Pacemaker & Defibrillator Procedures the physician indicated a left subclavianvenogramwas obtained to facilitate entry. Is it appropriate to report code 75820… Answer: No. The service

Pacemaker&DefibrillatorProcedures

JimCollins,CPC,CCCPresident,CardiologyCoder.Com,Inc.

1(c)2017CardiologyCoder.Comclient#756

The4PathwaystoPacemakerCoverage

CMSPublishedCoverage

SomeasymptomaticPatientsfromabove2

5MACdefinedindications

MACInterpretationofCMSCoverage

CMSPublishedCoverageDocumentednon-reversiblesymptomaticbradycardiaduetosinusnodedysfunction,orAVBlock(2nd or3rd Degree)

5MACDefinedIndications(nocodesprovided):1. Cardiacresynchronizationtherapy2. Obstructivehypertrophiccardiomyopathy3. Pacemaker/Generatorreplacements4. Sustainedpause-dependentVT5. Pacinginchildren,adolescents,&patientswithcongenitalheartdisease

MACInterpretation(symptomatic)Blocks:

AVBlockunspec (I44.30)1stDegreeAVBlock(I44.0)LBBother/unspecified(I44.7)RBBother/unspec (I45.10,I45.19)BBBunspec (I45.10,I45.19),RBBw/fasicular block(I45.2),otherBBB(I45.2)Bifascicular block(I45.2)Trifascicular block(I45.3)

SVTs(I47.1,I49.9)PersistentAF(I48.1)UnspecifiedAF(I48.91)Atrialflutters(I48.3,I48.4,I48.92)Carotidsinussyncope(G90.01)

MACInterpretation(asymptomatic)1st DegreeAVBlock(I44.0)2nd DegreeAVBlock(I44.1)CompleteAVBlock(I44.2)SSS(I49.5)

NarrativeforindicationsacrossallMACsisthesame.TheICD-10codesthatcorrelatewiththe“asymptomatic”indicationswereonlypublishedintheWPSarticle–theyaresummarizedabove.

Source:NationwideLocalCoverageAnalyses2(c)2017CardiologyCoder.Comclient#756

1)CMSPublishedCoverage– KXModifier

AVBlockComplete

AVBlock2nd

Degree

SSS

CongenitalHt.Block

• Documentednon-reversiblesymptomatic bradycardia dueto:

AVBlockComplete(I44.2)AVBlock2ndDegree(I44.1)SickSinusSyndrome(I49.5)CongenitalHeartBlock(Q24.6)

AddKXModifierto33206– 33208“Requirementsspecifiedinthemedicalpolicyhavebeenmet”

Source:NationwideLocalCoverageAnalyses 3(c)2017CardiologyCoder.Comclient#756

2)MACInterpretation– Symptomatic– KXModifier

EachMACpublishedaLocalCoverageArticlewhichprovidesadditionaldiagnosiscodesinterpretedbytheMACtobecoveredbyCMSnationalcoverage:• HeartBlocks:

1. Atrioventricularblock,unspecified(Symptomatic)2. Firstdegreeatrioventricularblock(SymptomaticwithPRintervalmorethan300ms)3. Leftbundlebranchblock,otherorunspecified4. Rightbundlebranchblock,unspecifiedorother5. Bundlebranchblock,unspecified6. Rightbundlebranchblockandleftposteriorfascicularblock7. Rightbundlebranchblockandleftanteriorfascicularblock8. Otherbilateralbundlebranchblock9. Bifascicular block10. Trifascicular block

• AtrialArrhythmias:1. SVTinwhichapacemakerisspecificallyforcontrolofthetachycardia2. SVTthatisreproduciblyterminatedbypacingwhencatheterablationand/ordrugsfailtocontrolthe

arrhythmiaorproduceintolerablesideeffects3. Atrialfibrillationwithsymptomaticbradycardiaduetonecessarymedicaltherapy4. Atrialflutterwithsymptomaticbradycardiaduetonecessarymedicaltherapy

• Other:1. Hypersensitivecarotidsinussyndromeandneurocardiogenic syncope(Syncopewithoutclear,provocative

eventsandwithahypersensitivecardioinhibitory responseof3secondsorlongerorforsignificantlysymptomaticneurocardiogenic syncopeassociatedwithbradycardiadocumentedspontaneouslyoratthetimeoftilttable testing


3)MACInterpretation– Asymptomatic– KXModifier• Awake,symptom–freepatientsinsinusrhythm,withdocumentedperiodsofasystolegreaterthan

orequalto3.0secondsoranyescaperatelessthan40beatsperminute(bpm),orwithanescaperhythmthatisbelowtheAVnode

• Awake,symptom freepatientswithatrialfibrillationandbradycardiawithoneormorepausesofatleast5secondsorlonger

• CatheterablationoftheAVjunction

• PostoperativeAVblockthatisnotexpectedtoresolveaftercardiacsurgery

• Patientswithneuromusculardiseases,e.g.,myotonicmusculardystrophy,KearnsSayre syndrome,Erb dystrophy,andperonealmuscularatrophy,withthird degreeandadvancedsecond degreeAVblockatanyanatomiclevelAsymptomaticpersistentthird degreeAVblockatanyanatomicsitewithaverageawakeventricularratesof40bpmorfasterifcardiomegalyorLVdysfunctionispresentorifthesiteofblockisbelowtheAVnode

• SecondorthirddegreeAVblockduringexerciseintheabsenceofmyocardialischemia

• Persistentthird degreeAVblockwithanescaperategreaterthan40bpminasymptomaticadultpatientswithoutcardiomegaly

• Asymptomaticsecond degreeAVblockatintra orinfra Hislevelsfoundatelectrophysiologicalstudy

• First orsecond degreeAVblockwithsymptomssimilartothoseofpacemakersyndromeorhemodynamiccompromise

• AsymptomatictypeIIseconddegreeAVblockwithanarrowQRS.

• SeconddegreeAVblockwithawideQRSincludingisolatedrightbundle branchblockSource:NationwideLocalCoverageAnalyses 5(c)2017CardiologyCoder.Comclient#756

4)MACDefinedIndications- SCModifier

AllMACsintroduced5indicationsthatwerenotassociatedwiththenationallymandatedindications.ICD-10codeswerenotprovided,possible ICD-10codesareparentheticallylisted:1. Cardiacresynchronizationtherapy

• QRS>120ms- AbnormalECG(R94.31)• LVEF< 35%- Abnormal:Echo(R93.1),FunctionStudy(R94.30/R94.39)• CMSCRTTechnologyAssessment:

2. Obstructivehypertrophiccardiomyopathy(I42.1)3. Pacinginchildren,adolescents,&patientswithcongenitalheartdisease(Q20– Q24)4. Pacemaker/Generatorreplacements

• NoERI/EOLdiagnosiscodesexist• Useclinicalindicationsfordeviceimplant

5. Sustainedpause-dependentVT(I47.2– VT)


ThePacemakerClaimProcessingParadox

Single&DualChamberCPTCodes

Bradycardiaistheprimaryindicationforimplant

Syncopewaspresentedasatextbookperfect

symptom

WhentheseICD-10codesareontheclaim,paymentisblocked- evenifoneofthecoveredcodesisalsoontheclaim.


NCDforDefibrillators:Circa2005

PrimaryPrevention• 6 indications• 3waitperiods• Q0(Q-Zero)modifier• RegistryIDRequired:

• Electronic:01999140• Paper:CT01999140

SecondaryPrevention• Cardiacarrest

• Nottransient• Notreversible

• SustainedVT• Nottransient• Notreversible• NotMIrelated

NCDforICDs(20.4)8(c)2017CardiologyCoder.Comclient#756

SummaryofIndications(fromNCD)


PossibleICDImplantICD-10Codes


PrimaryPreventionWaitPeriods

• MustnothavehadaCABGorPTCAwithinthepast3months

• MustnothavehadanacuteMIwithinthepast40days.

• PrimaryPreventionindication#7(NIDCMpatients)musthavehadthediagnosisofNon-IschemicDilatedCardiomyopathyforatleast3months.

• Listedas9monthsinindication7,reducedto3monthsbyindication9ifenrolledinatrialorregistry.

• CMSrequiresenrollmentintheregistryforallprimarypreventionindicationssothe9monthwaithasneverapplied.


InitialImplantofaSystem

• Pacemaker:• 33206- ImplantaPMgeneratorandanrt.atriallead• 33207- ImplantaPMgeneratorandart.ventricularlead• 33208- ImplantPMgenerator,RAlead,&RVlead

• Defibrillator:• 33249– single/dualchamberICDsystemimplant

• Adddefibrillationthresholdtestwhenperformed• 93640- DFTofleadsonly(notthegenerator)• 93641- DFTofsystemattimeofimplant• 93642- DFTofsystemonsubsequentday

• 33270– subcutaneousICDimplant&DFT


LeftVentricularLeadImplant

• Leftventricularleadimplantisan“add-on”service.TheLVleadimplantcodeshouldbereportedinadditiontotheappropriatesystemimplantorgeneratorchangecode.

• 33224- addLVleadtopreviouslyimplantedgenerator• 33225- addLVleadtonewgenerator• 33226- repositioningpreviouslyimplantedLVlead

• AbandonedLVleadimplant:• ReporttheLVleadcodewiththe53modifier(33225-53)

• 53– “DiscontinuedProcedure”• Documentdifficultiesinlaymen’sterms,inthereport• Denialinabout2weeks=requestfordocumentation• Submitcoverletterexplainingwhathappened• Submitoperativereportwithlaymen’stermshighlighted

• “itisnotappropriatetoseparatelyreportthevenousaccess…andvenography(includingfluoroscopicguidance)asthisisconsideredinherent”CPTAssistantJune,2012


Venography:NotBillable

• “Diagnosticvenography(radiologicalsupervisionandinterpretation)codesshouldNOTbeusedwithinterventionalproceduresfor:Contrastinjections,venography,roadmapping,and/orfluoroscopicguidancefortheintervention.”

CPT

• “Question:Duringtheinsertionofadual-chamberimplantablecardioverter-defibrillator,thephysicianindicatedaleftsubclavian venogram wasobtainedtofacilitateentry.Isitappropriatetoreportcode75820…Answer:No.Theservicedescribedisnotadiagnosticvenogram,butisratherusedforguidanceoftheleads"obtainedtofacilitateentry."Therefore,itwouldnotbeappropriatetoseparatelyreportcode75820.”

CPT®AssistantCodeConnect,May2008

• 75820- Venography,extremity,unilateral,radiologicalsupervisionandinterpretation

• 75860- Venography,venoussinus(eg,petrosalandinferiorsagittal)orjugular,catheter,radiologicalsupervisionandinterpretation

• CerebralSinus,NOTCoronarySinus 14(c)2017CardiologyCoder.Comclient#756

GeneratorChange

Pacemaker• 33227 - Removalofpermanentpacemakerpulsegeneratorwithreplacementofpacemakerpulsegenerator;single leadsystem

• 33228 - Removalofpermanentpacemakerpulsegeneratorwithreplacementofpacemakerpulsegenerator;dual leadsystem

• 33229 - Removalofpermanentpacemakerpulsegeneratorwithreplacementofpacemakerpulsegenerator;multiple leadsystem

Defibrillator• 33262 - Removalofpacingcardioverter-defibrillatorpulsegeneratorwithreplacementofpacingcardioverter-defibrillatorpulsegenerator;single leadsystem

• 33263 - Removalofpacingcardioverter-defibrillatorpulsegeneratorwithreplacementofpacingcardioverter-defibrillatorpulsegenerator;dual leadsystem

• 33264 - Removalofpacingcardioverter-defibrillatorpulsegeneratorwithreplacementofpacingcardioverter-defibrillatorpulsegenerator;multiple leadsystem

15

AlsoreportDFT(93640vs.93641)whenperformed.

(c)2017CardiologyCoder.Comclient#756

GeneratorChange&NewRA/RVLead

• Ifaright-sidedlead(RAorRV)isimplantedatthetimeofageneratorchange,DONOTreportthegeneratorchangecodes:

• Reporteverythingthatisremoved:• Generator:33233(PM)vs 33241(ICD)• Electrodes:33234/33235(PM),33244(ICD)

• Reporteverythingthatisimplanted,withthesystemimplantcodewhichaccuratelydescribesthehardwarepersonallyimplantedbythephysician:

• Pacemaker:33206,33207,33208• Differentiatedbywhichcomponentsareimplanted• Dualgeneratorchange+RAlead=33233&33206(singlechambersyst.)

• Defibrillator:33249• AlsoreportDFT(93641)whenperformed

• Alsoreportpocketrelocation(33222/33223)orLVleadimplant(33225)whenapplicable.


GeneratorChangeOut&NewLVLead(noRA/RVLead)

• Ifaleftventricular(LV)leadisimplantedatthetimeofageneratorchange,reporttheLVleadcode(33225)andthegeneratorchangecodereflectingthesystemthepatientreceives:

• Pacemaker:single(33227),dual(33228),multi(33229)• Defibrillator:single(33262),dual(33263),multi(33264)

• DualchamberICDgeneratorchange+LVlead=33264 +33225• GuidancefromtheAmericanMedicalAssociation:

• “Whenanexistingpacingcardioverter-defibrillatorpulsegeneratorisreplacedwithasystemthatisdifferentfromtheexistingsystem,codeselectionshouldbebasedonthefinalleadsysteminserted”

• “ifapacingcardioverter-defibrillatorpulsegeneratordual-leadsystemisremovedandamultiple-leadsystemisinserted,code33264foramultiple-leadsystemshouldbereported.”

June,2012AMACPTAssistant17(c)2017CardiologyCoder.Comclient#756

SubcutaneousICD(S-ICD)

• SICDElectrode(only)Procedures• Insertion– 33271• Removal– 33272• Reposition– 33273

• SICDGenerator(only)Procedures• Insertion– 33240• Removal– 33241• Generatorchange– 33262

• Sub-QDFT(notattimeofsystemimplant)• 93644-26- Electrophysiologic evaluationofsubcutaneousimplantabledefibrillator(includesdefibrillationthresholdevaluation,inductionofarrhythmia,evaluationofsensingforarrhythmiatermination,andprogrammingorreprogrammingofsensingortherapeuticparameters)


Reposition&RepairServices

PocketRelocation:33222(PM),33223(ICD)• Thepocketneedstobemovedfromonelocationtoanother• Pocketrevisionisnolongerbillable• Nationalcodingeditsnecessitatemodifier59oncodes33222&

33223whenpocketrelocationisperformedwiththemajorityofcodesinthispresentation(59Modifier- DistinctProceduralService)

LeadRepositioning:33215RepositionRAorRVelectrode• Openthepocket,handlethegenerator,repositionthelead• Electronicrepositioningisnotbilledwiththiscode• Ifbothleadsarerepositionedbill33215&33215

LeadRepair:PMorICD• 33218Repairsinglelead• 33220Repairmultipleleads


Upgrade– SingletoDualChamberPM

Whenupgradingfromasinglechamberpacemakertoadualchamberpacemakerwemustusecode33214:

33214- Upgradeofimplantedpacemakersystem,conversionofsinglechambersystemtodualchambersystem(includesremovalofpreviouslyplacedpulsegenerator,testingofexistinglead,insertionofnewlead,insertionofnewpulsegenerator)

Don’tbillseparatelyfor:RemovalofoldgeneratorImplantationofnewgeneratorImplantationofnewlead


SeldomPerformedServices

• Pacemaker• 33212 - Insertionofpacemakerpulsegeneratoronly;withexistingsinglelead

• 33213 - Insertionofpacemakerpulsegeneratoronly;withexistingdualleads

• 33221 - Insertionofpacemakerpulsegeneratoronly;withexistingmultipleleads

• Defibrillator• 33240 - Insertionofpacingcardioverter-defibrillatorpulsegeneratoronly;withexistingsinglelead

• 33230 - Insertionofpacingcardioverter-defibrillatorpulsegeneratoronly;withexistingdualleads

• 33231 - Insertionofpacingcardioverter-defibrillatorpulsegeneratoronly;withexistingmultipleleads

Onlyapplywhenanewgeneratorisinserted(byitself)andnooldgeneratorisremoved– example,hookingupanewgeneratortoepicardiallyplacedleads.


RightAtrialorVentricularLeadImplant

• Thesecodesonlyapplyifnogeneratorisimplantedduringthecase:

• 33216- Insertionofasingletransvenous electrode,permanentpacemakerorcardioverter-defibrillator

• 33217- Insertionof2transvenous electrodes,permanentpacemakerorcardioverter-defibrillator

• Samecodeforpacemakersanddefibrillators• Donotreportfluoroscopy(76000)


ModerateSedation• Includedinproceduralpaymentuntil2017• Sedation,anditsassociatedpayment,isnowcarvedout.

• Expected2017paymentfordualchamberpacemaker(33208)• 2016payment=$553.53+• 2017MACRA&BudgetNeutralityadj.(0.24%)=$1.32• Expected2017payment=$554.85

• Actual2017payment=$543.35

• Totalreductionformoderatesedation=$11.50

Appliesto:implantablelooprecordersurgeries,pacemakersurgeries,defibrillatorsurgeries,EPstudies,ablations,cardioversions(internalandexternal),andtransesophagealecho.


ModerateSedationCoding

• Moderatesedationisbillablein15-minuteincrements• 1st 15minutecodebillableafter10minutes• Additional15-minutecodebillableafter23minutes

• 2setsofcodes• Sedationbyoperator:

• 99152– 1st 15minutes(0.25wRVU)• 99153– eachaddtl.15minutes(nowRVU)

• Sedationbyotherqualifiedprofessional:• 99156– 1st 15minutes(1.65wRVU)• 99157– eachaddtl.15minutes(1.25wRVU)

• Someproceduresarereportedwithmultiplecodesthateachhadmoderatesedationcarvedoutofthem- unintendedpaymentreduction:

• Defibrillatorimplant(33249)&DFT(93641)• Electroderemoval,electroderepair,orskinpocketrelocationatthetimeofadeviceprocedure(implant,genchange)

Forpatients<5yrs.Oldsubstitute99151for99152and99155for99156

1hour=0.25wRVUs

1hour=5.4wRVUs

Documentmedicalnecessity

*2017MedicarePhysicianFeeschedule– NationalAveragepayment 24(c)2017CardiologyCoder.Comclient#756

ModerateSedationDocumentation

• Theoperativereportneedstosupportthecodesreported• 99152- Moderatesedationservicesprovidedbythesamephysicianorotherqualifiedhealthcareprofessionalperformingthediagnosticortherapeuticservicethatthesedationsupports,requiringthepresenceofanindependenttrainedobservertoassistinthemonitoringofthepatient'slevelofconsciousnessandphysiologicalstatus;initial15minutesofintraservice time,patientage5yearsorolder

• Establish“administrationofmoderatesedation”• Establishdurationofintraservice time

• Startswhensedatingagent(s)areadministered• Endswiththeprocedure– whenface-to-facetimeconcludes

• Documentthepresenceofadedicated,trainedobserver• 99156- Moderatesedationservicesprovidedbyaphysicianorotherqualifiedhealthcareprofessionalotherthanthephysicianorotherqualifiedhealthcareprofessionalperformingthediagnosticortherapeuticservicethatthesedationsupports;initial15minutesofintraservice time,patientage5yearsorolder

• Sameasabove,butnoneedforadedicated,trainedobserver


ServicesNotIncludedinPM/ICDSurgery

• Evaluationofthepatienttodeterminetheneedforsurgery.• Modifier57onE&Mforthedecisionformajorsurgery.

• Treatmentfortheunderlyingconditionorunrelatedconditions• Modifier24isneededontheappropriateE&Mservice.

• Diagnostictestsandprocedures• Devicechecks,remotemonitoring,etc…

• Complicationsthatrequireareturntriptotheoperatingroom• Modifier78isneededonthesurgicalservice• Examples:

• 10140-78- Incisionanddrainageofhematoma,seromaorfluidcollection• 10180-78- Incisionanddrainage,complex,postoperativewoundinfection

Medicare Claims Processing Manual


99024- $0PostoperativeChargeCode

• Onlypractitionerswhopracticeingroupswith10ormorepractitionersinFlorida,Kentucky,Louisiana,Nevada,NewJersey, NorthDakota,Ohio,Oregon,andRhodeIslandwillberequiredtoreport.

• Practitionersareencouragedtobeginreportingpost-operativevisitsforproceduresfurnishedonorafterJanuary1,2017,butthemandatoryrequirementtoreportwillbeeffectiveforservicesrelatedtoglobalproceduresfurnishedonorafterJuly1,2017.

• Practitionerswhoonlypracticeinsmallerpracticesorinothergeographicareasareencouragedtoreportdata,iffeasible.

• Reportingwillberequiredonlyforservicesrelatedtocodesreportedannuallybymorethan100practitionersandthatarereportedmorethan10,000timesorhaveallowedchargesinexcessof$10millionannually.

• 33207(singlechamberPM),33208(dualchamberPM),33228(dualPMgenchange)• 33249(ICDimplant),33263(dualICDgenchange),33264(multiICDgenchange)• 33282(ILRimplant)

2017PhysicianFeeSchedule


FrequencyofInPersonDeviceChecks

JACCOctober2,2012“MinimumFrequency”

Guidelines• Ataminimum,inpersonprogrammingevaluationsshouldbeperformed:

• Within72hoursofdeviceimplantation

• 2–12weeksafterdeviceimplantation

• Atleastannuallyuntilbatterydepletion

More frequent checks may be necessary


InPersonDeviceCheckCoding

Iterativeadjustmentstoassessprogramming?

No:(InterrogationEvaluation)Pacemaker:93288Defibrillator:93289Sub-QICD:93261

Yes:(ProgrammingEvaluation)

Pacemaker:Sgl (93279),Dual(93280),Multi(93281)Defibrillator:Sgl (93282),Dual(93283),Multi(93284)Sub-QICD:93260

Medicarerequiresdirectsupervisionofdevicechecksdonebyphysicianpracticeemployees.Directsupervisionmeansthephysicianisimmediatelyavailableintheofficesuitetofurnishassistancebutisnotrequiredtobeintheroomwherethedevicecheckisbeingdone.https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R169BP.pdf

“The final program parameters may or may not change after evaluation”

CPT Instruction


TechnicalComponentofDeviceClinicServices

StaffExpense63%

Non-StaffExpense37%

TechnicalComponent=$20.10

2017MedicarePhysicianFeeSchedule93280(DualChamberPMCheck)

2017MedicarePhysicianFeeSchedulePracticeExpenseInputs

• Staffexpenseincludedin93280• .26X10=$2.60medical/technicalassistant• .37X27=$9.99RN/LPN/MTA

• $12.59totalstaffexpense


• “MedicareguidelinesprohibitaphysicianfromreportingthetechnicalcomponentofservicesperformedprimarilybyanIEAPwhoisnotemployedbythephysician.”

HRSRecommendationsontheRoleofIndustryEmployedAlliedProfessionals(IEAPs)

• “ifapracticeemployeesuchasanurse— notadevicereporhospitalpersonnel— performstheinterrogation,youshouldchargethetechnicalcomponentandclaimreimbursementforthepracticeexpenseincurred.”HRS

SpecialtySocietyGuidance

Cardiology Coding Alert, 9/03

ExecutiveSummary:Addthe26modifiereverytimeadevicecompanyrepresentativecontributestoadevicecheck.Itreducescompensationbyabout$20.


LessCommonProgrammingTechniques

• Device-basedcardioversion&overdrivepacing– 93799(unlisted)

• AVoptimization• Automated– noseparatebill• ECG(93000-59- $17)

• 59Modifier:DistinctProceduralService• EstablishesthattheECGisseparatefromroutinedevicecheckprotocol

• Limitedecho,limitedDoppler,colorflow(93308,93321,93325- $207)

• Acompleteecho(93307)isnotindicatedorperformedtypically• Acompleteecho(93307)isafulldiagnosticprocedure

• Bioimpedance-derivedphysiologiccardiovascularanalysis(93701- $25)

• Externallymeasuredimpedance NCDfor93701


In-PersonInterrogationsvs.RemoteMonitoring

CurrentSettings

Arrhythmias

BatteryLifeRhythm

HeartRate

Malfunction

RemotemonitoringusingLATITUDE™NXTincludeseverythinginpersoninterrogationsdoplus…• In-homedatacollection• Programmablealertsforarrhythmiasanddevicemalfunction

• Redalertstriggernotificationwhentherapydeliveredbythedevicemaybecompromised

• Yellowalertstriggernotificationofcardiacarrhythmias

NotificationofalertsusingLATITUDE™NXTmayoccurviathewebsiteorviaemailalert,ifrequested.


RemoteMonitoringPremium

$64.14

$91.35

$0.00 $10.00 $20.00 $30.00 $40.00 $50.00 $60.00 $70.00 $80.00 $90.00 $100.00

Interrogation

RemoteMonitoring

• Remotemonitoringpays42%morethaninpersoninterrogation

• Multipletransmissionsmaytakeplacein90-dayperiod• IncentivizedbyMedicareinotherways:

• Billable4x/yr.inadditiontoin-personprogrammingevaluations• TheValueModifier


ConsensusonRemoteMonitoring

• “HRSExpertConsensusStatementonCardiovascularImplantableElectronicDevices.”• Remotemonitoring– aClass1Arecommendation• “Thisconsensusdocumentreflectsthewealthofrecentclinicaldatageneratedbylarge

randomizedprospectivetrialsfromaroundtheworldthatincludedpatientswithpacemakers,ICDs,andCRT-Dsfromvariousmanufacturers.TheseconsistentlyshowmeaningfulpatientbenefitsfromtheearlydetectioncapabilitiesofautomaticRM…ThesedataformthebasisofourrecommendationsthatRMrepresentsthenewstandardofcareforpatientswithCIEDs”

• AHA“Abstract13944:EarlyInitiationofRemoteMonitoringinCIEDPatientsisAssociatedwithReducedMortality”

• “Ourdatashowthatsurvivalishigherinpatientswhohaveashortertimebetweendeviceimplantandremotemonitoringinitiation,acrossallCIEDdevicetypes.ThesedatasuggestRMshouldbeinitiatedassoonaspossiblefollowingdeviceimplantation.”

• earlyinitiationofremotemonitoring(within91daysofdeviceimplant)reducesmortalitybyover16%...”


CPTCodesforRemoteMonitoring

• 93294($35*) - Interrogationdeviceevaluation(s) (remote),upto90days;single,dual,ormultipleleadpacemakersystemwithinterimphysiciananalysis,review(s)andreport(s)

• 93295($69*) - Interrogationdeviceevaluation(s)(remote),upto90days;single,dual,ormultipleleadimplantablecardioverter-defibrillatorsystemwithinterimphysiciananalysis,review(s)andreport(s)

• 93296($26*) - Interrogationdeviceevaluation(s)(remote),upto90days;single,dual,ormultipleleadpacemakersystemorimplantablecardioverter-defibrillatorsystem,remotedataacquisition(s),receiptoftransmissionsandtechnicianreview,technicalsupportanddistributionofresults

SubcutaneousICDremotemonitoring=93295+93296

*2017Medicarenationalaveragepayments.


RemoteMonitoringBillingBasics

• CPTDefinition• Oneormoretransmissionsmaytakeplaceduringthe90-dayperiod

• AmericanMedicalAssociation• “Codes93293– 93296arereportednomorethanonceevery90days.”

• Donotreportif“themonitoringperiodislessthan30days”• Medicare

• Thedateofservice/billing=thedateofcompletion• “Whilewedonothaveanationalpolicyonthis,oursenseisthattheDOSshouldbethedateofcompletion. Iftheserviceisfurnishedforlessthanthespecifiedtimeofthecodedescriptorthenthetimespanshouldbeindicatedontheclaimsform. Thiswouldallowustoknowforinstance,howmanyservicesarebilledonthe31st dayfora90dayservice.”

• CMSDirectorofExternalAffairs


Minimum 30-day monitoring period.

Exclude newly implanted devices in the last 30 days of the monitoring period.

✔

Date of Service

$

RemoteMonitoringTimeline


QuarterlyBillingAgenda

Claims for every monitored patient go out on the last day of each calendar quarter as long as the other two rules are satisfied.


UseDeviceCompanyWebsiteasSuperBill

40

Structure device clinic schedule to facilitate all interrogations within the first 80 days of each quarter.

Run “All Clinic Patients” Report on Day 80 as a “stop loss”

✓✓

(c)2017CardiologyCoder.Comclient#756

HeartFailureMonitoring

Non-ECGDerivedData(billable)

• Weight• Areliabletell-taleindicatorofheartfailure

exacerbationbecauselowerextremityandpulmonaryedemacausesuddenweightshift

• Bluetoothtransmissiontocommunicator• BloodPressure

• BlueToothtransmissiontothemonitor,remotetransmissiontowebsite.

• RV,LA,&pulmonaryarterypressuremeasurements

• RespiratoryRateTrend• Increasedlungwater=increasedRR• Detectheartfailureexacerbationby

monitoringrespiratoryrate• ThoracicImpedance

• Dropsinimpedancemayindicateheartfailureexacerbation

• NotFDAapprovedtotriggeralerts

OtherData(notbillablebyitself)

• HeartRateVariability• NotbillablebecauseitisECGderived• DecreasingHRVmayprecede

hospitalizationbyuptothreeweeks• Patientinterviews

• Fatigue• Dizziness• Edema• Dyspnea,Orthopnea,PND

• Smartdevicedata• Measurementsofphysicalactivitylike

numbersofstepstakeneachday• Dietarytrackingtools


CodesforHeartFailureMonitoring

• 93297 ($27*)- Interrogationdeviceevaluation(s),(remote)upto30days; implantablecardiovascularmonitorsystem,includinganalysisof1ormorerecordedphysiologiccardiovasculardataelementsfromallinternalandexternalsensors,physiciananalysis,review(s)andreport(s)

• 93299 (ContractorPriced)- Interrogationdeviceevaluation(s),(remote)upto30days;implantablecardiovascularmonitorsystemorimplantablelooprecordersystem,remotedataacquisition(s),receiptoftransmissionsandtechnicianreview,technicalsupportanddistributionofresults

Whenbilledonthesameday,93299isbundledinto93296(remotedevicemonitoringTC)

Bundlingonlyappliestoservicesbilledwiththesamedateofservice

*2017Medicarenationalaveragepayment


ContractorPricingfor93299

• PalmettoGBA $29• WisconsinPhysicianServices $123• NationalGovernmentServices $204• CGSAdministrators $28• Noridian HealthcareSolutions $13• Novitas $42• CahabaGBA $28• FirstCoastServiceOptions $36

• AveragePayment: $63/month• 2017HospitalOutpatientDept.Pay* $35/month

*Paymentswillvarybasedongeographiclocation.


AMA: must monitor the patient for at least 1/3 of monitoring period (10 days) before submitting claim.

“Atleastoneinterrogation/reportmustbeperformedduringthemonitoringperiod.”

✔

✔

$CMS: date of service must be the day on which the 30-days of monitoring is completed.


CommonICD-10Codes

ProgrammingEvaluations*

RemoteMonitoring&Interrogations*

*Alsoreportdeviceindication

(unspecified)(unspecifiedcause)


DeviceMalfunctionICD-10Codes

• Electrodebreakdown T82.110A*

• Generatorbreakdown T82.111A

• Displacementofelectrode T82.120A

• Displacementofgenerator T82.121A

• Otherelectrodecomplication T82.190A

• Othergeneratorcomplication T82.191A

7th CharacterisAorD:• Aindicatesthisistheinitialepisodeofcare• D indicatesasubsequentepisode

*Subsequentencounter:“aftertheactivephaseoftreatmentand whenthepatientisreceivingroutinecarefortheinjuryduringtheperiodofhealingorrecoveryaftertheactivephaseoftreatmentandwhenthepatientisreceivingroutinecarefortheinjuryduringtheperiodofhealingorrecovery.Forexampleapatientwithananklesprainmayreturntotheofficetohavejointstabilityre-evaluatedtoensurethattheinjuryishealingproperly..”

• CodeitRight Insights1/12

Routinebatterydepletionisnotamalfunction–donotreportitasageneratorbreakdown.


JimCollins,CPC,CCCCertifiedProfessionalCoder,[email protected] (518)320-4376

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