Below is suggested documentation that could help support Medicare criteria for single or dual chamber cardiac pacemakers insertions. This list in not all inclusive, but is representative of the type of documentation that you may wish to include in your medical records.
1. Complete History and Physical: An in-depth history and physical is of vital importance. Historical information regarding the patient’s past medical care, alternative treatments and pertinent lifestyle changes should be included. If single-chamber pacemaker has been previously attempted, this information should also be included.
2. List of Medications: Current medications for this hospital stay, along with information on previous medications that the provider has tried. Include whether or not the medication was effective, the type of symptoms the patient had, and any adjustments made in medications.
3. Diagnostic Reports: Include any diagnostic report that may have been ordered and performed. The diagnostic tests to support the surgical procedure may have happened on the billed “Date of Service” or prior to it. Include the patient’s prior inpatient/outpatient services that include any diagnostic tests performed that support why this surgical procedure was necessary.
4. Surgical Report: This will provide an accurate description of the procedure and may include mitigating factors affecting the surgery.
5. Pertinent Hospital Documentation: Include all pertinent hospital documentation for the requested dates of service such as physician orders, progress notes from all disciplines, surgical reports, anesthesia evaluations and notes, recovery room records, laboratory reports, etc.
Medicare Report: September 2010
If the medical necessity of the dual-chamber pacemaker is not met, the CERT reviewer will deny the entire admission based on CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 5.4, Review of Procedures Affecting the DRG. This CMS guideline states:
“The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DRG was reasonable and medically necessary. When a procedure was not medically necessary, the contractor shall follow these guidelines:
– If the admission was for the sole purpose of the performance of the non-covered procedure, and the
beneficiary never developed the need for a covered level of service, deny the admission;
– If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e. remove from the DRG calculation), but approve the admission. “
Health care providers staying aware of current coverage requirements and having documentation to support medical necessity are the first steps in preventing denials.