Physician Reimbursement Primer for Cardiac ... - Boston Scientific

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Chapter 2 10 Physician Reimbursement Primer for Cardiac Rhythm Management
Chapter 3 Indications and Coverage Determinations This chapter outlines the general coverage policies for CRM devices. CMS establishes national Medicare coverage policy, but its contractor payers may provide local guidance with more detailed—yet sometimes differing—billing and coding instructions. National Coverage Determinations The Centers for Medicare & Medicaid Services (CMS) publishes national coverage determinations (NCDs) to specify the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Local Medicare contractor payers are required to follow these NCDs where they exist. Where they do not exist, it is up to the Medicare contractor to make local coverage determinations (LCDs). Roughly 90 percent of all health care services are covered at the local contractor level, and 10 percent at the national level through the publication of an NCD. Medicare has applicable NCDs for AICDs, cardiac pacemakers, and cardiac pacemaker follow-up services. They can be found at http://www.cms.hhs.gov/CoverageGenInfo/. Medicare NCD for Cardiac Pacemakers 5 Item/Service Description Cardiac pacemakers are self-contained, battery-operated units that send electrical stimulation to the heart. They are generally implanted to alleviate symptoms of decreased cardiac output related to abnormal heart rate and/or rhythm. Pacemakers are generally used for persistent, symptomatic second- or third-degree atrioventricular (AV) block, and symptomatic sinus bradycardia. Indications and Limitations of Coverage Cardiac pacemakers are covered as prosthetic devices under the Medicare program, subject to the following conditions and limitations. While cardiac pacemakers have been covered under Medicare for many years, there were no specific guidelines for their use other than the general Medicare requirement that covered services be reasonable and necessary for the treatment of the condition. Services rendered for cardiac pacing on or after the effective dates of this instruction are subject to these guidelines, which are based on certain assumptions regarding the clinical goals of cardiac pacing. While some uses of pacemakers are relatively certain or unambiguous, many other uses require considerable expertise and judgment. Consequently, the medical necessity for permanent cardiac pacing must be viewed in the context of overall patient management. The appropriateness of such pacing may be conditional on other diagnostic or therapeutic modalities having been undertaken. Although significant complications and adverse side effects of pacemaker use are Physician Reimbursement Primer for Cardiac Rhythm Management 11
Page 1 and 2: GuidePoint GuidePoint is simplifyin
Page 3 and 4: Contents Chapter 1: Introduction ..
Page 5: How This Guide Is Organized Ablatio
Page 8 and 9: Chapter 1 Acronym Term CRM cardiac
Page 10 and 11: Chapter 2 detail below). This payme
Page 12 and 13: Chapter 2 procedure, the hemodynami
Page 14 and 15: Chapter 2 MS-DRG Logic for CRM Proc
Page 18 and 19: Chapter 3 relatively rare, they can
Page 20 and 21: Chapter 3 3. Sino-atrial block or s
Page 22 and 23: Chapter 3 Since there are more than
Page 24 and 25: Chapter 3 c. Ejection fractions mus
Page 26 and 27: Chapter 3 At this time there is no
Page 28 and 29: Chapter 3 Cardiac Resynchronization
Page 30 and 31: Chapter 4 because the physician may
Page 32 and 33: Chapter 5 • Disconnection of lead
Page 34 and 35: Chapter 5 • Temporary pacing is n
Page 36 and 37: Chapter 5 Pacemaker Revision to Ski
Page 38 and 39: Chapter 5 ICD Generator Replacement
Page 40 and 41: Chapter 5 individual payers regardi
Page 42 and 43: Chapter 5 Outpatient Procedure Codi
Page 44 and 45: Chapter 5 • Do not report this co
Page 46 and 47: Chapter 5 • Assign modifier 26 to
Page 48 and 49: Chapter 5 • Code 93652 is reporte
Page 50 and 51: Chapter 5 44 Physician Reimbursemen
Page 52 and 53: Chapter 6 Case Study 3 Procedure De
Page 54 and 55: Chapter 6 resistance 577, threshold
Page 56 and 57: Chapter 6 50 Physician Reimbursemen

Physician Reimbursement Primer for Cardiac ... - Boston Scientific

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