Billing and Coding: Implantable Automatic Defibrillators

The National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators was revised with an effective date of February 15, 2018. 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 20.4. (CMS policy language is in italics.) The NCD “Item/Service Description” and “Indications and Limitations” are repeated here. This article does not alter previous CMS A/B Medicare Administrative Contractors (MACs) instructions for coding and billing of NCD 20.8.3 (National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers) nor does it alter MAC Local Coverage for Cardiac Resynchronization Therapy. Item/Service Description A. General An ICD is an electronic device designed to diagnose and treat life-threatening ventricular tachyarrhythmias. Indications and Limitations of Coverage B. Nationally Covered Indications Effective for services performed on or after February 15, 2018, CMS has determined that the evidence is sufficient to conclude that the use of ICDs, (also referred to as defibrillators) is reasonable and necessary: 1. Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF). Patients must have demonstrated: An episode of sustained VT, either spontaneous or induced by an Electrophysiology (EP) study, not associated with an acute Myocardial Infarction (MI) and not due to a transient or reversible cause; or An episode of cardiac arrest due to VF, not due to a transient or reversible cause. ICD-10-CM codes which describe the above: I46.2, I46.9, I47.2, I49.01, I49.02, I49.3, I49.9, I5A, Z45.02 or Z86.74. 2. Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) ≤ 0.30. Patients must not have: New York Heart Association (NYHA) classification IV heart failure; or, Had a Coronary Artery Bypass Graft (CABG), or Percutaneous Coronary Intervention (PCI) with angioplasty and/or stenting, within the past three (3) months; or, Had an MI within the past 40 days; or, Clinical symptoms and findings that would make them a candidate for coronary revascularization. For these patients identified in B2, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Social Security Act (the Act)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared-decision making encounter may occur at a separate visit. ICD-10-CM code I25.2 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43. 3. Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF ≤ 35%. Additionally, patients must not have: Had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months; or, Had an MI within the past 40 days; or, Clinical symptoms and findings that would make them a candidate for coronary revascularization. For these patients identified in B3, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision-making encounter may occur at a separate visit. ICD-10-CM code I25.5 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43. 4. Patients who have severe, non-ischemi