The contractor for the Comprehensive Error Rate Testing (CERT) program has identified providers who are billing for noncovered uses of dual chamber pacemakers. Highmark Medicare Services reminds providers of the National Coverage Determination (NCD) for Cardiac Pacemakers
This NCD applies only to permanent cardiac pacemakers and does not apply to the use of temporary non-implanted pacemakers. According to the NCD, the indications for single-chamber pacemakers differ from those for dual-chamber pacemakers. While the DRG is the same regardless of the pacemaker type implanted, it is not appropriate to bill for a dual-chamber pacemaker if a single-chamber pacemaker is used. It is also not appropriate to implant a dual-chamber pacemaker when medical necessity, as detailed in the NCD, only supports use of a single-chamber pacemaker.
The CERT reviewers look for documentation to support the medical necessity of the procedure as well as severity of illness and intensity of services to support the inpatient hospital level of care. To support the necessity of the surgical procedure CERT reviews medical records for patient’s presenting symptoms and prior more conservative treatments.
In the case of dual-chamber pacemakers, there are specific criteria listed in the CMS NCD
that indicate medical necessity. They are as follows:
1. Patients in who single-chamber (ventricular pacing) at the time of pacemaker insertion elicits a definite drop in blood pressure, retrograde conduction, or discomfort.
2. Patients in whom the pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms, has already been experienced with a pacemaker that is being replaced.
3. Patients whom even a relatively small increase in cardiac efficiency will importantly improve the quality of life, e.g., patients with congestive heart failure despite adequate other medical measures.
4. Patients in whom the pacemaker syndrome can be anticipated, e.g., in young and active people, etc.
Highmark Medicare Services recommends providers be familiar with this NCD when determining the need for pacemaker insertion and when documenting whether a single or dual chamber pacemaker insertion is medically necessary.