Local Coverage Article

Billing and Coding: Implantable Automatic Defibrillators

A56343

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Article ID
A56343
Article Title
Billing and Coding: Implantable Automatic Defibrillators
Article Type
Article
Original Effective Date
03/26/2019
Revision Effective Date
10/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text

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, I47.20, I47.21, I47.29, I49.01, I49.02, I49.3, I49.9, 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 forty 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 forty 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-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF ≤ 35%, been on optimal medical therapy for at least three (3) months. 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 forty days; or,
  • Clinical symptoms and findings that would make them a candidate for coronary revascularization.

For these patients identified in B4, 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 codes I42.0, I42.6, I42.7 or I42.8 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.

5. Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy).

For these patients identified in B5, 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 codes which describe the above: I42.1, I42.2, I45.6, I45.81 or I45.89.

6. Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.

For each of the six (6) covered indications above, the following additional criteria must also be met:

  1. Patients must be clinically stable (e.g., not in shock, from any etiology);
  2. LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography;
  3. Patients must not have:
    • Significant, irreversible brain damage; or,
    • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than one (1) year; or,
    • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.

Exceptions to waiting periods for patients that have had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months, or had an MI within the past forty days:

Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers, and who meet the criteria in this national coverage determination for an ICD, may receive the combined devices in one procedure, at the time the pacemaker is clinically indicated;

Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, ERI, or device/lead malfunction.

ICD-10-CM codes which describe the above: T82.110A, T82.111A, T82.118A, T82.119A, T82.120A, T82.121A, T82.128A, T82.129A, T82.190A, T82.191A, T82.198A, T82.199A, T82.7XXA or Z45.02.

C. Nationally Non-Covered Indications

N/A

D. Other

For patients that are candidates for heart transplantation on the United Network for Organ Sharing (UNOS) transplant list awaiting a donor heart, coverage of ICDs, as with cardiac resynchronization therapy, as a bridge-to-transplant to prolong survival until a donor becomes available, is determined by the local Medicare Administrative Contractors (MACs).

ICD-10-CM code Z76.82 must be billed with ICD-10-CM code I50.84 which describes the above.

All other indications for ICDs not currently covered in accordance with this decision may be covered under Category B Investigational Device Exemption (IDE) trials (42 CFR 405.201).

ICD-10-CM code which describes the above: Z00.6.

The coding and billing guidelines apply to the following ICD-10-Procedure codes: insertion codes: 0JH608Z, 0JH609Z, 0JH60FZ, 0JH638Z, 0JH639Z, 0JH63FZ, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z, 02H43KZ, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, 02HL4KZ and removal codes: 0JPT0FZ, 0JPT0PZ, 0JPT3FZ, 0JPT3PZ, 02PA0MZ, 02PA3MZ, 02PA4MZ and 02PAXMZ.

The coding and billing guidelines also apply to the following CPT® codes: 33202, 33203, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448, 33215, 33216, 33217, 33218, 33220, 33224 and 33225.

Coding Information

CPT/HCPCS Codes

Group 1

(25 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
33202 Insert epicard eltrd open
33203 Insert epicard eltrd endo
33215 Reposition pacing-defib lead
33216 Insert 1 electrode pm-defib
33217 Insert 2 electrode pm-defib
33218 Repair lead pace-defib one
33220 Repair lead pace-defib dual
33223 Relocate pocket for defib
33224 Insert pacing lead & connect
33225 L ventric pacing lead add-on
33230 Insrt pulse gen w/dual leads
33231 Insrt pulse gen w/mult leads
33240 Insrt pulse gen w/singl lead
33241 Remove pulse generator
33243 Remove eltrd/thoracotomy
33244 Remove elctrd transvenously
33249 Insj/rplcmt defib w/lead(s)
33262 Rmvl& replc pulse gen 1 lead
33263 Rmvl & rplcmt dfb gen 2 lead
33264 Rmvl & rplcmt dfb gen mlt ld
33270 Ins/rep subq defibrillator
33271 Insj subq impltbl dfb elctrd
33272 Rmvl of subq defibrillator
33273 Repos prev impltbl subq dfb
G0448 Place perm pacing cardiovert

ICD-10-CM Codes that Support Medical Necessity

Group 1

(44 Codes)
Group 1 Paragraph

ICD-10-CM codes I25.2, I25.5, I42.0, I42.6, I42.7, I42.8 and Z76.82 must be reported with a secondary diagnosis as described above.

Group 1 Codes
CodeDescription
I25.2 Old myocardial infarction
I25.5 Ischemic cardiomyopathy
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.2 Other hypertrophic cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I45.6 Pre-excitation syndrome
I45.81 Long QT syndrome
I45.89 Other specified conduction disorders
I46.2 Cardiac arrest due to underlying cardiac condition
I46.9 Cardiac arrest, cause unspecified
I47.20 Ventricular tachycardia, unspecified
I47.21 Torsades de pointes
I47.29 Other ventricular tachycardia
I49.01 Ventricular fibrillation
I49.02 Ventricular flutter
I49.3 Ventricular premature depolarization
I49.9 Cardiac arrhythmia, unspecified
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.84 End stage heart failure
T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter
T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter
T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter
T82.120A Displacement of cardiac electrode, initial encounter
T82.121A Displacement of cardiac pulse generator (battery), initial encounter
T82.128A Displacement of other cardiac electronic device, initial encounter
T82.129A Displacement of unspecified cardiac electronic device, initial encounter
T82.190A Other mechanical complication of cardiac electrode, initial encounter
T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter
T82.198A Other mechanical complication of other cardiac electronic device, initial encounter
T82.199A Other mechanical complication of unspecified cardiac device, initial encounter
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
Z00.6 Encounter for examination for normal comparison and control in clinical research program
Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
Z76.82 Awaiting organ transplant status
Z86.74 Personal history of sudden cardiac arrest

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R3

Under Article Text subsection heading Item/Service Description B. Nationally Covered Indications revised the statement, “ICD-10-CM codes which describe the above: I46.2, I46.9, I47.2, I49.01, I49.02, I49.3, I49.9, Z45.02 or Z86.74” to remove the deleted code I47.2 and added codes I47.20, I47.21, I47.29. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted I47.2 and added I47.20, I47.21, I47.29. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

10/01/2019 R2

Under Article Title changed title from Implantable Automatic DEFIBRILLATORS - Coding and Billing to Billing and Coding: Automatic Implantable Defibrillators. Under Article Text "D. Other " added ICD-10-PCS codes 0JH60FZ, 0JH63FZ, 0JPT0FZ and 0JPT3FZ. These revisions are due to the Annual ICD-10 Updates and become effective on 10/1/2019.

03/26/2019 R1

Corrected typographical errors within the Article Text.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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Public Versions
Updated On Effective Dates Status
08/19/2022 10/01/2022 - N/A Currently in Effect You are here
08/26/2019 10/01/2019 - 09/30/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Implantable
  • Automatic Defibrillators
  • Defibrillators
  • AICD