Billing and Coding: Implantable Automatic Defibrillators

CMS NCD 20.4 covers ICD implantation for secondary prevention (prior sustained VT/VF or cardiac arrest) and for specific primary prevention populations defined by prior MI or ischemic/nonischemic cardiomyopathy with specified LVEF thresholds and NYHA classes. Several primary prevention groups (B2–B5) require a formal shared decision‑making encounter with an evidence‑based tool prior to initial implantation; exclusions include recent MI (within 40 days), CABG/PCI within 3 months, NYHA class IV in the prior-MI subgroup, limited noncardiac life expectancy (<1 year), significant irreversible brain damage, and poorly controlled SVT/AF. Device replacements are allowed for battery depletion or malfunction, billing must include the indicated ICD-10-CM/PCS and CPT codes and site-of-service restrictions apply, and local MAC determinations govern bridge-to-transplant and some investigational scenarios.

"Patients with a personal history of sustained ventricular tachyarrhythmia (sustained VT) or cardiac arrest due to ventricular fibrillation (VF), not associated with an acute MI and not due to a tra..."