. The developers of the criteria sets included representatives from the disciplines of radiology, internal medicine, nursing, and cardiology and other specialty groups. We have noticed a trend in some tests where the codes that would have met medical necessity prior to oct.
The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Coverage for a wearable cardioverter defibrillator varies across plans. Antiarrhythmic drug therapy is usually applied as an adjunctive therapy in aicd patients who experience frequent shocks or less commonly as primary therapy in patients who refuse or are not candidates for aicd implantation. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with medicare or other. Subcutaneous implantable cardioverter defibrillator icd system. This coverage policy addresses the wearable cardioverter defibrillator, automatic external defibrillators in the home and leadless cardiac pacemakers. The automatic implantable cardioverter defibrillator icd is a device designed to monitor a patients heart rate, recognize ventricular fibrillation vf or ventricular tachycardia vt, and deliver an electric shock to. Medical policy medical records documentation guidelines. Sample letter of medical necessity must be on the physicianproviders letterhead form 12 072011 please use the following guidelines when submitting a letter of medical necessity. Documentation of this diagnosis information and medical necessity for the appropriate date of service must be documented in the patients medical records. Medical necessity continues to be open for interpretation by all parties involved. Many thirdparty payers have created lists of criteria they use to interpret medical necessity. If the physician provides documentation that supports the reasonable and medically necessary criteria and is also implanting. Put simply, the payer will absolutely, without fail, pay only for those procedures that are deemed medically necessary.