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January 11, 2018

Single Chamber and Dual Chamber Permanent Cardiac Pacemakers-Coding and Billing

Refer to:

The National Coverage Determination (NCD) 20.8.3, Single Chamber and Dual Chamber Permanent Cardiac Pacemakers were revised with an effective date of August 13, 2013. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following provides coding and billing instructions for the implementation of NCD 20.8.3. The NCD "Item/Service Description" and "Indications and Limitations" are repeated here.

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Local Coverage Article (LCA): Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)

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Common Denials Found

  • Not utilizing KX modifier appropriately
  • Utilization of SC modifier inappropriately
  • Afib only two covered…I48.1 and I48.91 and require KX modifier
  • Resynchronization (must use KX modifier only if Diagnosis used from Group I-II)
  • Use of SC modifier that doesn't meet Reasonable and Necessary (R&N) requirements

Case Example 1: Upgrade from Existing to Resynchronization

Ensure Claim Contains and Medical Record Supports:

  • Correct CPT code billed
  • Covered diagnosis
  • ICD 10 code from Group I or II with KX modifier
  • If falls under "Other" Group III use SC Modifier that meets R&N requirements

Case Example 2: Component Replacement

Ensure Claim Contains and Medical Record Supports:

  • Original Indication for pacing (even if replacing)
  • Correct CPT code billed
  • Covered diagnosis
  • ICD 10 code from Group I or II with KX modifier
  • If falls under "Other" Group III use SC Modifier that meets R&N requirements
  • Include T82XXX (mechanical problem with generator) if related to battery failure

Cardiac Pacemakers


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