I47.19 — Other supraventricular tachycardia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Bradycardia due to essential long-term drug therapy may be covered with Modifier -KX when no acceptable alternative exists; documentation of the drug therapy and lack of alternatives must be on file.
- Objective diagnostic documentation (e.g., ECG/Holter/monitoring showing heart rate, asystole duration, pauses, electrophysiologic study results, tilt-table testing, and surgical notes) should be maintained to support attestation and coding.
- Practitioners must attest with Modifier -KX that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression requiring a permanent pacemaker for Groups I and II.
- Group III (conditions not addressed by NCD or contractor) requires attestation with Modifier -SC when billed.
Key Coverage Criteria
- Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
- Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to second-degree and/or third-degree atrioventricular (AV) block.
- Contractor-allowed (Group II) indications covered with attestation include symptomatic AV block, symptomatic first-degree AV block with PR interval >300 ms, and bundle branch/fascicular blocks when symptomatic or otherwise meeting contractor criteria.
- Pacemaker implantation is allowed when used specifically to control supraventricular tachycardia (SVT) that is reproducibly terminated by pacing after failure or intolerance of catheter ablation and/or medical therapy.
- Pacemaker implantation is allowed for atrial fibrillation/atrial flutter with symptomatic bradycardia that is due to necessary medical therapy (when no acceptable alternative exists), with attestation.
- Pacemaker implantation is allowed for hypersensitive carotid sinus syndrome or neurocardiogenic syncope when there is a cardioinhibitory response of ≥3 seconds or significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or on tilt-table testing.
20 Active Policies
A57476 — Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
J05
A54958 — Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker
J05
A56915 — Billing and Coding: Urine Drug Testing
J05
A56391 — Billing and Coding: Implantable Automatic Defibrillators
J05
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