Dual-Chamber Cardiac Pacemaker Insertion Billing
Submitting complete documentation to support the services being billed is important. Comprehensive Error Rate Testing (CERT) has indicated a trend in denials for Dual-Chamber Cardiac Pacemaker Insertion due to missing or incomplete documentation.
CMS concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion).
Providers should submit the following documentation in support of dual-chamber cardiac pacemaker implantation:
- History and Physical: The patient's history of previous medical care, including alternative treatments and lifestyle changes. If the patient has had a single-chamber pacemaker implanted or attempted in the past, this information should be submitted.
- Providers may wish to review other inpatient and outpatient services a beneficiary received within the six to twelve months prior to the billed surgery. There may be services or notes that may help support the level of service, e.g., single versus dual chamber device.
- Diagnostic Reports: Diagnostic reports of all relevant testing should be included, regardless of the date of testing. Ensure that both inpatient and outpatient services that support this surgical procedure are included.
- Surgical Report: The surgical report is essential. It provides reviewers with a complete description and verification of the procedure and any factors affecting surgery.
- Hospital Documentation: Submit all hospital documentation for the requested dates of service including physician orders, progress notes, consultations, anesthesia evaluations and notes, recovery room records, nursing notes, laboratory reports, and radiology reports.
- Providers should submit documentation regarding current medications, those given during the most recent hospital stay, and previous medications. Records related to medications' effectiveness, any symptoms the medications may have cause and any adjustments made to the medications should also be provided to reviewers.
- Documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
- Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.
In the CMS Internet-Only Manual (IOM) Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.8 , CMS published guidelines for cardiac pacemakers (and defibrillators) and included a section specific to dual-chamber cardiac pacemakers. Prior to service and prior to submission of a claim for pacemaker implantation, providers should review this NCD, especially the following indications, which are considered acceptable or necessary for dual-chamber pacing:
- "Patients in whom single-chamber (ventricular pacing) at the time of pacemaker insertion elicits a definitive drop in blood pressure, retrograde conduction or discomfort
- Patients in whom the pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms, has already been experienced with a pacemaker that is being replaced
- Patients in whom even a relatively small increase in cardiac efficiency will importantly improve the quality of life, e.g., patients with congestive heart failure despite adequate other medical measures
- Patients in whom the pacemaker syndrome can be anticipated, e.g., in young and active people, etc."
Some examples of potentially appropriate dual-chamber pacemaker claims and documentation follow.
Mr. Smith had a complete heart block and was given a single-chamber pacemaker, a procedure which was covered under NCD 20.8. In order to upgrade the single chamber pacemaker with a dual chamber pacemaker, the provider should consider and document, if applicable, such things as "pacemaker syndrome" or ventricular asynchrony or the medical need based on cardiac status as indicated in the NCD. Documentation should be included to support the patient's need for atrial pacing in addition to ventricular.
Ms. Jones who has a predominant rhythm of atrial fibrillation with the mention of bradycardia presents with "sweating". Her medical records do not document the relationship of the heart rates to her symptom. The Holter monitor findings do not correlate with the appearance of the symptom. The insertion of a dual-chamber is non-covered based on the nationally non-covered indications list in NCD 20.8.
Mrs. Jones has a history of atrial fibrillation treated with anticoagulation, prominent right heart failure and severe tricuspid regurgitation; all of which suggest that she may have right atrial enlargement. She has no history of prior pacemaker insertion. Based on the requirements listed in the NCD and the absence of other documentation, symptoms are insufficiently supported for a dual-chamber pacemaker implantation.
Mr. Smith has a history of hypertension, hyperlipidemia, and Holter monitor findings indicating tachy/brady syndrome. He denies shortness of breath, dizziness, syncope, chest pain, weakness or fatigue. CMS criteria were not met for single- or dual-chamber pacemakers, per CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.8, Cardiac Pacemakers .
Last Updated Jul 15, 2015