Hello, and welcome to the MedAxiom Academy. The session I'll be covering with you today is on electrophysiology device coding. My name is Jamie Quimby, and I'm a revenue cycle senior coding consultant with MedAxiom. So for those that are new to cardiac device implant coding, I want to give you a brief rundown of understanding the heart's electrical system. So your heart has its own internal electrical system that controls the rate and rhythm of your heartbeat. With each heartbeat, an electrical signal spreads from the top of your heart to the bottom. As the signals travel, it causes the heart to contract and pump blood. Each electrical signal normally begins in a group of cells called the sinus node. As the signal spreads from the top of the heart to the bottom, it coordinates the timing of the heart cell activity. First the two upper chambers, which are the atrium, those contract. That contraction pumps blood then into the heart's two lower chambers, which is our ventricles. The ventricles then contract and pump blood to the rest of the body. This combined contraction of the atrium and the ventricles is what gives you your heartbeat. So sometimes when there's faulty electrical signaling in the heart, this would cause some of the arrhythmias that we'll be seeing as we go through the presentation. So we're going to start with some of the device definitions and what the codes look like for those particular devices. There are a variety of different systems now that they can implant. The two common are the first two that we'll cover in detail. So first we'll start with our pacemaker system. So this is a small device that's either placed in the chest or the abdomen to help control abnormal heart rhythms. The device uses electrical pulses to prompt the heart to beat at a normal rate. A pacemaker can relieve some arrhythmias, symptoms such as fatigue or fainting. You'll see commonly too sometimes patients that have syncope, those types of symptoms correlate a lot of times and they'll be evaluated to see if they might need a pacemaker system. You can see here in the picture that the generator was placed in the patient's chest and it does show a lead that was placed in the right atrium and the right ventricle. This would be our standard dual chamber pacemaker system and probably one of the more implantable devices that we do see. Our next big system is our implantable cardioverter defibrillator or what we commonly refer to as an ICD. This is a specialized device designed to directly treat many dysrhythmias. It is specifically designed though to address ventricular tachyarrhythmias. ICDs have revolutionized the treatment of patients that are at risk for sudden cardiac death due to that ventricular tachyarrhythmia. The device will deliver pacing signals and also shocks as needed to correct the patient's condition. So with the pacemaker and the defibrillator, there are leads that can be placed in multiple areas. We are going to define what CPT guidelines are in reference to the number of leads or chambers. Looking at CPT definition, a single chamber pacemaker or ICD system, it will include a pulse generator and then you have one electrode that is either inserted in the right atrium or the right ventricle. A dual chamber system would include that pulse generator, but then it would have two electrodes inserted usually in the right atrium and the right ventricle, but sometimes they may place a lead in the right ventricle and the coronary sinus to pace that left ventricle. Just keep in mind, you're looking at the number of leads placed in the chambers and then that will kind of help you define how many were placed and how you would code it appropriately. So a multilead, this would include the pulse generator, but it would also include at least three electrodes that are inserted in the right atrium, the right ventricle, and then that coronary sinus to pace the left ventricle. So going into that, so a biventricular device. So sometimes this means a multilead device was implanted, but sometimes it may not. Sometimes they may only have two leads still, so they won't have that atrial lead implanted. So for example, a patient that may have chronic atrial fibrillation, they may not have that lead in the right atrium because it's not medically necessary, but they would have a lead in the left ventricle and the right ventricle. So that would qualify as a biv device, which is a biventricular device, but it would be coded as a dual system, not a multi because you only have two chambers paced. So now let's cover the cardiac resynchronization therapy. An implantable CR device is a medical device that's used in that cardiac resynchronization therapy. It resynchronizes the contractions of the heart's ventricles by sending tiny electrical impulses to the heart's muscles, which then can help the heart pump blood throughout the body more efficiently. There are two types of these devices. There's one for a pacemaker system and one for that ICD system. So you can see here on the slide how they have a CRTP and then that CRTD. So that would tell you the P would be for pacemaker, the D would be for a defibrillator. So breaking this down further and defining it, that cardiac resynchronization therapy has been used to describe biventricular pacing, but it can be achieved by left ventricular pacing only. An implantable CR device is a medical device that is used in that CR therapy. It resynchronizes the contractions of the heart's ventricles by sending tiny electrical impulses to the heart's muscles, which of course will then help your heart pump blood throughout the body. Again there are those two types of systems, as you can see here on the slide, the pacemaker and defibrillator. So that CRTP device, which is for our pacemaker, this is used by keeping the heart from beating. Typically they're implanting it because the heart, they're trying to keep it from beating too slowly. The device has an additional lead that's placed on the left side of the heart, which would be in that left ventricle, and they place it there to help the left ventricle beat at the same time as that right ventricle. The goal is to improve that left ventricular function, reducing pre-systolic mitral regurgitation and improving that left ventricle diastolic filling time. You might need a CRTP system if you have heart failure despite medication and lifestyle changes, if your heart beats too slowly, where you may have bradycardia, or if the left side of your heart is beating out of time with that right side. Now looking at the CRTD device, which is for our defibrillator systems, typically these are placed in patients that have heart failure. They have previously had or are at risk for having that ventricular tachycardia, that VT, or ventricular fibrillation, which is VF, causing your heart to beat too fast, or maybe it has damage to the pumping action of the heart, which was caused by a heart attack. The CRTD device is designed to help the two lower chambers, the left ventricle and right ventricle. It helps for them to beat at the same time in a normal sequence. These devices, of course, will also detect any life-threatening arrhythmias and then automatically correct it. So there are four essential categories of generator coding options for a permanent pacemaker and the ICD defibrillator system. So we'll cover the four categories in detail. So for a new implant, we'll cover new implants, we'll cover generator changes that have no lead involvements, we'll cover a generator change that does involve a lead procedure, and then we'll cover, finally, a generator that is being attached to existing leads. There is a helpful table in your CPT book. So I would open that up and then go to the 3000 section where these codes are located. The CPT does give, in that table, multiple examples and then what the coding scenarios would be depending if it was a pacemaker system or that ICD system. So to cover the first category, this is a new system. So what this means is it would be a new insertion of both a generator and a lead or leads, depending on what the medical necessity is for that patient. So meaning that would either be a lead in the right atrial and or the right ventricle, or of course that could include that left ventricle. Fluoroscopy is not separately billable with these services. It is bundled into the implant itself. Again, if that left ventricular lead is also placed, that is also separately reportable. We will cover the LV lead codes in an upcoming slide, so we'll cover those in detail. There is something that's also called DFT testing, which is only reportable with our traditional defibrillator implants, so we'll cover those codes in detail as well. But if that is performed also, you can report that service separately with the defibrillator. So these are the codes for our new system implants. So you can see with the 33206 for our pacemaker, this would be an insertion of a new generator, with a lead that's only placed in that right atrial. The 33207 would be insertion of a new pacemaker generator with a lead that's placed in the right ventricle. And then our 33208 would be an insertion of a new pacemaker generator, and then a lead would be both in the right atrium and the right ventricle. So that would be, again, our standard dual chamber system. Now for the defibrillator initial implant, the 33249, this would include the defibrillator generator, and this would include either single or dual chamber leads. So it doesn't matter, there's no distinction or difference in the coding for the defibrillator system. So typically they are placing leads, dual chamber leads, but sometimes they may not need, like I said, that lead in the atrium, so they would only be having lead placed in the ventricle. So the coding would not change depending on the number of leads on the right side of the heart, so that right atrium or right ventricle. This is the DFT testing that I was talking about. You may also see it called NIPS, which means non-invasive program stimulation. A patient may have a change in their health or medications that can interfere with the device functioning, so the provider may want to perform this NIPS procedure or DFT testing. This is similar to a cardio version. The heart is stimulated to test the defibrillator's ability to return that heart to a normal rhythm. Adjustments can be made to the device based on the NIPS or the DFT testing results. As you can see here, there are three CPT codes available. So based on documentation would depend on what you would report. The most common that we see supported is the 93641, which is where they are testing the defibrillator device at the time of implant, so they're testing the leads and the generator at the same time. What you have to see in the documentation is that an unstable arrhythmia such as B-fib, that ventricular fibrillation, is induced, and then the provider is going to have that defibrillator shock the patient back into a stable arrhythmia. So that is an important piece of the documentation. If you don't see that there, then most likely all they're doing is just testing the leads itself, not so much doing this DFT testing itself. If they're only evaluating the leads function and parameters, then that's bundled in with the implant itself. It's not separately billable. So again, with the DFT testing, you have to see in that documentation that there was an abnormal unstable arrhythmia induced and that the provider used that defibrillator to shock the patient back into a stable arrhythmia. So category two is a straight generator change. These are used when a generator is removed and a new one is inserted. They typically are performing this type of procedure when a patient's previously implantable system, their generator is at the end of its life, essentially. So the batteries don't last forever in these, so they do have to periodically replace the generators so that they have new battery life. You might see it abbreviated in the note as ERI, which is elective replacement interval, or EOS, which is end of service. So again, this means the battery of the generator is at the end of its life and the provider is replacing just the generator with the new one. You'll identify the number of existing leads that are being attached to the new generator in order to select that correct coding for that reporting. So these are the CPT codes available for our pacemaker system and our defibrillator system. Just again, depending on which system they have and then how many leads are being attached to that device. So again, example pacemaker system, a lot of patients have that dual chamber system. So if they're not doing anything with those right-sided leads, it would simply just be that 33228, and that would include removal of the old generator and insertion of the new one. Our third category, and one of the more confusing categories, is a generator change. So that was what we were just previously talking about, but the patient also is in need of a right-sided lead procedure. So that's a lead in the right atrium or the right ventricle. So guidance from CPT, and this is in that table I was telling you about with the examples that they list in the book. So if a patient, again, has to have a right-sided lead procedure involved along with that generator change, the guidance is to code for what was removed, and then you would code for what was implanted. So in this case, just to give you an example, we may have a pacemaker system, and maybe their right atrial lead is not functioning. So the provider is going to place a new right atrial lead. Their battery of their generator is also at the end of its life. So in that kind of example, you would report the removal of the pacemaker generator. And then you would report a new implant of a right atrial lead along with that new generator. So that would be that 33206. And then you would also report the removal, of course, of that pacemaker generator. So again, it just depends. Just keep in mind, if there's a right-sided lead procedure involved, you first code what was removed, then you code what was implanted. So these are the removal codes. The 33233 is a removal of a pacemaker generator only, and then the 33241 is for the ICD defibrillator generator. Now, if they do have to remove a lead, sometimes they will just cap the lead. So like in that example we were just talking about with the right atrium, say that the physician doesn't end up removing the lead itself, he just ends up capping it and leaving it in place, but then implanting a new right atrial lead. There's nothing to code if they cap it, because they're not really doing anything, they're still leaving it implanted, it's just not going to be attached to the new system. So keep that in mind if it's capped, nothing separately reportable. But if they do remove the system, of course it just depends on how many leads they're taking out and the approach that they're taking it out. Most common is the transvenous extraction. They do these sometimes by a laser technique, sometimes it may be by a snare. So it just again depends. There's no difference in the coding based on those types of techniques. So again, most common that we see in cardiology is the transvenous. You do have codes that are specific to your pacemaker lead systems versus your defibrillator lead system. So just kind of keep that in mind too, depending on the type of lead that they have in the system that they're attached to. The last category is our generators that are attached to existing leads. So this is the least common of the categories that we see performed. But to give you an example of when you may see this, there are times where a patient may have a defibrillator implanted, but for whatever reason, the provider wants to change the defibrillator to a pacemaker system. So they're not necessarily doing anything with the leads itself, but they're going to attach a different generator to the leads that are already implanted. So that's an example of when you may see this system coded. Again, these are the codes. It depends on the type of system, the generator being implanted, and of course, how many leads will be attached to that generator. So again, if they have a defibrillator that's in place, but they want to downgrade it to that pacemaker system, let's say it's a dual chamber. So they have a lead in the right atrial and the right ventricle. You would code the removal of that defibrillator, the 33241. So that's the removal of your ICD generator. And then you would code that 33213, which will be a new pacemaker generator attached to those existing leads. All right. So some additional details. So this is the left ventricular lead that we've been talking about. So this is the coding options for this service. The most common is the 33225, which keep in mind, it has that plus sign in front of it. So that means it's an add-on service. So it can never be reported by itself. It always has to have a primary procedure with it. The 33224 can be performed. This is where they're only implanting a left ventricular lead. It's going to be attached to the system that's already in place. There's no further changes to that system already in place. Don't see that one a whole lot. Typically, they're going to be doing something with the generator that's in place. They're going to be implanting this new LV lead. So most times you're going to be coding for the generator procedure performed. And then, of course, the 33225 for that addition of that left ventricular lead. The 33226 is reportable if for any reason they have to reposition that LV lead that's already in place. Again, not too terribly common that we see that. But if the LV lead that's in place gets dislodged for whatever reason and the provider has to go back in and resuture it back into place, then that's when you would report that. So this is a CPT assistant article on a generator change that has the addition of a new left ventricular lead. So in the question, it says when an existing pacing cardioverter defibrillator pulse generator, so that's our ICD device, when that is replaced with a system that is different from the existing system, code selection should be based on the final lead system inserted. So the answer from CPT assistant is if that ICD defibrillator generator is a dual lead system is removed and a multi-lead system is inserted, so meaning they had two existing leads in the right atrium, the right ventricle, now they're having an addition of that left ventricular lead and they're having that generator replaced. So that would be coded with the 33264, which is that ICD generator change out multi-lead system. And you would also code that 33225, which is that add-on code for the left ventricle lead itself. So your primary CPT in this example would be that 33264 and then you would report again that 33225 for that addition of that LV lead. His leads, we have limited information on this right now. We are hoping that there will be a CPT code born in the future, but we are still waiting. So current guidance right now and a common question I get of course is how do you code a HIS bundle lead system? So we are seeing that they are placing the HIS bundle leads now for that resynchronization therapy. The lead is placed at the bundle of HIS or which is placed either below or above the tricuspid valve. It's more commonly placed in the right atrium, but it could also be placed in that right ventricle. So when you're looking at a HIS bundle lead, you got to look at the level of where that lead was placed. The providers are always detailed in the report, so they will tell you if it's either going to be placed at the level of that right atrium or that right ventricle. So because of that, current guidance for this is to code the procedure to the location of where it's placed. The HIS bundle leads, even though they're placing them for that resynchronization therapy, that resynchronization therapy is defined as pacing in the left ventricle. So the HIS bundle lead is not being placed in the left ventricle. So that's why we can't code it with the 3-3-2-2-5. So again, you would just code it to the level that it is placed. Another common question, too, that we get is, can we build the 9-3-6-100, which is the HIS bundle recording? So CPT manual specifies that this code is reportable when you're trying to identify tachyarrhythmias for a separate distinct procedure, and it has to be performed for diagnostic purposes. So a lot of times they do this HIS bundle recording when placing a HIS bundle lead, but they're doing it kind of as roadmapping to place the lead and make sure it's in the appropriate position. So not so much for diagnostic purposes for those tachyarrhythmias. So in those scenarios, you would not be allowed to report in the 9-3-6-100 if it's used to aid in placement of that lead. Pacemaker upgrade. So this code is used when the provider is removing the existing system and they're going to upgrade it. So they have a single chamber system, and they're going to convert them to a dual chamber. So this would include, you know, placement of a new generator. It would also include that additional lead that was placed. So it would simply just be the 3-3-2-1-4, and that would include everything in regards to upgrading that patient from a single chamber to that dual chamber system. So we've covered some of the lead removal codes already, just depending on the type of lead they have in the system and the method of the removal. So these are other lead procedure codes that are available, just depending, of course, on what's supported by the documentation. So you have new insertion codes, and these would apply to whether it's a pacemaker or a defibrillator. You also have repositioning, and again, this is reportable with the pacemaker or defibrillator system. And then you have repairs. So again, just depending on if they're doing a single lead or a dual lead, and, you know, they were going to repair that lead that's in place. Repairs are not as common that I see. Repositioning can happen, and the new insertions can happen. So sometimes their existing generator is fine, but for whatever reason, one of their leads may not be functioning. So the provider may need to insert just a new lead itself and not do anything further to the system. And then so that you would just report a new lead only in those cases. So pocket relocation. Definitely don't see these a whole lot because of how they're defined by the CPT guidelines. So a pocket relocation, it has to be moved from one location to another. So there used to be a code some years ago for a pocket revision, and they took that code away from us quite a few years ago. And we don't have any code now available for just a revision itself. So if a pocket is only revised, it's included in the primary procedure being performed. Now, if they do a complete relocation, then that would be where these codes come in place. And of course, it would depend if they have that pacemaker or that defibrillator system. So just keep that in mind. They have to completely move the pocket from one location to another to be able to build this. This is a CPT assistant article again on the pocket relocation. So again, medical necessity for that pocket relocation has to be supported. And again, that pocket relocation may be performed as a standalone procedure or it can be performed at the same time as another device procedure, such as a generator or lead procedure. CPT assistant does give a patient comes in for a generator change and the pocket is moved to a different location. This is an example where you could report both of those services together. Venograms, this is a common area that gets asked. So venogram to place a lead is included as part of the lead placement and it's not separately billable. If the provider has to do a venogram due to suspected blockage or other medically necessary reasons, so it's not just being done to simply place the lead, you may be able to bill it depending on what all is documented as that medical necessity, of course. So the report should clearly state what the intent of the venogram is. On this CPT assistant Q&A, it was asked during the insertion of a dual chamber ICD, the physician indicates performing a left subclavian venogram to facilitate entry. Would you be able to report that 75820? CPT said no. The service described is not a diagnostic venogram, but was used as guidance of placing that lead. So again, details in the documentation have to be there. Most times they are just doing the venograms to place the lead itself, so it would not be reportable. Okay, so another area I want to cover with you is ultrasound guidance. So this is actually from the Medicare NCCI manual. As you can see in the red highlight, this is specific to our EP studies and ablations as well as our EP device procedures. So you can see down here where it specifically references CPT code ranges. So that 33202 through the 33249, that is all of our device implantable procedure codes, that whole range. So what Medicare states in this edit is that ultrasound guidance is not reportable with these CPT codes. Now if you look at the other code range, the 93600 to that 93662, that's all of our electrophysiology EP studies and our ablation codes. That's the whole CPT range set for those sets of service. So a lot of EP providers ask if that ultrasound guidance is reportable because they do perform it on almost every procedure. It's never reportable. There's no way to override the edit with this manual, so you wouldn't be able to bill it. So now we're going to cover some of the other systems. So this is our temporary pacemaker codes that are available depending if it's a single chamber or a dual. Keep in mind NCCI edits again bundle this procedure in with any other procedures being performed on the same day. So if it's performed as a solo procedure by your provider, you can report it, but sometimes the patient, it may be pacemaker dependent or they may be an unstable complete heart block and the provider's having to get them on a temporary system while they're implanting a permanent system. So in those cases, you cannot report your temporary pacemaker. It would be bundled in with the primary procedure performed. So again, not too common. We see these performed solo. Sometimes it can happen though if the patient is severely sick and they're very unstable. Sometimes the provider will go in and implant that system right away and then they may monitor them for a couple days and then place a permanent system later. So in those cases, if it's a solo procedure, you're okay to bill it. Again, this is from the NCCI manual. This one pertains to our device implant services specifically. It does clearly state that our temporary system would not be reportable and there is no modifier allowed to override that edit. All right, we have a leadless pacemaker system now and this is actually what they look like. These are the two types that are available in the market. So unlike our conventional pacemaker systems, the leadless pacemaker is placed directly in the heart without a need for that surgical pocket or those pacing leads. The device is much smaller than a conventional pacemaker system and it's comprised of a pulse generator that includes a battery and a steroid eluting electrode that sends pulses to the heart when it recognizes a problem with the heart's rhythm. These procedures are typically implanted via the femoral vein. This is a very small device. As you can see, it's designed to be fully retrievable so it can be readily repositioned during the implant repositioned during the implant procedure or later retrieved if necessary. And again, you can see there's one of these systems is a Medtronic device and the other one is the St. Jude. All right, there have been several changes to the leadless pacemaker systems. They have added some additional coding services. Originally, it was a Category 3 code for the right ventricle chamber. They have since added a right atrial leadless system and then there's also a dual leadless system. So we have additional coding options. What you see on the screen here are the different CPT reporting. And as you can see, there's Category 3 codes. So for your initial just a single chamber RV leadless system, you're going to code that 33274 for the initial placement and 33275 if they're just removing the system. Those do edit together and it's very rare that they would do a removal and an insert during the same session. So just know if that does happen, you can only report the insertion. And then for a single right atrial system only, you can see here the different coding options. If they do a dual lead system and let's say, for example, they had an existing RV system already in place, so now they're upgrading it to a dual system, but during the procedure, they're obviously only going to be placing that right atrial component. So you can see here the different coding options based off of what is happening during that session. So if you just have the right atrial component only, because that existing RV component is already there, you would select that 0796T. Remember, the T codes are all temporary codes currently. We do expect that they will graduate to a permanent Category 1 service, at least within the next couple years, because these procedures are being performed quite frequently. They're in clinical trial still. So to touch up on our next slide, these are the available clinical trial numbers that are currently active. So just depending on the vendor of the device, the type of system, and the chambers, these are the applicable clinical trial numbers that you will need to apply to your claim form. You will also need to make sure you append that Q0 modifier along with that secondary diagnosis code that Z00.6. Next system is a subcutaneous defibrillator or you commonly might see it as a subQ or that S-ICD. So a subcutaneous implantable defibrillator system avoids the need for transvenous placements of electrodes. The subcutaneous implantable defibrillator system requires a pulse generator with greater defibrillation energy compared to our traditional ICD generators as well as that subcutaneous electrode lead. So implantation is completely subcutaneous and it's performed by tunneling the electrode lead just under the skin with no hardware within the heart or blood vessels. It does differ from that transvenous ICD system in several respects. So the subcutaneous system that we see here, it cannot paste the heart whereas the transvenous system can. The transvenous system may be inserted in a single chamber or in the dual chamber like we've covered or of course it can have that biventricular system also. The subcutaneous system cannot, it only has a single lead which is not placed in the heart's chambers at all. The transvenous devices again may use that combination of that anti-tachycardia pacing, low energy cardioversion or defibrillating shocks to treat those ventricular tachyarrhythmias whereas the subcutaneous system can only provide the defibrillating shocks. This is a CPT reporting for this type of defibrillator. It's not as common as that traditional ICD device that we've already covered but there are times where this may be more medically appropriate for the patient. 33270 would include your initial insertion which would have that generator and that tunneled electrode. Important thing to point out with this, the DFT testing at the time of this particular system implant is not separately billable at the time of the implant. It is bundled whereas with our traditional defibrillators we can report that DFT testing if it's performed. So just keep that in mind, this bundles in and would not be separately billable. Another common procedure that we see is the subcutaneous cardiac rhythm monitor, commonly referred to as a loop recorder. You can see the size on the picture here. It's actually about the size of a paper clip. It's very small. They actually can perform these now in the office setting. It just takes a tiny little incision. They usually just do local numbing to the skin and they'll place it right into it and it'll monitor the patient. This also does have a battery life to it so eventually the battery will run out. Usually by then they are going to just fully remove the system at that time. Occasionally they may decide to monitor the patient longer and they'll implant a new one. This is the CPT coding for that type of system. So the 33285 would be your initial insertion and then the 33286 would be for that removal. Now if they're doing, they already have a previously placed system and the battery is at the end of its life and they're going to do a removal and then a new implant. The guidelines for this type of system, so if they're going to remove the previous system and implant a new one in the same location, you can only report the new insertion. Now if they're going to remove it and then place a new one in a different location, that's when you can bill both. So there is an edit with these codes. You can't override the edit with a modifier 59 but again it has to be a totally new location. So most commonly it's not. They're going to put it in the same spot so you would only bill that 33285. Now I wanted to cover some of, Medicare has some national coverage determinations or what we commonly refer to as an NCD. They have one specific to a pacemaker system or that traditional pacemaker and then our defibrillator, the traditional defibrillator. So we're going to cover those in detail. Certain criteria have to be met in order for them to be covered by Medicare. So this is the NCD for our traditional cardiac pacemaker systems. Coverage is specific to the 33206, 07, and 08. So keep that in mind. If they're just doing like a battery changeout, this policy would not apply to just those battery changeout codes only. So documentation must show that they have documented non-reversible symptomatic bradycardia due to sinus node dysfunction and or symptomatic bradycardia due to second degree and or third degree AV block. Each local Medicare contractor will have their own policy on these services. Most will list what is nationally not covered and of course those nationally covered indications. So Medicare puts out an NCD on this, but then your local Medicare contractors will further define this NCD article from National CMS and they'll add more detailed information to their local coverage determination, which is that LCD. So I highly recommend you look at your local Medicare contractor. They all have their own policies on these pacemaker systems. So non-covered indications would be reversible causes of bradycardia such as maybe electrolyte abnormalities, medications on drugs. Maybe they have asymptomatic sinus bradycardia, so that would be something that Medicare considers non-covered for a pacemaker system. Again asymptomatic first degree AV block, second degree AV block, those are on this previous slide here. So these are covered, but if the patient is not symptomatic is when they can be not covered. So detailed in the provider documentation is very important when it comes to these types of systems. So again, these are just a continuation of nationally non-covered indications, so if a patient maybe has syncope, they haven't yet defined the cause of where that syncope is coming from. Maybe they only have bradycardia that's documented during sleep, so those types of things again would be that those would fall under non-covered indications. Modifiers are required on the pacemaker system implants, the 3320607 and 08, so if the requirements of the policy have been met, then you would append a KX modifier, and that tells Medicare that the patient does meet the requirements and it's supported by documentation and the KX would let them know that. An SC modifier is when medically necessary service or supply, I'll cover that in detail, and then your GA or your GZ would tell the carrier that the requirements have not been met and you would append one of these modifiers based on whether or not the patient signed an ABN. So breaking the policy down, so they list the KX modifier supported within groups, within a local coverage determination. So group one meets that symptomatic bradycardia or the AV blocks where they're symptomatic, so these are all the diagnoses that they will cover with that KX modifier on your initial implant code. Additional, so they have a group two, so these are additional codes that they say each MAC can publish at the local coverage determination and whether or not that they will cover these additional diagnoses. So important thing to point out, so you have AV block unspecified, but the patient is symptomatic, so again that's the key, symptoms or no symptoms would depend if that KX is supported. Then you have left bundle branch, you have your right bundle branch, but again these are all symptomatic. Additional groups, so these have to correlate with arrhythmias. Important one to point out is your, this third bullet here with the AFib. So if it's documented as persistent or unspecified along with symptoms of bradycardia, then you can report it, report the AFib as your diagnosis with your KX appended. So if it's proximal AFib, which is your I48.0, that would not fall in this category, so that's where it becomes important with the level of specificity on the conditions and again whether or not they're symptomatic, if they have that symptomatic bradycardia along with the atrial arrhythmia that's included. So again, just details definitely will help determine whether or not you can report that KX. There's another group too, which is that hypertensive carotid sinus syndrome. I personally have not ever seen this diagnosis reported for a pacemaker system, but if the patient did have this, it would be, it would fall under your KX modifier group. SC modifier, so this is an important one to point out. So remember we talked earlier about your cardiac resynchronization therapy procedures with your pacemaker defibrillator. So sometimes if they have to place that left ventricular lead, so they're getting that CRT device implanted, maybe they're not meeting any of the KX diagnosis requirements, but they're getting that CRT device. Medicare states that you would append the SC modifier on those to show the patient's getting that pacemaker for that CRT therapy. Usually with the, that cardiac resynchronization therapy with that addition of that left ventricular lead, those patients have heart failure and most common, that's why they're placing that LV lead, so that patient has heart failure along with other, you know, problems. Sometimes they may have a left bundle branch block, sometimes they may have cardiomyopathy, so it just depends, but they're getting that LV lead for those reasons, so that's when you would append the SC modifier. Now the pacemaker or generator replacements, so what that, that doesn't fall under our generator only code, so that's when you have a generator procedure with a right lead procedure. So again, don't commonly see the SC reported on those, so that would be when you're reporting your 33233, which is your removal of your previous pacemaker generator, and then maybe they had, again, to have a new atrial lead implanted, so you've got your 33206, which is a new pacemaker generator with that new atrial lead, so in those types of cases, you can append modifier SC to those. Again, I don't see that too commonly needed, typically they're still meeting that KX modifier requirement for those procedures. Now to move on to Medicare's national coverage determination for our defibrillator system, so that's that 33249. So there are six nationally covered indications for that type of system. There's no modifier requirements that are needed to report the service, so you primarily, importantly, want to make sure your diagnoses are falling within one of the six listed covered indications. So covered indication number one would be a patient that has a personal history of ventricular tachycardia, or they had cardiac arrest due to V-fib, and then further demonstrating they had that episode of sustained VT, or they had that induced, that was induced by an EP study, or it was spontaneous, it was not associated with a myocardial infarction, and maybe an episode of cardiac arrest that they had due to V-fib that was not due to any transient or reversible causes, so that would fall under category one. Most commonly though will be some of these other categories that we'll talk about. Category two is a patient with a prior MI, and they have a measured left ventricular ejection fraction of less than 30, so you'll find those types of details most commonly in an echocardiogram reading, or in a cardiac cath itself, they'll document that LV finding. Again, patients have that heart failure, or they've had bypass graft, or they've had a PCI, which is a stent or angioplasty within the last three months, they had an MI within the past 40 days, so this is patients must not have had under category two within that time period, and then clinical symptoms and findings that would make them a candidate for coronary revascularization. Category indications number three and four are the two common ones that we see supported for placing that defibrillator system, so patients who have severe ischemic dilated cardiomyopathy, but they've had no personal history of VTAC or cardiac arrest due to V-fib, they have heart failure, and they have that LVEF of less than 35 percent. Additionally, they state the patient cannot have had a bypass graft or a PCI in their coronaries within the past three months. Again, they can't have that cardiac MI within the past 40 days, and those symptoms and findings would make them a candidate for that coronary revascularization. So these patients typically, they'll document they have the ischemic dilated cardiomyopathy, and then they'll have maybe chronic systolic heart failure, and they haven't had that bypass or PCI or MI within that time period, then you would fall under this indication number three. Number four is severe non-ischemic dilated cardiomyopathy. Again, they have no personal history of cardiac arrest, heart failure of with that the LVEF at less than 35 percent, they've been on medical therapy for at least three months, and then the same additional information, you know, can't have CABG or PCI in the last three months or that MI in the past 40 days. Number five is patients with documented familial or genetic disorders. Don't typically see this supported in documentation. Like I said, the most common I see are indications, you know, number three and number four. Number six is a patient with an existing ICD that their battery is at elective replacement. So again, if they're doing a battery change out, then that would meet your covered indication number six. Additional criteria must also be met for these on top of the six indications, so must show the patient is clinically stable for the procedure. The LVEF must be measured by that echocardiogram, a nuclear study, you know, a cardiac MRI, or that catheter-based angiography. So you have to have that LVEF measurements. They don't have to necessarily document it within the implant report, but it has to be available in the patient's chart. The carriers do want that documented. And then thirdly, patients must not have had significant irreversible brain damage, any disease other than cardiac disease. So for example, cancer, renal failure, liver failure, with that likelihood of survival of being less than one year. And then they had superventricle tachycardia, such as AFib, with a poorly controlled ventricular rate. So these are requirements where patients cannot have those three things in addition to meeting the six covered indications. All right, and with that, that brings us to the end of this course. If you have any questions in regards to device coding for electrophysiology, please feel free to shoot an email, and we'll be happy to help answer any further questions. Thanks so much for listening.

electrophysiology

device coding

cardiac device implantations

pacemakers

implantable cardioverter defibrillators

Current Procedural Terminology

lead placements

cardiac resynchronization therapy

Medicare National Coverage Determinations