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 and 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. First, we'll start with our pacemaker system. 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 to sometimes patients that have syncope, those types of symptoms that will correlate a lot of times and they'll be evaluating 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 in 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. The next thing we're going to talk about is the pacemaker and the defibrillator. In both the pacemaker and the defibrillator, there are leads that can be placed in multiple areas, so we're going to kind of define what CPT guidelines are in reference to the number of leads or chambers. The pacemaker or ICD system, it will include a pulse generator and then you have one electrode that's either inserted in the right atrium or the right ventricle. The defibrillator or ICD system, it will include a 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. So 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. The defibrillator or ICD system, it will 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 moving on to that, so a biventricular device. So sometimes this means a multi-lead 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 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 moving on to the cardiac resynchronization therapy. So a cardiac resynchronization therapy 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. So there are two types of devices that are used in cardiac resynchronization therapy. 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. 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. Again, 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. Now, 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. 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. The CRTD device will detect any life-threatening arrhythmias and automatically correct it. Next slide, please. There are four essential categories of generator coding options for a permanent pacemaker and the ICD defibrillator system. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. The ICD defibrillator system is a generator that is being attached to existing leads. It is not separately billable. The patient is not doing this DFT testing itself. If they are only evaluating the leads function and parameters, that is bundled in with the implant itself. With the DFT testing, it is not separately billable. It is not separately billable. Category 2 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 battery is replaced. The battery is not permanent. The batteries don't last forever. They have to periodically replace the generators so they have new battery life. You might see it abbreviated as ERI, or EOS, or EOS. You will identify the number of existing leads that are being attached to the new generator in order to select the correct coding for that reporting. These are the CPT codes available for the pacemaker system and defibrillator systems. They are not separately billable. Example pacemaker system, a lot of patients have that dual chamber system. If they are not doing anything with the right-sided leads, it would be 33228. It is not separately billable. The next two confusing categories is a generator change, but the patient is also in need of a right-sided lead procedure. That is a lead in the right atrium or ventricle. It is not separately billable. The patient has to have a right-sided lead procedure involved along with the generator change. The guidance is to code for what was removed, and then code for what was implanted. We may have a pacemaker system, a generator change, and a right-sided lead. The battery of the generator is also at the end of its life. You would report the removal of the pacemaker generator. You would report a new implant of a right atrial lead along with the new generator. You would report a new implant of a right atrial lead along with the new generator. If there is a right-sided lead procedure involved, you first code what was removed and then what was implanted. These are the removal codes. The 33233 is the removal of a pacemaker generator only. You would report a new implant of a right atrial lead along with the new generator. If you have to remove a lead, sometimes they will just cap a lead. Say the physician does not 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. You would report a new implant of a right atrial lead along with the new generator. Keep that in mind if it is capped. If they do remove the system, it depends on how many leads they are taking out and the approach they are taking it out. Most common is the transvenous extraction. It depends on the type of lead you have. There are different types of coding based on those types of techniques. 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. Keep that in mind depending on the type of lead they have in the system . The next category is generators that are attached to existing leads. This is the least common of the categories that we see performed. 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 generator is not attached to the system. They are not necessarily doing anything with the leads itself, but they are going to attach a different generator to the leads that are already implanted. That is an example of when you may see this system coded. These are the codes. It depends on the type of system, the generator being implanted, the type of generator being implanted, the type of defibrillator that is in place, but they want to downgrade it to the pacemaker system. Let's say it is a dual chamber so they have a lead in the right atrial and ventricle. You would code the removal of the defibrillator, the 33241, the 33224, and the 33225. This is the left ventricular lead that we have been talking about. This is the coding options for this service. The most common is the 33225, which has the plus sign in front of it. It can never be reported by itself. The 33225, it is going to be attached to the system that is already in place. There are no further changes to that system already in place. Don't see that one a whole lot. Typically they will be doing something with the generator that is in place. They will be implanting this new LV lead. The 33226, it is the left ventricular lead. The 33226 is reportable if for any reason they have to reposition that LV lead that is already in place. Not too terribly common that we see that, but if the LV lead that is in place gets dislodged for whatever reason and the provider has to go back in and resuture it back into place, it can be a problem. This is a CPT assistant article on a generator change that has the addition of a new LV lead. In the question, it says when an existing pacing cardioverter defibrillator, pulse generator, when that is replaced with a system that is different from the existing LV lead, it can be a problem. If that ICD defibrillator generator is a dual lead system, is removed and a multi-lead system is inserted, meaning they had two existing leads in the right atrium, the right ventricle, and the left ventricle, it can be a problem. If 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. 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. So, 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. Current guidance right now, and a common question I get is how do you code a HIS bundle lead system? We are seeing that they are placing the HIS bundle leads now for that right ventricle lead. The HIS bundle lead is placed either below or above the tricuspid valve. It is more commonly placed in the right atrium, but it could also be placed in that right ventricle. When you are looking at a HIS bundle lead, you have to look at the level of where that lead was placed. The providers are always detailed in the report, and that is why we can't code the procedure to the location of where it is placed. The HIS bundle leads, even though they are placing them for that resynchronization therapy, that resynchronization therapy is defined as pacing in the left ventricle. The HIS bundle lead is not being placed in the left ventricle. That is why we can't code it with the 33225. Another common question that we get is can we build the 93600, which is the HIS bundle recording? The CPT manual specifies that this code is reportable when you are trying to identify tachyarrhythmias for a separate distinct procedure. It has to be performed for diagnostic purposes. A lot of times they do this HIS bundle recording when placing a HIS bundle lead, but they are doing it as road mapping to place the lead and make sure it is in the appropriate position. Not so much for diagnostic purposes for those tachyarrhythmias. In those scenarios, you would not be allowed to report the 93600 if it is used to aid in placement of that lead. Pacemaker upgrade. This code is used when the provider is removing the existing system and they are going to upgrade it. They have a single chamber system and they are going to convert them to a dual chamber. This would include placement of a new generator. It would also include that additional lead that was placed. It would simply be the 33214 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 they were gonna 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. So, 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, it 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 wanna 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. So that's the whole CPT range set for those sets of service. So a lot of EP providers asked 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 gonna 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 in 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 of 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 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. So this is the coding for a leadless pacemaker system. 33274 is for your initial insertion and the 33275 would be removal of the system. Next system is a subcutaneous defibrillator or you commonly may see it as a sub-Q 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 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 pace 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 of the, on the picture here it's actually about the size of a paperclip. It's very small. They actually can perform these now in the office setting. It's 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 gonna 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 an, they already have a previously placed system and the battery's at the end of its life and they're gonna do a removal and then a new implant. The guidelines for this type of system. So if they're gonna remove the previous system and implant a new one in the same location, you can only report the new insertion. Now, if they're gonna remove it and then place a new one in a different location, that's when you can build both. So there is an edit with these codes. You can 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 gonna put it in the same spot. So you would only build 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 gonna 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 change out, this policy would not apply to just those battery change out 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. Okay. 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 would, 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, 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 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 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 that the patient's getting that pacemaker for that CRT therapy. Usually with 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 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 replacement. So 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, wanna 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 the 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%. 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 that 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 with that, the LVEF at less than 35%. They've been on medical therapy for at least three months, and then the same additional information, with 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, 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, 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 supraventricle 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

Jamie Quimby

pacemakers

ICDs

biventricular devices

CRT devices

lead placement

Medicare's coverage determinations

device coding